cms_AZ: 89

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
89 DESERT HAVEN CARE CENTER 35062 2645 EAST THOMAS ROAD PHOENIX AZ 85016 2017-02-03 323 D 0 1 TPN311 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy and procedures, the facility failed to ensure the environment was free from accident hazards, by failing to ensure a physical restraint was properly applied to one resident (#71) and by having resident door frames with exposed sharp edges. Findings include: -Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the behavioral unit. A review of the clinical record revealed a physician's orders [REDACTED]. A fall risk care plan included an intervention for the use of a lap buddy when in a wheelchair for poor safety awareness. The care plan also included to check the lap buddy for positioning and placement every shift. According to the CNA (Certified Nursing Assistant) care sheet, a lap buddy was to be used for this resident. The (MONTH) (YEAR) TAR (Treatment Administration Record) included the physician's orders [REDACTED]. An observation of the resident was conducted on (MONTH) 30, (YEAR) at 1:27 p.m. At this time, the resident was observed sleeping in a wheelchair, with a waist restraint on. The device was a non self-releasing cloth belt. The belt went around the front of the resident's waist and criss crossed behind the resident. The belt then went around the back of the wheelchair and one end was tied to the other end, which was then looped over the back rung of the wheelchair. An interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the ADON (Licensed Practical Nurse/Assistant Director of Nursing/staff #45). She stated that she had also observed the resident on (MONTH) 30, with the non self-releasing waist restraint on. Staff #45 stated that after her observation, she replaced the non self-releasing waist restraint with a lap buddy. She stated that she had spoken with the staff on duty and they had reported that the night shift had gotten the resident up, and had put the non self-releasing waist restraint on the resident. She confirmed that the non self-releasing waist restraint was incorrectly applied and that the resident should have had a lap buddy applied. An interview was conducted on (MONTH) 2, (YEAR), with a LPN (staff #126). She stated that although the CNAs were responsible to apply the physician ordered devices, the nurses were responsible to ensure that they are being applied. A facility policy titled, Use of Restraints included the following: 9. Restraints shall only be used upon written order of a physician . 12. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident. b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. -An observation was conducted on (MONTH) 30, (YEAR) at approximately 2:46 p.m., of the bathroom in room #33 and #42. The bathroom metal door framing was observed to have extensive deterioration of the door frames, which had disintegrated through on the lower portions, exposing sharp metal edges. An environmental tour was conducted on (MONTH) 1, (YEAR) at 11:30 a.m., with the Administrator (staff #49) and the maintenance/housekeeping supervisor (staff #48). They both stated that they were not aware of the extensive deterioration of the door frames in the rooms. The Administrator stated the rooms identified would be prioritized, due to safety concerns. 2020-09-01