cms_DC: 43
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 43 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2018-09-26 | 689 | D | 0 | 1 | PSFH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 38 sampled residents facility staff failed to provide care in accordance with physicians' order and professional standards of care as evidenced by a resident fall. Resident # 33. Findings included . Facility staff failed to maintain safety to prevent a resident fall by failing to raise the bed side rails when providing incontinent care. Resident # 33 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 9/24/18 at 10:00 AM of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) resident is scored as 0 which indicate resident is rarely/never understood. Section G (Functional Status) resident is coded as 4' totally dependent on staff for activities of daily living (dressing, toilet use, bathing, and personal hygiene). Section H (Bladder and Bowel) Resident is coded as 3 which indicate, always incontinent of bladder and bowel. Section J (Health Conditions) J1700 Fall History on Admission/Entry or Reentry is coded as 1 which indicate resident had a fall during the last month; J1900 Number of Falls since Admission/Entry or Reentry Prior Assessment is coded as 1 No injury (no evidence of any injury is noted on physical assessment by the nurse or primary care clinician). Review of the nursing care plan showed Resident at risk for falling; approaches assess resident frequently to assure that resident is positioned correctly on the bed, keep call light in reach at all times, observe frequently and place in supervised area when out of bed, provide incontinent care as needed. Review of the physician order [REDACTED]. On 9/24/18 at 11:30 AM a review of the nurses note dated 5/3/18 showed Resident has fallen while the Certified Nursing Assistant (CNA) and family member were changing the resident, CNA rolled the resident to her side, and she (resident) had fallen to the floor, there were no visible injuries, and the CNA stated the position of the side rails was down, the CNA was provided education that the side rails must be up when providing care. On 9/24/18 at 1:00PM observed resident lying quietly in bed and the 1/2 side rails were raised, secured to the bed and functioning as intended. During an interview with Employee#15, yes, I am aware of the resident's fall but there was no injury. During an interview on 9/24/18 at 1:30 PM Employee#24 stated I received training on safety precautions to prevent falls, it takes two staff to provide incontinent care I should have asked staff for help and put the side rails up. During an interview on 9/24/18 at 4:00 PM, Employee# 23 stated I was here and Employee #24, CNA called for help I met the resident on the floor, there were no visible injuries, we got the resident on the bed and sent her (resident) to (hospital name). During an interview with Employee#15, yes, I am aware of the resident's fall but there was no injury. A review of the medical record showed on resident was transferred to (Hospital name). A further review of the medical record showed resident did not sustain an injury following the fall (5/3/18). Facility staff failed to maintain safety to prevent a resident fall by failing to raise the bed side rails when providing incontinent care. During a face-to-face interview on 9/24/18 at 5:00 PM Employee #15 acknowledged the finding. | 2020-09-01 |