cms_ID: 32
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 32 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 241 | G | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family and staff interview, the facility failed to ensure 4 of 19 sampled residents (#1, #7, #12 and #13) were provided care and services in a manner enhancing their dignity and respect. This resulted in harm to Resident #1 when she experienced resentment and demoralization when a tab alarm was attached to her clothing and the loud alarm that sounded when she moved or stood. It also placed Resident #7 at risk of psychosocial harm when she was not provided with toileting assistance necessary to avoid incontinence and incontinence briefs were put on her when she had been continent previously. Residents #12 and #13 were administered insulin injections during meals in the main dining room, creating the potential of embarrassment and humiliation. Findings include: 1. Resident #1 was admitted to the facility on [DATE]; current [DIAGNOSES REDACTED]. Resident #1 received hospice care for end stage [MEDICAL CONDITION]. Review of the 4/20/16 quarterly MDS indicated Resident #1 was usually understood by others, had no behavioral symptoms, and had a history of [REDACTED]. Resident #1's Care Plan, reviewed and revised on 6/10/16, stated a tabs alarm was initiated to address the problem of potential for falls on 3/21/16. Documentation included, I may hide or disable it because the sound bothers me, remind me it alerts the staff that I may need help. Resident #1 was observed with large writhing movements, primarily of her arms and upper body, at various times during the survey (6/12/16 at 8:00 pm - 8:30 pm, 6/13/16 at 7:00 am and 9:30 am, and 6/14/16 at 6:10 pm). Resident #1 was interviewed on 6/13/16 at 9:30 am, and reported she had a history of [REDACTED]. She stated she resented the alarm due to the loud sound that emanated when it went off. She stated it was very important to remain independent as much as she could. Resident #1 was interviewed a second time on 6/14/16 at 9:50 am, and stated she was capable of disconnecting the alarm by unclipping it from her clothing. Resident #1 stated she had unclipped it at times because it bothered her, but was encouraged by staff to keep it connected. Resident #1 reported she had not disconnected it recently. Resident #1 concluded, stating the tab alarm use was upsetting and made her feel, Like a dog on a leash. Resident #1 was observed during the survey, between 6/12/16 and 6/17/16, a number of times without the alarm connected. She was also observed during the survey with the alarm connected. On 6/14/16 at 6:10 pm, Resident #1 was observed eating dinner in the dining room. Within a period of 5 minutes (6:10 pm - 6:15 pm), the alarm sounded with a loud, piercing beep, 4 times. Within 5 seconds of each incident, a staff member turned the sound off and reconnected the alarm to Resident #1's clothing. Resident #1 reached down once to pick something up off the floor; however, in the other 3 instances the alarm was set off by Resident #1's writhing movements of her upper body in the wheelchair. She was not attempting to stand, get out of the chair, or do something unsafe in 3 of the 4 instances the alarm sounded. CNA #1 was interviewed on 6/13/16 at 9:30 am, and stated Resident #1 was to have the tab alarm on when she was in the wheelchair and verified Resident #1 removed it at times. She stated Resident #1 had a history of [REDACTED]. The DNS was interviewed on 6/16/16 at 5:30 pm, and verified Resident #1 had a history of [REDACTED]. She verified Resident #1 was capable of removing the tab alarm and it was not an effective measure to prevent falls. She stated Resident #1 was stubborn, knew what she wanted, and desired independence. 2. Resident #7 was admitted to the facility on [DATE], for rehabilitation following a total knee replacement. She had an admission [DIAGNOSES REDACTED]. Resident #7 required staff assistance for toileting and transfers when admitted . During an interview on 6/13/16 at 2:10 pm, Resident #7 stated that she had problems with her bladder when she was initially admitted after knee replacement surgery. She stated it was hard for her to get to the bathroom on time. Resident #7 stated it took 2 to 3 staff to assist her with toileting initially, because of her limited weight bearing status following surgery. She stated she was prescribed [MEDICATION NAME] and was incontinent the first couple days because staff did not help her. Resident #7 stated she waited an hour to an hour and a half to be toileted. Resident #7 reported staff came to her room and turned off her call light and said they would come back but did not come back. She stated she remained in wet incontinence briefs for extended timeframes. Resident #7 stated staff got angry when they had to come and assist her to the toilet. It took several staff to do so and reported one staff member stated, Again? when she needed assistance to toilet. Family Member #1 was interviewed on 6/14/16 at 3:00 pm. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago. Family Member #1 stated Family Member #2 was with Resident #7 during the day she was admitted (6/3/16) to the facility following surgery. Family Member #1 stated he was with Resident #7 during the second day (6/4/16) following Resident #7's admission and that both he and Family Member #2 went and spoke with the Administrator due to their concerns. Family Member #1 stated Resident #7 had been completely continent prior to the surgery and was aware when she needed to use the toilet. Family Member #1 stated Resident #7 had a catheter in the hospital but it was removed prior to her coming to the facility. He stated Resident #7 was put into incontinent briefs when she was admitted to the facility even though she was continent. Family Member #1 stated both he and Family Member #2 observed Resident #7 waiting too long for assistance and Resident #7 was incontinent, urinating in her brief, as a result. He stated he had medical training and helped Resident #7 to the toilet twice when he was visiting because staff did not come timely and Resident #7 had already been incontinent. Family Member #1 stated he was concerned because Resident #7 had what looked like skin breakdown to her bottom. A Bowel and Bladder Continence Evaluation, dated 6/8/16, documented Resident #7 was incontinent of urine a total of 4 times on 6/3/16 and on 6/4/16. On 6/5/16 and 6/6/16, there were no recorded incidents of incontinence; however, there was one incident of Resident #7 being wet. A SNRC Admission Assessment, dated 6/3/16, noted Resident #7's buttocks area was red and excoriated. The Administrator was interviewed on 6/16/16 at 2:00 p.m. He stated Family Member #1 and Family Member #2 came into his office on 6/6/16 and expressed their concerns regarding Resident #7's lack of care, including toileting. He stated he grabbed a complaint form and documented their concerns at that time. He stated he went to the charge nurse after the discussion and began investigating the concerns immediately. He stated that he found out Resident #7 was admitted with an incontinence brief on and had since been progressed to an incontinence pull up. He stated he directed staff to respond timely to call lights and toileting assistance after talking with Family Member #1 and Family Member #2. 3. On 6/13/16 at 7:00 am, Resident #12 was observed in the small dining room eating breakfast. LN #7 had administered Resident #12's oral medications. LN #7 then assisted Resident #12 in lifting the left corner of her shirt and administered Resident #12's insulin. On 6/16/16 at 9:30 am, Resident #12 stated she was not asked about getting her injection in the dining room, that it was just how it was done. 4. On 6/13/16 at 7:20 am, Resident #13 was observed in the small dining room eating breakfast. LN #7 had administered Resident #13's oral medications. LN #7 then assisted Resident #13 in lifting the right corner of his shirt and administered Resident #13's insulin. On 6/16/16 at 10:00 am, Resident #13 stated he was not asked about getting his medications in the dining room and he had always got his insulin in the dining room. Resident #13 stated he had not been asked. | 2020-09-01 |