cms_NV: 57
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 57 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 684 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure total dependent residents were not pre-charted for their every two hour repositioning for 2 of 12 sampled residents (Resident #123 and #5). Findings Include: Resident#123 Resident #123 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/16/19 at 8:52 AM, the Director of Nursing (DON) explained Resident #123 was not able to walk, could not feed self, and could not turn self in bed. The DON verbalized this was the condition of the resident on the day the resident was admitted . The DON confirmed the resident was a total dependent on staff for assistance and required turning every two hours. The DON explained a Care Plan for Activities of Daily Living (ADL) would include the resident's total dependence and requirement to turn every two hours. The DON confirmed the Resident did not have an ADL care plan completed. Resident #5 Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 5's Care Plan for [MEDICAL CONDITION] initiated 01/30/19 documented the resident required frequent turning and repositioning every two hours. On 10/15/19 at 2:40 PM, a Certified Nursing Assistant (CNA) explained Licensed Nurses and CNAs turned residents. There was a turn sheet list for documenting who last turned the residents and when they were turned. The CNA explained Resident #5 was turned every two hours. On 10/15/19 at 2:48 PM, the CNA verbalized Resident #123 was total dependent on staff and was turned every two hours in bed and adjusted frequently when in a Geri-chair. On 10/15/19 at 2:58 PM, a CNA provided a Resident Turn Schedule for Resident #123 and Resident #5. The form documented the CNA positioned Resident #123 on rp right position at 4:00 PM and on back at 6:00 PM on 10/15/19. The form documented the CNA positioned Resident #5 on rp right position at 4:00 PM and lp left position at 6:00 PM on 10/15/19. On 10/15/19 at 2:59 PM, the DON reviewed the charting for the CNA for the turning of Resident #123 and Resident #5 at 4:00 PM and 6:00 PM for 10/15/19. The DON verbalized it was pre-charting and it was illegal. The DON confirmed the 4:00 PM and 6:00 PM documentation was initialed by the same CNA before the times had occurred. On 10/15/19 at 3:04 PM, the CNA confirmed it was this CNA's initials documented for the turning of Resident #123 and Resident #5 4:00 PM and 6:00 PM. The CNA explained if there was a change to the resident's position then the CNA would change the documentation but tried to reposition the resident's the way she documented. The CNA verbalized the CNA was not trained to pre-chart but had found this was one way it had worked for her. The CNA explained four CNAs were working the afternoon and would all reposition residents and check the halo ring for residents. The CNA verbalized this CNA did the charting for all the CNAs. On 10/16/19 at 8:57 AM, the DON verbalized the CNA was not taught to pre-chart. The DON verbalized whoever turned the resident was supposed to sign it personally and it was not one CNA documenting for all. | 2020-09-01 |