cms_OR: 27
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 27 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2018-03-13 | 580 | D | 1 | 0 | CI9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record reviews it was determined the facility did not immediately inform the resident representatives of significant change of condition for 2 of 3 sampled residents (#s 1 and 2) reviewed for significant change of condition. This placed the residents at risk for unmet needs. Finding include: 1. Resident 1 was admitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 12/21/17 progress notes written at 9:12 AM documented by Staff 3 (LPN) stated the resident had an altered mental status and hands in the air trying to grab something. Resident 1 kept dozing off during conversations and had no fever. Vital signs were stable though low O2 sats of 79. The resident was placed on 2 liters of oxygen and O2 sats stayed between 82-86 percent. The local emergency medical transportation service was contacted and the resident was transported to the local hospital emergency department. Staff 3 documented there was no phone contact listed for notification. Interviews conducted on 3/6/18 at 3:18 PM through 3/7/18 at 2:51 PM revealed the following: Staff 3 (LPN) stated on 12/21/17 when the resident was sent to the local hospital emergency department Resident 1's record did not list any family members or emergency contact information. Staff 3 stated the information regarding Witness 1 (Caregiver) was entered into the system after Resident 1 was transferred to the local hospital. Staff 3 stated Staff 9 (Admissions Coordinator) usually entered the contact information in the resident's Admission Record/Face Sheet. Staff 9 (Admissions Coordinator) reviewed the resident's electronic record and determined the contact information was submitted in the computer program on 12/21/17. Staff 9 stated he entered what was available to him when the resident was admitted to the facility. Staff 9 stated Staff 10 (Social Services) followed up to ensure the information was included in the resident's record. Staff 10 (Social Services) stated contact information for Witness 1 was included in the local hospital discharge information so did not know why the contact information was not included in the resident's Admission Record/Face Sheet. On 3/8/18 at 10:22 AM Staff 2 (Administrator) provided written documentation to indicate the facility had no formal policy regarding family notification. Staff 2 indicated it was the facility's practice to notify emergency contacts if a resident was sent to the hospital or if there is some sort of incident On 3/12/18 at 2:00 PM Staff 1 (DNS) and Staff 2 (Administrator) stated documentation indicated the facility notified Witness 1 (caregiver/friend) the same day the resident went to the local hospital emergency department. The 12/21/17 progress note written at 1:55 PM documented Witness 1 (caregiver/friend) called the facility and was very upset about the transfer to the local hospital emergency department. There was no documentation the facility contacted Witness 1 (caregiver/friend). 2. Resident 2 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 10/19/17 physician's progress note written as a late entry at 6:47 PM indicated the resident had an acute fall and had a laceration across her/his left upper eye. Resident 2 was identified by the physician to be confused and was transported to the local hospital emergency department. The 10/19/17 Incident Investigation indicated the resident was found on the floor at 2:20 PM and the physician was notified at 2:55 PM by Staff 6 (RN). The 10/19/17 local hospital emergency department notes written at 3:41 PM indicated a right hip x-ray was negative for a fracture and a CT (computerized tomography) scan was negative for an [MEDICAL CONDITION]. The 10/19/17 Incident Investigation indicated Staff 6 (RN) contacted the resident's family member at 4:00 PM. The 10/26/17 progress note documented Witness 3 (family member) was upset the family did not receive a phone call until three hours after the resident's fall. The facility's progress notes indicated the time line of the fall and notification revealed the following: -Resident 2 fell at 2:40 PM -ambulance arrived at 3:30 PM -admitted to the hospital at 3:45 PM -phone call made to the family and voice message left for family member at 5:00 PM -phone call made to family members from the local hospital emergency department at 7:00 PM. On 3/5/18 at 10:09 AM Witness 3 (family member) stated the resident sustained [REDACTED]. Witness 3 stated the facility did not contact family members when the resident was transported to the local hospital emergency department. Witness 3 stated the resident had a [DIAGNOSES REDACTED]. On 3/6/18 at 4:24 PM Staff 6 (RN) stated she tried to call the resident's family as soon as possible. On 3/8/18 at 10:22 AM Staff 2 (Administrator) provided written documentation to indicate the facility had no formal policy regarding family notification. Staff 2 indicated it was the facility's practice to notify emergency contacts if a resident was sent to the hospital or if there is some sort of incident On 3/12/18 at 2:00 PM Staff 2 (Administrator) and Staff 1 (DNS) stated Staff 6 (RN) stayed with Resident 2 because she/he sustained a head injury and informed the physician who was at the facility. Staff 6 continued to stay with the resident until emergency transport service arrived. Staff 1 and Staff 2 were asked if there were other staff available to contact the resident's family. They stated they did not know the whereabouts of the other staff members. | 2020-09-01 |