cms_OR: 92
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 92 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 690 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to provide adequate incontinent care for 1 of 3 sampled residents (#20) reviewed for incontinent care. This placed residents at risk for unmet needs. Findings Include: Resident 20 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A Urinary Incontinence and Indwelling Catheter CAA dated 5/7/19 indicated the resident was frequently incontinent of urine due to a decrease in the resident's mobility, pain and need for assist with toileting. The resident was at risk for skin break down and urinary tract infections related to incontinence. Pad and briefs were to be utilized. A Pressure Ulcer CAA dated 5/7/19 indicated Resident 20 admitted with a DTI to her/his coccyx was at risk for skinbreak down related to urinary incontinence, decreased mobility and diabetes. The resident required extensive assist of two staff with bed mobility. Preventative measures were in place to protect the resident's skin. The coccyx wound was being monitored by nursing. A complaint was received on 5/20/19 indicating the facility was not providing timely incontinent care. An interview on 5/21/19 at 11:06 AM Witness 19 (Complainant) stated he was in the building often to check on Resident 20 and it was difficult finding staff for assistance. He felt Resident 20 was not repositioned enough and had to wait longer than 20 minutes before getting her/his brief changed and the brief would often be soaked. The witness stated the wound on the resident's bottom had gotten worse due to untimely brief changes. An interview on 5/22/19 at 9:31 AM Resident 20 stated she/he waited greater than 20 minutes to receive ADL care and often sat in wet briefs. The resident indicated she/he needed assistance and could not utilize the toilet due to her/his broken leg. She/he stated I pay attention to time. An observation on 5/22/19 at 1:34 PM revealed Resident 20 was asleep in bed and the door was open. At 1:45 PM Staff 45 (CNA) woke the resident and stated she was going to change the resident's brief and get the resident some water. Staff 45 returned with fresh ice water and exited the room. During an observation and interview on 5/22/19 at 2:50 PM Resident 20 stated Staff 45 came into her/his room around 2:00 PM and stated she was going to change the resident's brief, however Staff 45 never came back and I am still in my wet brief. The resident turned on her/his call light at 2:52 PM. The resident stated she/he could wait up to greater than 30 minutes around meal times and shift change to get her/his brief changed and this was very frustrating. At 3:02 PM Staff 46 (CNA) came in answered the call light and changed the resident's brief and reposition the resident. On 6/5/19 at 1:19 PM Staff 11 (RNCM) stated her expectation was for staff to answer call lights timely and indicated if a CNA tells a resident they will be right back for a brief change then this should be prioritized and staff should follow through. On 6/19/19 at 2:38 PM Staff 1 (Administrator) and Staff 2 (DNS) stated that for residents that have incontinence issues they expected staff to check on those residents anytime they are doing rounds and make sure they are clean and dry. Staff 2 further stated Staff 45 who checked on Resident 20 at 1:45 PM should have returned, changed the resident's brief and repositioned the resident. | 2020-09-01 |