cms_SD: 15

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
15	AVANTARA HURON	435020	1345 MICHIGAN AVENUE SW	HURON	SD	57350	2018-02-07	609	E	0	1	TWBV11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure: Four of four unwitnessed falls with injury had been reported to the South Dakota Department of Health (SD DOH) in a timely manner for two of two sampled residents (17 and 62). Thorough investigations had been completed for three of three falls for one of one sampled resident (62) who had cognitive impairment. Findings include: 1a. Review of resident 62's medical record revealed: She had been admitted on [DATE]. She had fallen on 11/21/17, 12/9/17, and 12/17/17. Review of resident 62's 1/2/18 Minimum Data Set (MDS) assessment revealed: Her Brief Interview for Mental Status (BIMS) assessment score was six indicating her cognition was severely impaired. She had two or more falls with injury during that assessment period. b. Review of resident 62's 11/21/17 internal fall report revealed: She had fallen at 5:05 p.m. in her room. Staff heard her calling for help from her room. Upon entry she was found lying on her back with her head towards the doorway. The walker had been laying across her abdomen. She stated she was throwing a piece of trash away. She stated she hit head. -Staff had noted a reddened area on the back of her head. Staff initiated neurological checks. They had not reported the fall to the SD DOH. The following had not been included in the investigation: -Her level of orientation. -What level of assistance she required. -When staff had assisted her last. There had been no documentation of if the care plan had been followed. There had been no documentation of staff interviews. c. Review of resident 62's 12/9/17 internal fall report revealed: She had fallen at 11:00 a.m. in her room. Staff heard her calling for help. They found her lying on the floor in front of her recliner. She stated she stood up to look into her dresser, turned, and fell down. She had complained of right shoulder pain. Staff initiated neurological checks. They had not reported the fall to the SD DOH. The following had not been included in the investigation: -What level of assistance she required. -When staff had assisted her last. -It had been marked she was on a toileting program, but it had not included when she had last used the bathroom. There had been no documentation of if the care plan had been followed. There had been no documentation of staff interviews. d. Review of resident 62's 12/17/17 internal fall report revealed: She had fallen at 1:10 a.m. in her room. Staff found her on the floor in front of her recliner. She was unsure how she had gotten on the floor. Staff initiated neurological checks. She slept in her recliner, and the foot of the recliner had still been raised. She complained of right hip pain and was transferred to the emergency room (ER). They had not reported the fall to the SD DOH. The following had not been included in the investigation: -What level of assistance she required. There had been no documentation if the care plan had been followed. There had been no documentation of staff interviews. Surveyor: 2. Review of the resident 17 complete medical record revealed: She had been found on the floor in her room on 12/31/17 at 7:50 p.m. She was able to move all extremities without pain. Staff had put an ice pack on her forehead. -No time was documented. She was sent to the emergency room per ambulance on 1/1/18 at 5:00 a.m. -After her eye had started to blacken. -When her neuological checks had changed. That incident had not been reported to the SD DOH. Surveyor: 3. Interview on 2/7/18 at 11:30 a.m. with resident care coordinator A revealed: They would not have reported the above falls to the SD DOH unless there was a fracture or bleeding. If someone had been sent to the ER and a fracture was found they would then report to the SD DOH. When asked about meeting the two-hour time frame for reporting major injuries she was unsure how they would meet the two-hour requirement with their current process. They had not reported resident 62's above mentioned falls to the SD DOH. Interview on 2/7/18 at 3:42 p.m. with the director of nursing and the administrator regarding the above falls for resident 62 revealed: They had not reported any of the above falls due to there being no fracture. They understood major injury to be a fracture and had not thought they should have reported the above falls. They had no other documentation regarding the above investigations. Review of the provider's 10/11/12 Abuse Investigations policy revealed: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. *The investigation process should have included at a minimum the following: -Review the completed documentation forms. -Review the resident's medical record to determine events leading up to the incident. -Interview the person(s) reporting the incident. -Interview any witnesses to the incident. -Interview the resident (as medically appropriate). -Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition. -Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. -Interview the resident's roommate, family members, and visitors. -Interview other residents to whom the accused employee provides care and services. -Review all events leading up to the alleged incident.	2020-09-01