cms_SD: 3

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.

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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
3	PRAIRIE HEIGHTS HEALTHCARE	435004	400 8TH AVENUE NW	ABERDEEN	SD	57401	2018-03-29	686	E	0	1	XF2S11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and guideline review, the provider failed to ensure interventions were in place for two of three sampled residents (8 and 60) who developed pressure ulcers. Findings include: 1. Interview on 3/27/18 at 2:11 p.m. with licensed practical nurse (LPN) [NAME] and the administrator regarding the list of residents with pressure areas revealed: Three out of the seven residents had suspected deep tissue injuries (SDTI). -If the area was deep purple or the blister was blood filled, it would indicate it was a deep tissue injury. The Braden Risk Assessment tools were completed on the computer. The Pressure Ulcer Scale for Healing (PUSH) tool was completed on paper. The registered nurses staged the skin areas. They had identified resident 60's left heel had a SDTI due to the blister being filled with blood. Observation and interview on 3/27/18 at 2:38 p.m. with LPN D and the director of nursing (DON) revealed: They were completing a dressing change to resident 60's left heel. The resident was sitting in her wheelchair. She had a wound vac on the outer side of her left foot. -They were not to do anything with that at that time, as she had just returned from an appointment for it. The orders were for a foam dressing and [MEDICATION NAME]. She had a heel protector on her left foot. The SDTI was approximately the size of a quarter. -It was unopened but dark purple and black in color. It had developed while she had been a resident in the facility. Observation on 3/27/18 at 4:15 p.m. of resident 60 revealed she was in her room visiting with a visitor. She was sitting up in her wheelchair. Observation on 3/27/18 at 5:14 p.m. of resident 60 revealed she was propelling herself in her wheelchair going to the dining room. Observation on 3/28/18 at 8:39 a.m. of resident 60 revealed she was in therapy. Review of resident 60's medical record revealed: Her admitted had been 1/17/18. Her [DIAGNOSES REDACTED].>-Personal history of [MEDICAL CONDITION]. -Unspecified injury of unspecified kidney, initial encounter. -Other [MEDICAL CONDITION]. -Charcot's arthropathy. -[MEDICAL CONDITION], stage 4. -Acidosis. -[DIAGNOSES REDACTED]. -Mantle cell [MEDICAL CONDITION], unspecified site. -Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. -[MEDICAL CONDITION], unspecified. -Diabetes mellitus due to underlying condition with diabetic [MEDICAL CONDITION], unspecified. Upon admission she had the following skin concerns: -Coccyx: opened area 3 centimeters (cm) x (by) 2.5 cm. -Groin: redness. -Left groin: pin point incision 0.1 cm x 0.1 cm. -Bottom left ulcer: 5 cm x 2 cm x 1.5 cm. -Right foot: lateral aspect, excoriated area 8 cm x 2.2 cm. Review of resident 60's 1/24/18 Braden Scale for Predicting Pressure Sore assessment revealed her score had been seventeen indicating she was at risk for developing pressure ulcers. Review of resident 60's undated care plan revealed interventions for the current left foot ulcer and for potential skin breakdown had been: Nutrition supplements two times per day initiated on 1/24/18 and revised on 3/11/18 by the registered dietician. Administer treatment per physician's orders. Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician prn (as needed) initiated on 1/17/18. For wound care, treat wound as needed. Currently had maggot therapy with nursing staff to reinforce dressing as needed only, initiated on 2/22/18. Encourage to reposition as needed, use assistive devices as needed, initiated on 1/17/18 and revised on 3/13/18. Pressure redistributing device on bed/chair per facility protocol, initiated on 3/13/18. Provide preventative skin care routinely and prn, initiated on 3/13/18. They had been no interventions for the left heel pressure ulcer or the use of the heel protector. Interview and record review on 3/29/18 from 8:58 a.m. through 9:35 a.m. with LPN [NAME] and the DON regarding resident 60 revealed: The left heel pressure ulcer or SDTI had developed on 3/12/18. They thought it had developed because her heel rested on the foot pedal. -She had to hold her foot at a different angle due to the wound vac on the side. She had not had a heel protector on at that time. -She had worn a gripper sock on that foot. -The heel protector had been initiated after the left heel pressure ulcer had been found. She was not one to lay down throughout the day and was very active. A progress note indicated the physician had been notified, but there were no physician's orders in her record. At 9:32 a.m. we went into LPN E's office for her to look as she thought she remembered writing it down. -She could not locate the physician's order for treatment. -The DON stated the process was to write the phone order, put it in the resident's chart, and send off the part to the doctor to have it signed. -They could not find that part. The left heel pressure ulcer had not been on the care plan. -They both agreed it should have been. 2. Interview on 3/27/18 at 10:22 a.m. with resident 8 revealed: She knew she had a bedsore on her backside. She did not know why it had developed. There had not been any pain. -It had caused her pain once when the adhesive from a dressing was being removed. She was mostly numb from the waist down; not a new condition. -Staff were aware that she had limited sensation from the waist down. She was able to readjust herself in her wheelchair, but she forgot because it did not hurt. -Staff did not remind her to readjust herself. -She was able to demonstrate how she could reposition herself but stated that if she were to lean too far forward she would lose control of her upper body and fall out of her wheelchair. Review of resident 8's medical record revealed: An admission date of [DATE]. [DIAGNOSES REDACTED]. -Early onset cerebellar ataxia. -Muscle weakness. -Need for personal care. -Unspecified dorsalgia. A 3/23/18 cognition score of fifteen indicated she had intact cognition. Her initial 3/25/17 Braden Scale for Predicting Pressure Sore Risk score had been nineteen indicating she had no risk of developing pressure ulcers upon admission. Review of her initial 3/25/17 care plan revealed: A focus area: At risk for alteration in skin integrity related to: impaired mobility fracture of right wrist had the following interventions: -Observe skin conditions with activities of daily living and report abnormalities. -Use pressure redistributing device on bed/chair. -Provide preventative skin care routinely and as needed. The above focus area had been resolved on 9/1/17 resulting in no care plan to address skin integrity. Review of her Braden Scale for Predicting Pressure Sore Risk scores for the following revealed: For 7/18/17 and 10/2/17 had scores of sixteen indicating she had been at risk. For 12/5/17 had a score of twelve indicating high risk. Review of her 12/5/17 Pressure Ulcer Healing Chart form revealed: A pressure ulcer was now present. The length times width had been 3.1 to 4. The exudate amount had been light. The tissue type had been [MEDICATION NAME]. Review of her 12/5/17 care plan revealed: She had a stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. Interventions had included: -To assist with repositioning her in wheelchair and when in bed. -Complete a daily body audit. -To receive dietary supplements. -To encourage her to lie down during the day to reduce pressure to coccyx. --She had voiced agreement in lying down one hour per day. -Offer a whirlpool on shower days to help with circulation. -Place a pressure redistributing mattress on the bed and cushion to the wheelchair. Review of the 1/30/18 Pressure Ulcer Healing Chart form revealed the pressure ulcer had resolved. Review of the 12/5/17 care plan revealed it had been resolved on 1/30/18; there had been no care plan for skin integrity. Review of her 2/14/18 care plan revealed: A new focus area for risk of alteration in skin integrity: related to history of pressure ulcers, impaired mobility, and incontinence had been initiated. Interventions included: -Barrier cream to perineal area/buttocks as needed. -Encouragement to reposition as needed and use of assistive devices as needed. -Observation of skin condition with activities of daily living and report abnormalities. -Use of pressure redistributing device on bed and chair. Review of the 3/16/18 Braden Scale for Predicting Pressure Sore Risk tool revealed a score of twelve indicating high risk. Review of 3/16/18 Pressure Ulcer Healing Chart form revealed: A pressure ulcer was now present. The length times width had been 2.1 to 3. The exudate amount had been none. The tissue type had been [MEDICATION NAME]. Review of the 3/16/18 care plan revealed: She had a stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. Interventions had included: -A daily body audit. -Dressing changes as ordered. -To encourage resident to lie down during the day. -Offer a whirlpool on shower days. -Use a pressure redistributing support surface-air pressure mattress on bed and ish-dish cushion to wheelchair. Interview on 3/27/18 at 3:52 p.m. with RN unit manager A regarding resident 8 revealed: She had been admitted on [DATE] with no pressure ulcers. She had not been at risk on her initial assessment but should have been due to decreased feeling/sensation in her lower body, and because she was often wet due to incontinence. Some preventative measures had been put into place. She had not been as talkative when she had first been admitted to the facility, so she might not have told her about the decreased sensation in her lower extremities. She had then developed a stage two pressure ulcer. A new care plan had been developed to reflect the stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. When the pressure ulcer had closed on 1/30/18 she had stopped the treatment on that day. -She felt she could have continued the treatment longer. She did not know why there had not been preventative measures in place between 1/30/18, when the first pressure ulcer had been resolved, and 2/14/18 when the skin integrity care plan had been re-initiated. -She agreed there should have been a skin integrity care plan after the first pressure ulcer had healed. Surveyor: Observation on 3/28/17 at 1:45 p.m. of resident 8's pressure ulcer revealed: She was lying on her left side, and had been in bed lying down to allow pressure relief to coccyx. The dressing had been removed prior to observation. The wound on the coccyx was almost healed. Area was cleansed with wound cleanser. [MEDICATION NAME] dressing was applied per physician order. Surveyor: Interview on 3/29/18 at 7:23 a.m. with the DON regarding resident 8 revealed: All newly admitted residents had a skin assessment completed. A skin care plan would have been developed for every new resident. It was not as individualized towards her specifically as it could have been. If a skin issue were to develop another care plan would have been created. She agreed after the first pressure ulcer had healed they should have created an in-depth, individualized care plan to prevent further pressure ulcers. Observation and interview on 3/29/18 at 9:50 a.m. with resident 8 revealed: She was lying on her left side in bed with a pillow propped under her back and hip area. She was watching her television. She stated she was laying down, because it was good for her bottom. -She had agreed to lie down more often. -She did not like to lay down. -Some days they asked her to lay down, and some days they did not. She did like whirlpools. If she sat in her wheelchair too long she could sometimes feel burning in her buttocks. Interview on 3/29/18 at 10:00 a.m. with certified nursing assistant (CNA) B revealed: When residents had skin issues she was informed through verbal report. Resident 8 was one resident they encouraged to lay down. -It was over a month ago that she was informed resident 8 needed to lay down every day. They carried a sheet with residents' names and the type of assistance needed. -The sheets did not address if the residents had skin issues. Interview on 3/29/18 at 10:05 a.m. with CNA C revealed: She did not usually work on the hall resident 8 resided on. Verbal report had informed her resident 8 should have been encouraged to lay down. -No other instructions had been given to her regarding her skin interventions. --She was not aware she should have encouraged resident 8 to reposition herself in her wheelchair. 3. Interview on 3/29/18 at 10:10 a.m. with RN unit manager A revealed: All different nurses were currently completing the Braden Scale for Predicting Pressure Sore Risk tool. A new MDS coordinator had recently been hired, and she would be doing the quarterly assessments to promote consistency. Communication to CNAs had been given during the daily verbal report. -There was also a communication book and an area to leave a communication note at the nurses station. Surveyor: Review of the providers (MONTH) 2013 Skin Practice Guide revealed: The Braden assessment provides data on general pressure ulcer risk and assists clinicians to plan care accordingly. The subscale scores provide information on specific deficient's such as moisture, activity, nutrition, and mobility. Those areas could have been specifically addressed in the care plan. Upon completing an evaluation, the interdisciplinary team develops a patient specific care plan to include prevention and management interventions with measurable goals.	2020-09-01