cms_SD: 46

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
46	MONUMENT HEALTH CUSTER CARE CENTER	435032	1065 MONTGOMERY ST	CUSTER	SD	57730	2018-03-28	700	D	0	1	CZRE11	Based on observation, interview, and record review, the provider failed to ensure assessments had been followed for two of two sampled residents (41 and 53) who had repositioning bars on their beds. Findings include: 1. Observation of resident 41 on 03/13/18 at 08:19 a.m. revealed she was laying in her bed. There were repositioning bars on both sides near the head of her bed. Review of resident 41's medical record revealed: Her 3/13/18 care plan had no mention of repositioning bars. Her 8/1/17 Bed Cane (Repositioning Bar) Assessment indicated: -She had none on her bed. -At this time, bed canes are not recommended for Pt (patient/resident) due to Pt is able to complete bed mobility (rolling side to side, scooting in bed) with no assistance. Pt is able to get out of bed with assistance without using a bed cane. Her 2/19/18 Repositioning Bar Assessment Screen indicated:-The therapy assessment had not been completed. -The nursing assessment stated she would not use repositioning bars. -The section for notifying maintenance was not filled out. 2. Observation on 03/13/18 at 04:19 p.m. of resident 53 during personal care revealed:He was laying in his bed. -There were repositioning bars on both sides near the head of his bed. Certified nursing assistants assisted him with bed mobility and using a total mechanical lift to move him from his bed to his wheelchair. -During the observation he made no attempt to use the repositioning bars to assist with his bed mobility. Review of resident 53's medical record revealed:His 2/16/18 baseline care plan and 3/13/18 comprehensive care plan had no mention of repositioning bars. His 3/6/18 Repositioning Bar Assessment/Screen indicated:-The therapy assessment recommended repositioning bars. -The nursing assessment stated he would not use repositioning bars. -On 3/6/18 at 1:00 p.m. maintenance was notified by work order. Interview on 03/15/18 at 08:44 a.m. with licensed practical nurse A regarding resident 53 revealed:She thought he might use the repositioning bars to assist with his bed mobility at times. She agreed his assessment stated he should not have repositioning bars, and that had not been followed. Interview on 03/15/18 at 09:27 a.m. with physical therapy assistant C regarding resident 53 revealed: His repositioning bars would have been appropriate according to therapy, but if nursing did not agree they should not have been on his bed. His assessment should have been followed. 3. Interview on 03/15/18 at 09:45 a.m. with the plant operations supervisor regarding resident repositioning bars and the above residents revealed:When maintenance staff were notified of any repositioning bars that needed to be put on or removed from a resident's bed they would complete that as soon as possible. Work orders for repositioning bars were a priority item. He stated work orders were submitted electronically. He was unsure if they had received work orders to remove the repositioning bars from residents 41 or 53's beds. -He indicated he would look for those work orders and make a copy for the surveyor to review. -Those copies were not received by the end of survey on 3/28/18. Interview on 03/27/18 at 3:40 p.m. with the director of nursing and director of nursing support person B regarding the above resident's assessments and repositioning bars revealed: Therapy and nursing both participated in the repositioning bar assessments. If therapy and nursing did not agree they would have followed the nursing assessment. Residents 41 and 53 should not have had repositioning bars on their beds. -Their assessments had not been followed. *Maintenance staff were informed through work orders to either put on or remove repositioning bars from residents' beds after the assessments were completed. -The surveyor again asked for documentation to support work orders had been done and was not provided those prior to the end of the survey on 3/28/18.	2020-09-01