cms_SD: 55

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
55	MONUMENT HEALTH CUSTER CARE CENTER	435032	1065 MONTGOMERY ST	CUSTER	SD	57730	2018-09-13	740	E	0	1	YYKW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure two of three sampled residents (12 and 41) who exhibited symptoms of mental health instability had been assessed and evaluated in a timely manner to ensure their psychosocial well-being. Findings include: 1. Random observations on 9/11/18 from 7:15 a.m. through 10:29 a.m. of resident 12 revealed he had: Been sitting in a wheelchair (w/c) either in the hallway or inside of his room. Been able to propel himself up and down the hallway. Made non-sensical statements or would repeat what the surveyor stated when he was approached and attempted to visit with. Interview on 9/11/18 at 10:29 a.m. with certified nursing assistant (CNA) A regarding resident 12 revealed he had: Been confused and alert to self only and was not interviewable. A history of inappropriate behaviors towards staff and other residents. -Those behaviors had recently increased due to a change in his medications and acquiring a urinary tract infection [MEDICAL CONDITION]. Review of resident 12's medical record from 3/1/18 through 9/12/18 revealed: An admission date of [DATE]. His [DIAGNOSES REDACTED]. He had: -Required staff assistance to ensure all of his activities of daily living were met. -Required the use of anti-psychotic, anti-depressant, and hormonal medications to help with stabilizing his mood and behaviors. -Experienced an exacerbation in his behaviors when the physician attempted to decrease his anti-psychotic medication in (MONTH) (YEAR). --Those increased behaviors included: inappropriate advances and touching of female residents and staff; exit seeking behaviors with successful elopements out of the facility while attempting to locate his wife; hitting, kicking, and a decreased safety awareness which had resulted in several falls. -Required one-on-one monitoring by the staff during those periods of increased agitation and inappropriate behaviors. -Acquired a UTI and had required the use of an antibiotic to treat the infection. On 5/21/18 the physician had written an order for [REDACTED]. No documentation to support: -When the resident had been evaluated by the psychologist. -What recommendations the psychologist had for the resident to help him with those behaviors. Review of resident 12's psychotherapy progress note revealed: On 7/2/18 the psychologist had completed an evaluation on the resident. -That evaluation had not been completed until forty-eight days after the physician had written an order for [REDACTED]. The psychologist had made several recommendations for the staff to follow when assisting the resident during an increase in his behaviors. The psychologist had not completed his review and signed the progress note until 9/13/18. It had not been a part of the resident's medical record for the staff and physician to review to ensure appropriate care and services had been delivered to the resident. Interview on 9/12/18 at 10:27 a.m. with the social services designee (SSD) regarding resident 12 revealed: She had confirmed the resident's medical record and documentation to support an increase in his behaviors from (MONTH) (YEAR) through (MONTH) (YEAR). She confirmed there was no documentation to support: -When the psychologist had completed his consult on the resident. -What recommendations the psychologist had made for the staff to follow when assisting the resident during an increase in his behaviors. -The recommendations made by the psychologist had been available for the primary physician to review and approve. She stated: -He comes in to the facility every week to see his residents. -I notify him when we get orders for him to see a resident. -I give him a completed clinical history form on any new residents for him to review. -He did not always follow-up with me or the staff on his recommendations. Sometimes he would. -He does not give us a list of who he is going to visit with when he is here. -We do not know when he will be in the facility. -He does not have a secretary to help him and does his own dictated notes. -It can be up to three months or more before we get his notes and recommendations in the facility. -Yes, this is a concern of ours and we have visited with him about it. There was no system or procedure in place to ensure the psychologist: -Completed an evaluation on a resident with increased behaviors in a more timely manner to promote mental health well-being. -Completed and provided his progress notes and recommendations for the physician and staff to review in a more timely manner. 2. Observation on 9/11/18 at 12:03 p.m. of resident 41 revealed she had: Been sitting in the dining room eating her noon meal. Required staff support and cueing to complete that meal. Made no attempt to respond verbally when spoken to. Review of resident 41's medical record revealed: An admission date of [DATE]. Her [DIAGNOSES REDACTED]. She had: -Required staff assistance to ensure all of her activities of daily living were met. -Been able to move around the facility independently with the use of a w/c. -Required the use of anti-psychotic and anti-depressant medications to help with her mood and behaviors. On 5/3/18 she had been: -hospitalized due to an exacerbation of her behaviors. --Those behaviors been exit seeking, hitting, kicking, screaming, and yelling at other residents and staff. -Considered a safety risk for herself and others. On 5/7/18 she had: -Been readmitted to the facility after the hospital had determined she was no longer a safety risk to herself and others. -Continued to exhibit the behaviors above and required one-on-one monitoring. -Denied admittance to other facilities to assist her with the stabilization of her mental health well-being. The physician had written an order for [REDACTED]. No documentation to support the psychologist had been: -Notified of those orders until 7/24/18. -In the facility to complete an evaluation of the resident. 3. Interview on 9/13/18 at 9:45 a.m. with the director of nursing and administrator regarding residents 12 and 41 revealed: They: -Confirmed the above medical record reviews for those residents. -Had no explanation for the missing order for resident 41. -Had no process in place to ensure the psychologist had received his orders. The DON stated: -When we get consult orders I will give them to the (staff name) (SSD) during stand-up meetings Monday through Friday. -I'm not sure what her process is with the order after that. *They: -Confirmed the psychologist was a consultant for the facility and residents. -Agreed: --The expectations for the timeliness of his consults/evaluations, availability of his recommendations/documentation should have been the same as all of the other providers. --His reports and recommendations should have been in place to ensure the mental health well-being of the residents had occurred in a more timely manner. -Had no policy or procedure in place to ensure those expectations would have occurred.	2020-09-01