cms_SD: 60
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
60 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2018-05-16 | 610 | D | 0 | 1 | 4XMM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on observation, interview, and record review, the provider failed to complete and fully investigate a staff-to-resident incident for one of one sampled resident (33) who had complaints of severe pain after a facility acquired injury had occurred. Findings include: 1. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her needs known. *There was no documentation to support: -An incident report was completed after the injury had been reported by CNA I on 5/12/18. -A formal investigation was completed to rule out abuse and ensure no major injury had occurred to the resident's left leg. -Systems, protocols, and education were provided and implemented to ensure this type of incident and injury would not have occurred again. *The physician had not been notified of: -The incident and injury that had occurred to the resident's left leg. -The resident's complaints of increased pain and discomfort -The ineffectiveness of the pain medications the staff had give her for those complaints of discomfort. Refer to F697, finding 1. | 2020-09-01 |