cms_SD: 61

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
61	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2018-05-16	686	G	0	1	4XMM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (44) who required staff assistance with care had not developed a facility acquired pressure injury. Findings include: 1. Observation on 5/15/18 at 8:30 a.m. of resident 44 revealed she: Had been: -In the dining room eating her breakfast. -Sitting in a Broda wheelchair (w/c) with pressure relieving boots on both of her feet. -Wearing a specialty brace that started at her neck and extended down to her waist. -Able to move her arms without difficulty, but no spontaneous movement of her legs was noted. -Complaining of discomfort and requested an unidentified staff member to take her back to her room. Appeared weak, frail, and her hair was unkempt. Observation and interview on 4/15/18 at 8:45 a.m. with resident 44 revealed: She had been: -In her room and sitting in her Broda w/c. -Alert with some confusion to date and time. -Listening to country music on her television and watching the activities going on outside of her window. She: -Had just received some pain medication and was feeling better. -Continued to wear the speciality brace and pressure relieving boots to both of her feet. -Was not able to remember why she had to wear a specialty brace or boots to both of her feet. Her: -Feet had been resting on the footrest of the w/c. -Left foot and leg were slightly turned inward. Interview on 5/15/18 at 9:10 a.m. with licensed practical nurse (LPN) J regarding resident 44 revealed: She had: -Been recently admitted with a compression fracture in her back. -Required the use of a specialty brace for safety and support while the fracture healed. -A wound located on her left heel. -Acquired that pressure injury while she had been receiving care and services in the facility. LPN J stated She has a black area on her left heel. The surveyor had: -Informed LPN J and certified nursing assistant (CNA) B she would like to watch them with personal care throughout the day. -Been informed by the staff the resident would turn on her call light if she needed assistance to go to the bathroom or wanted to lay down in her bed. Random observations on 5/15/18 from 8:30 a.m. through 4:30 p.m. of resident 44 revealed: From 8:30 a.m. to 10:00 a.m. she had been in her room sitting in her Broda w/c as observed above. From 10:10 a.m. through 11:15 a.m. she continued to sit in her Broda chair as observed above but had been taken outside for an activity. At 11:50 a.m.: -She continued to sit in her Broda w/c but had been brought back to her room. -CNAs A and B approached the surveyor to watch personal care on her and another resident. --They provided personal care for the other resident first. At 12:30 p.m. CNAs A and B had prepared to assist the resident with personal care and toileting. -The resident was not in her room and had been taken down to the dining room for dinner. At 12:35 p.m. she had been observed in the dining room eating her dinner. At 1:30 p.m. CNAs A and B assisted the resident with laying down in her bed and personal care. -They positioned her onto her back, left the pressure relieving boots on, and elevated her feet off of the bed with a pillow. --She remained in that position from 1:30 p.m. until 4:30 p.m. At 4:30 p.m. CNAs K and L assisted the resident to get out of the bed and into her Broda w/c. From 8:30 a.m. through 4:30 p.m. she had been assisted with repositioning twice. Interview on 5/15/18 at 12:33 p.m. with CNA A regarding their policy for repositioning residents who required staff assistance stated: We have an every two hour repositioning schedule to follow. We didn't get to her this morning before she went outside and down to the dining room. Observation on 5/15/18 at 1:45 p.m. of resident 44's left heel with CNA B revealed: There was a blackened area on her left heel. The pressure injury was: -Located on the inner aspect of the left heel. -Approximately 2 centimeters (cm) in length and 1.5 cm wide. -Uncovered and opened to the air. Review of resident 44's medical record on 5/16/18 at 12:50 p.m. with the Minimum Data Set (MDS) assessment coordinator revealed: An admission date of [DATE]. Her [DIAGNOSES REDACTED]. She was dependent upon the staff to: -Assist her with all of her mobility needs (transferring from place-to-place and moving in bed) and activities of daily living (ADL). -Implement any preventative interventions to ensure skin breakdown would not have occurred. Her 4/5/18 admission nursing physical assessment identified no skin concerns to her left heel. She had: -A Brief Interview Mental Status (BIMS) score of fourteen indicating she had good memory recall. -Been capable of making her needs known. -Been admitted with no opened wounds or pressure injuries to her left heel. Her Braden Scale score on 4/15/18 had been a sixteen. --That score had indicated she was at mild risk for skin breakdown. On 4/16/18: -A pressure relieving distribution mattress had been applied to her bed. -The staff were to have elevated and off-loaded her heels when in bed. On 4/23/18: -The charge nurse had documented an area of concern to her left heel. -The left heel was pink and boggy. -The size, type, and stage of the pressure injury had not been documented. -There was no documentation to support the family and physician were notified. -That area of concern had been eighteen days after her admitted . On 5/2/18: -The left heel wound measured 2 cm x(by) 3.5 cm, and the skin underneath of the pink area was light purple in color. -The staff had been directed to apply Hydrogaurd to the wound and relieve pressure using heel protectors and pillows. -No documentation to support: --The family or physician had been notified of the wound. --The type and stage of the pressure injury. On 5/4/18: -A weekly skin assessment had been completed by the charge nurse. -The wound had been dark purple in color. -No documentation to support: --The family or physician had been notified of the wound. --The type and stage of the pressure injury. On 5/10/18 and 5/11/18: -The charge nurse had documented the wound was black in color, dry, and had no change in size. -The physician assessed the wound on 5/10/18 and had ordered Hydrogaurd to be applied to the left heel ulcer twice a day. --That order had not identified what type of ulcer the wound was nor the stage. On 5/10/18 was the first documentation to support the physician had been notified of the wound to her left heel. -That was eighteen days after the area of concern to her left heel had been identified. Review of resident 44's 4/25/18 initial care plan summary revealed: The summary had been completed by the MDS assessment coordinator and was reviewed with the resident's daughter on that date. The summary had identified an area of concern to her left heel and it required close monitoring. The staff were to have off-loaded her heels with pillows or use foam heel protectors. -No documentation in the medical record to support those heel protectors were initiated before 5/2/18. The resident was using a pressure redistributing mattress. Review of resident 44's 4/16/18 comprehensive care plan revealed: A focus area: Skin integrity: -That focus area was not developed until 4/25/18 and was two days after an area of concern had been identified to her left heel. The goal for that focus area was: Skin integrity-maintain. Interventions for that focus area: -Were the same as documented above by the charge nurses. -Supported the dates for initiation as documented above by the charge nurses. The dietary department had not updated the care plan to reflect nutritional interventions were put in place to support and promote healing of the wound. Interview on 5/16/18 at 12:50 p.m. with the MDS assessment coordinator at the time of the medical record review for resident 44 revealed she had confirmed: Preventative measures were not implemented in a timely manner to ensure an adverse event for the resident had not occurred. The staff were reactive versus proactive in ensuring preventative measures were in place, so that a pressure injury had not occurred during the resident's care in the facility. The staff should have included the resident's health condition upon admission when utilizing the Braden Score assessment to determine the risk level of skin breakdown. The resident had been at risk for skin breakdown and should have been repositioned every two hours. We have been trying to keep her life as real as we can. I never thought about off-loading while sitting in a Broda w/c. Yes, the Braden Score is a good resource, but we should really be reviewing the resident as a whole. Yes, the residents do have the right to not acquire a wound or have a wound worsen while under our care. I can't say I agree that her wound worsened. I believe a wound has to evolve to see what it really is first and her wound was never open. The charge nurse had been responsible to notify the physician, family, and dietician upon the identification of a wound. The dietary department should have updated their care plan to support their involvement with the wound healing process. Interview on 5/16/18 at 3:40 p.m. with the director of nursing and administrator regarding resident 44 confirmed and supported the interview above with the MDS assessment coordinator. Review of the provider's (MONTH) (YEAR) Pressure Ulcer Prevention and Wound Treatment policy revealed: Purpose: To improve resident safety by identifying individuals at risk for healthcare-acquired pressure ulcers to: -Systematically assess and document skin risk factors. -Implement skin-protection components of care. -Provide appropriate treatment when indicated. Policy: -Interventions were to be implemented based on the Braden Scale Score assessment. -At Risk: Braden Scale Score: 15 to 18 - weekly head-to-toe skin inspection by licensed nurse. -Interventions will be implemented to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition, and hydration, and minimizing pressure. -When a pressure ulcer or wound is discovered, whether upon admission or thereafter, the licensed nurse on duty is responsible for notifying the physician, the resident's family, the Clinical Care Coordinator, Assistant Director of Nursing, and dietician. Assessment and Documentation: -Documentation should include: location, stage, size, undermining/tunneling, wound bed tissue type. *Treatment: A physician order [REDACTED].	2020-09-01