cms_SD: 76
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 76 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 225 | D | 0 | 1 | X0TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and plan review, the provider failed to thoroughly investigate and have adequate documentation to support findings of an unsubstantiated conclusion of allegations of neglect for two of two sampled residents (1 and 5). Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE] with a [DIAGNOSES REDACTED]. *She was alert, and oriented to person, with periods of confusion. -She was able to state her needs. *She was bedridden due to her obesity and the number of staff it would have required to safely transfer her. Further review of resident 1's medical record revealed: *12/11/16 nurses note It was brought to nurses attention that resident had been on bedpan indefinite time period. Resident had the indentation in the shape of a bedpan pressed into her skin and the indentation was 1/16 to 1/8 deep and red in appearance. Resident states is left on bedpan for hours at a time but no one believes her and generally happens at shift change. The nurse asked all staff from med aides to CNA's (certified nursing assistants) on each hall if they had placed or assisted another staff member on helping place the resident on bedpan anytime between the hours of 5:30 am to 10:45 am on 12/11/16. All staff answered no. -It was also brought to the nurses attention at the time the bedpan was discovered the CNA (name) stated the Foley catheter had not been emptied and contained 1550 ml (milliliter) at 1045 raising the question if it had been emptied at the end of the night shift. *12/12/16 fax sent to the physician: (Resident name) was on the bedpan for an extended period of time on 12/11. *Review of resident 1's 11/02/16 care plan revealed: Resident was at risk for skin breakdown. Staff were to assist me to change position at least every two hours. Review of the initial report/investigation sent to the South Dakota Department of Health (SD DOH) on 12/11/16 for the above incident of resident 1 revealed: *The resident was incapable of providing an explanation of the event or capable of participating in an investigation. *On 12/11/16 at roughly 1045 AM (10:45 a.m.) (CNA name) notified charge nurse (registered nurse (RN) name) that resident (name) had been on the bedpan for an extended period of time. All day shift were interviewed and all denied that they had placed (resident's name) on the bedpan. Upon initial investigation, it appears (CNA name) placed (resident name) on the bedpan prior to leaving his shift at 0530 (5:30 a.m.). He states that he notified his co-workers of this over the walkie talkie prior to leaving his shift. However, it appears that there was a breakdown in the communication as the oncoming shift reports not hearing this come through on the walkie talkie upon initial assessment of skin on 12/11 there were no issues with skin integrity. Skin assessment conducted 12/12 revealed a reddened area to buttock, not open. Review of the final report with the conclusive summary statement of the facility's investigation regarding resident 1's above incident revealed: *Upon investigation, all CNAs working the day shift on 12/11 state they did not hear (CNA name) over the walkie talkie, communicating that he had placed (resident name) on the bedpan. The charge nurse working the night of 12/11 states he did hear (CNA name) inform his co workers of (resident's name) being on the bedpan, however none of the day shift responded to him. Our investigation shows that (CNA name) had communicated this information to the oncoming shift; however the oncoming shift was not finished with report and did not yet have their walkie talkies on them. Written education has been provided to (CNA name) on not leaving his shift until the residents he places on the bedpan and/or toilet are finished and removed from toileting. Written education has also been provided to (CNAs names) on our repositioning policy and procedure and educated all nursing staff they are not allowed to leave their shift or leave for break while they have residents they put on the bedpan and/or toilet. *Was abuse/neglect allegation substantiated? No. Continued review of the above incident regarding resident 1 revealed the provider's internal investigation revealed: *Resident Interview: At time resident was found: resident told nurse (RN name) that she is left on the bedpan for hours at a time but no one believes her and generally happens at shift change. *Witness Summary: (CNA name) was working on the 400 hall that day. She started her shift at 0530 (5:30 a.m.). It was not reported to her or did she hear on the walkie talkie that resident was on the bed pan. She provided oral care, washed resident's face and combed her hair that morning at approximately 0730 (7:30 a.m.). Resident had this care provided in her bed. Resident did not communicate that she was on the bedpan. (CNA name) passed her hydration at approx. (approximately) 1000 (10:00 a.m.) and again resident did not communicate she was on the bed pan. When (CNAs names) went to reposition her approx. 1045 (10:45 a.m.) they discovered she had been on the bedpan and notified the nurse. *Summary/Outcome of Investigation Findings included a recap of the above findings, and It was determined that day shift did not follow care plan and reposition at least every 2 hours. Interview on 1/31/17 at 3:00 p.m. with the administrator and the director of nursing regarding resident 1 revealed: *It was expected that any staff that placed a resident on a bedpan or in the bathroom was assisted off the bedpan or out of the bathroom before they left their shift. -That had not happened in the above incident. *They confirmed based on the length of time the resident was left on the bedpan, the CNA had not followed the care plan for repositioning the resident every two hours. -That had not occurred in the above incident. *Because of excess weight the resident could probably not feel the bedpan under her which was why she might not have told staff it was there. *They could not explain how they had concluded neglect had not occurred. 2. Review of resident 5's medical record revealed: *She had been admitted on [DATE] with a [DIAGNOSES REDACTED]. *She was totally dependent on staff for all activities of daily living. Further review of resident 5's medical record revealed: *10/31/16: Resident was back in room after having bath was being transferred with sling and Hoyer lift with assist of 2 to bed when she slipped out of the sling and hit her head. *Fax sent to the resident's physician: Resident was being transferred back to bed from bath chair didn't have sling hooked properly and resident slid out the bottom hitting her head on floor. Review of the provider's final investigation report submitted to the SD DOH 11/2/16 regarding the 10/31/16 incident for resident 5 revealed: *On 10/31/16 at 10:15 AM (resident's name) was back in her room after receiving a bath. She was being transferred with a Hoyer lift, Hoyer lift sling and assist of 2 staff members, (NA's and CNA's names) back into bed when she slipped and fell to the floor. *Conclusive summary statement of facility investigation: After investigating the situation occurred, it was found that (NA name) did not have the bottom of the lift hooked up correctly as the sling being used requires the straps be crossed under the resident's legs before hooking it to the mechanical lift. (CNAs names) stated that (resident's name) slid out of the bottom of the lift and hit her shoulder on the wheelchair pedal and she bumped her head on the floor. *Was abuse/neglect allegation substantiated: No. Continued review of the provider's investigation into resident 5's 10/31/16 fall revealed: (NA and CNA names) were transferring (resident name) from the tub chair to her bed with a sling, Hoyer lift and assist x2 (two staff). (CNA name) was at the top hooking up the lift when (NA name) was on the bottom hooking up the lift. They started to lift her up from her chair to the bed when she slid to the floor. *Witness Summary Page: (CNA name) stated that she had assumed (NA name) had used this type of lift before and that she should have checked to make sure that she was secured in place before starting the lift. -(NA name) states that she has never used this type of sling before. Interview on 1/31/17 at 3:15 p.m. with the administrator and the director of nursing regarding resident 5's fall on 10/31/16 revealed: *The NA had said she had never used that kind of lift before and had only been on the floor a very short time, maybe a week. She was being overseen by the CNA she was working with at the time of the fall. -She was not yet certified as a nurses aide at the time of the incident. *The CNA should have verified the NA had done everything correctly. -She had not done that. *They could not explain how they determined neglect had not occurred since the CNA had not provided appropriate oversight of the new NA hooking up the Hoyer sling. 3. Review of the provider's (MONTH) (YEAR) Abuse Prevention Plan revealed Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. | 2020-09-01 |