cms_SD: 86

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.

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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
86	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2018-03-01	600	D	0	1	2S8V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and policy review, the provider failed to ensure one of one sampled resident (43) who was dependent upon the staff for all activities of daily living (ADL) was not left on a toileting device for an extended period of time resulting in bruising to the skin. Findings include: 1. Record review for resident 43 revealed: She was admitted on [DATE]. Her Brief Interview for Mental Status score was eleven indicating she had moderate impairment. Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. She was dependent upon the staff for all her ADL. Record review of a 2/18/18 incident regarding resident 43. revealed: CNAs W and V had assisted her onto a bedpan on 2/18/18 at 5:08 p.m. CNA W did not check back on her. She was left on the bedpan for over an hour. -Call Light report showed her call light had been on for twenty one minutes prior to being answered at 6:48 p.m. CNA R had answered her call light and discovered she was on the bedpan. -Resident stated her hip hurt. -Cleaned her up and went to get the nurse. RN K assessed her and found a 1.5 inch by 6 inch bruise in the shape of the bedpan on her left hip/buttock area. Resident had been interviewed by RN K and the administrator by phone. -She had not remembered being on the bedpan. -She had not used the call light for assistance off the bedpan. -She had put her call light on when she noticed her hip hurt. Both CNAs were suspended pending the investigation. -CNA V had returned to work the next day, 2/19/18. -CNA V was educated on the new bedpan use. -CNA W resigned without notice. Findings were substantiated. QAPI with immediate education began 2/18/18. Interview on 2/27/18 at 1:00 p.m. with registered nurse (RN) I regarding resident 43 care revealed: She needed total assistance of two staff with a Hoyer lift for transfers. She used a bed pan for her bladder and bowel needs. -She did not have use of her extremities. -She had the potential for skin break down. She had the potential for skin break down. She was able to move her head up and down. She used a soft touch pendant for her call light. Interview and observation on 02/27/18 at 4:00 p.m. with resident 43 regarding the call lights and the 2/18/18 incident revealed she: Acknowledged the 2/18/18 incident had occurred. -Had been placed on the bedpan. -Had not been taken off the bedpan for over an hour. -That had made her upset and uncomfortable. -Put on her call light when her hip started to hurt. -Stated CNA R had come to help her off the bedpan. Needed total assistance of two staff with a Hoyer lift for transfers. Used a bedpan for her bladder and bowel needs. Was now checked on frequently when put on the bedpan. Had no use of her extremities. Was able to move her head up and down. Used a soft touch pendant for her call light. She would depress the call light with her chin. Staff attached the call light to the bed sheet or her clothing. -That prevented the call light from falling or slipping. She stated Since the bedpan incident they check on me frequently. -She stated her call light was answered quickly since the 2/18/18 incident. Interview on 2/28/18 at 2:30 p.m. with CNA T regarding resident 43's care and the call light revealed: She stated Since the incident where the resident was left on the bed pan and forgotten: -She was watched closely throughout the day. Used a bedpan for her bladder and bowel needs. She was checked every five minutes while on the bedpan. The staff had been educated to get a nurse: -If she requested to be on the bedpan longer than twenty minutes. -Nurse would educate her on the potential for skin breakdown. The digital board at the end of the hallway would light up when a call light was pressed. -It would display the resident's room number. The resident's room number would be displayed on the computer screen at the nurses station. To her knowledge that was the only way to know if the resident had put on their call light. There was no alarm system alerting them of a call light being on. Staff had walkie-talkies to use if they needed assistance from other staff. Interview on 2/28/18 at 2:40 p.m. with CNA R regarding the care of resident 43 revealed she: Had a [DIAGNOSES REDACTED]. Needed total assistance of two staff with a Hoyer lift for transfers. Was checked on every two hours. Was a vulnerable resident. She had no use of her extremities. Used a bedpan for her bladder and bowel needs. Staff had been educated to check residents every five minutes when on the bed pan. Acknowledged an incident where the resident had been placed on the bedpan and forgotten. -She was not sure how long the resident had been on the bedpan An incident report had been filled out. Interview on 2/28/18 at 3:55 with the director of social services regarding resident 43 revealed: She was a vulnerable resident. Facility had a new bedpan usage policy in place. Staff had been educated on the new bedpan usage policy. Interview on 2/28/18 at 10:00 with the director of nursing regarding the 2/18/18 incident with resident 43 revealed: She acknowledged the incident had taken place. It was reported to the local law enforcement. It was reported to the state. She provided copies of the: -Incident report filed with the state. -Internal investigation form. They had procedures in place to prevent that from happening in the future such as: -Quality assurance performance improvement (QAPI) plan for bedpan usage. -Check resident every five minutes while on the bedpan. -After twenty minutes get the nurse. -Nurse to educate resident on the risk. -Reposition resident and check every five minutes. -Staff were educated on the new procedures. Her care plan had been updated after the incident to reflect her current bladder and bowel needs. Record review of the 2/18/18 QAPI meeting minutes interventions revealed: Immediate education was given to all staff to check on all residents who are put on a bed pan every 5 mins (minutes) to see if they are ready to be taken off the bed pan. If they are not taken off after 20 mins (minutes), the nurse needs to explain the risks to the resident and if they still request to stay on the bed pan, the resident should be repositioned on the bed pan and checked again every 5 mins (minutes), and nurse assessment every 20 minutes. Audits x (times) 4 weeks and reviewed for continuation at QAPI. Record review of the 2/18/18 incident regarding resident 43. revealed: CNAs W and V had assisted her onto a bedpan on 2/18/18 at 5:08 p.m. CNA W did not check back on her. She was left on the bedpan for over an hour. -Call Light report showed her call light had been on for twenty one minutes prior to being answered at 6:48 p.m. CNA R had answered her call light and discovered she was on the bedpan. -Resident stated hip hurt. -Cleaned her up and went to get the nurse. RN K assessed her and found a 1.5 inch by 6 inch bruise in the shape of the bedpan on her left hip/buttock area. Resident had been interviewed by RN K and the administrator by phone. -She had not remembered being on the bedpan. -She had not used the call light for assistance off the bedpan. -She had put her call light on when she noticed her hip hurt. -Call Light report showed her call light had been on for twenty one minutes prior to being answered at 6:48 p.m. Both CNAs were suspended pending the investigation. -CNA V had returned to work the next day, 2/19/18. -CNA V was educated on the new bedpan use. -CNA W resigned without notice. Findings were substantiated. QAPI with immediate education began 2/18/18. Review of the following device activity report (call light report) for resident 43 revealed: On 2/16/18 at 8:39 p.m. call light was on for sixty-four minutes and fifty-five seconds before being turned off. On 2/18/18 at 10:35 a.m. call light was on for thirty-two minutes and fifty-seven seconds before being turned off. On 2/18/18 at 6:48 p.m. call light was on for twenty-one minutes and twenty-six seconds before being turned off. Review of the revised 2/21/18 care plan for resident 43 revealed: Her current bladder and bowel needs had been updated on 2/19/18. -I have a history of pushing my call light after I am done using the bed pan, but am not frequently doing so anymore and would like staff to check frequently on me while I am on the bed pan. The new bedpan usage policy for checking resident every five minutes while on the bedpan, was not on her care plan. Review of the revised (MONTH) 2014 Bedpan Urinal, Offering or Removal policy and procedure revealed: Do not allow the resident to sit on a bedpan for extended periods. (Note: This is not only uncomfortable to the resident, it also causes skin breakdown.) Review of the revised (MONTH) (YEAR) Abuse Prevention plan-South Dakota revealed: In accordance with the Vulnerable Adult Law of the State and the Centers for Medicare and Medicaid, (CMS), it is our policy that all residents residing in the facility will be protected from abuse, neglect, and that interventions are implemented to provide the vulnerable adult with a safe living environment. All residents have the right to be free of abuse and neglect. A vulnerable adult means any resident receiving services from this facility who may be unable to report maltreatment without assistance due to physical or mental impairment. 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. (CMS Definition) 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