cms_SD: 87
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 87 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 610 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to thoroughly investigate twenty-four falls for one of five sampled residents (41). Findings include: 1a. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had twenty-four falls since her admission date of [DATE]. -Two of those falls resulted in major injury. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. Review of resident 41's 12/19/17 fall scene investigation reports revealed: *She had been found on the floor of the bathroom at 9:00 p.m. -She crawled out of bed and got to the bathroom. -She urinated on bathroom floor and had a lg (large) round BM (bowel movement) which she was holding in her left hand. -She moved all extremities and tried to crawl back to her bed during assessment. -What appeared to be the root cause of the fall had been Needing to toilet. --At 4:00 a.m. Res (resident) has been caught 6x's (times) trying to crawl out of bed. She needed and voided in toilet each time. -They had added one hour checks to her care plan. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. b. Review of resident 41's 12/29/17 fall scene investigation reports revealed: *She was found on the floor at 10:30 a.m. in the resident's room by the bathroom door. -She had been alone and unattended. -Resident stated she was trying to get to the bathroom. -Last time she had been toileted was at 8:30 a.m. --She had been dry but Had a BM right away. -The root cause had been Resident has unsteady gait. -Initial interventions to prevent future falls had been Educated staff to cue resident to toilet every 2 hours and PRN (as needed). -Summary of falls team meeting had been Resident attempted to toilet self after breakfast. -There had been no conclusion or additional care plan updates documented. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. c. Review of resident 41's 12/30/17 fall scene investigation reports revealed: *She had been found on the floor in the resident's room in the doorway at 8:50 p.m. -She had been alone and unattended. -Staff were unsure if she had been crawling, but her bed had been in low position. -The last time toileted had been marked unsure. -Conclusion had been Cont with low bed/mat. She continues to crawl out of bed. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. d. Review of resident 41's 1/3/18 fall scene investigation reports revealed: *She had been found sitting on the mat next to her bed at 2:20 a.m. -Last time toileted had been at 12:10 a.m., and she had been dry. -Root cause had been been Cont to crawl out of bed. Toileting. -Initial interventions to prevent future falls had been Cont with low bed/mat. Cont with toileting upon rising, before and after meals, before bed and PRN. -Conclusion had been Cont with frequent toileting, checks and low bed/mat. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. e. Review of resident 41's 1/3/18 fall scene investigation reports revealed: *She had been found on the floor at 6:30 a.m. by the bathroom door. -She had been alone and unattended. -When the resident was asked what she was doing just before the fall she Kept requesting to go to the BR (bathroom). -The last time toileted had not been completed. -Root cause had been Resident got up per self to go to the BR - too unsteady to stand per self. -Conclusion had been change care plan to toilet every two hours. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. f. Review of resident 41's 1/10/18 fall scene investigation reports revealed: *The resident had been found on the floor in her room by the recliner at 1:45 p.m. -She had been alone and unattended. -When asked what she was doing prior to the fall she Just kept say(ing) 'I have to go to the BR.' -She had last been toileted at 12:30 p.m. --She had been wet and had a BM. -She had been at the hospital prior to this fall, so no medications had been given to her. -Root cause had been Resident attempted to get up per self from recliner chair - had to go to the BR. -Initial interventions to prevent future falls had been Initiate hourly checks. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. g. Review of resident 41's 1/14/18 South Dakota Department of Health report revealed: *She had been found on the floor in front of the recliner by three certified nursing assistants (CNA). *Two of the CNAs had used a gait belt to lift her off the floor prior to notifying the nurse. *She had been sent to the emergency room and was found to have a left [MEDICAL CONDITION]. *There had been no fall scene investigation completed. *There had been no documentation regarding the following investigation areas: -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last assisted her. -If there had been any medication changes. h. Review of resident 41's 2/22/18 fall scene investigation reports revealed: *She fell forward out of her wheelchair (w/c) and hit her head on the floor at 11:20 a.m. -She had been alone and unattended. -She had last been toileted at 9:00 a.m. and had been wet. -Root cause had been Resident leaned forward too far in w/c and fell out. -Initial intervention to prevent future falls had been Resident in w/c only for transportation. -Conclusion had been Recliner or bed between meals. Leg extenders added to w/c. LCD (last completion date) was yest (yesterday) for therapy. Will set up restorative plan. -According to the 2/22/18 attached incident note the Resident was incontinent of urine through her pants. -Per investigation staff were educated to not leave the resident alone in her wheelchair. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -What level of assistance she required. -If the care plan had been followed. -Why she had not been assisted to the bathroom since 9:00 a.m. -Who had last assisted her. -If there had been any medication changes. i. Review of resident 41's interdisciplinary notes from 12/19/17 through 2/27/18 revealed: *She had also fallen on the following dates: -1/2/18. -1/3/18 a third time. -1/4/18. -1/5/18 two times. -1/6/17. -1/27/18. -1/28/18. -2/1/18. -2/2/18 two times. -2/5/18. -2/6/18. -2/7/18. *There had been no fall scene investigation reports or other documentation the above falls had been investigated. j. Interview on 3/01/18 at 2:03 p.m. with the director of nursing revealed she agreed the above falls had not been thoroughly investigated. Review of the provider's (MONTH) (YEAR) Abuse Prevention Plan policy revealed: *Facility will investigate all incidences such as falls, bruises, medication errors, resident complaints, etc. *Facility will identify the staff member(s) responsible for: -The initial report. -Initiating the investigation. -Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. -Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; -Providing complete and thorough documentation of the investigation. -Reporting the results to the proper authority within the 5-day state requirement. | 2020-09-01 |