cms_SD: 97

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
97	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2018-03-01	909	D	0	1	2S8V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and manufacturer's manual review, revealed the provider failed to assess the safety for one of one sampled resident's (320) mattress to ensure it was secured to the bed frame and free from unsafe movement. Findings include: 1. Observation and interview on 2/27/18 at 8:57 a.m. with resident 320 revealed: He had been: -Located in the transitional care unit (TCU). -Sitting on the edge of his bed. The repositioning bar had been in the down position on the right side of his bed. The left side of his bed had been placed against the wall. The bed frame had: -Been exposed underneath of his right leg. -Long metal brackets attached to each end of it. --Those metal brackets were used to secure the mattress in place. His mattress was not secured in place by those brackets and had shifted sideways on the bed frame. -That movement had created the bed frame to be exposed underneath of his leg by approximately 2 to 3 inches in width. He confirmed: -He was independent in his room and could transfer himself on and off of the bed. -The mattress had shifted and moved around on the bed frame since he was admitted on [DATE]. He stated They did offer me another bed, but I refused it as I didn't want to cause any problems. He denied any injury from the exposed bed frame. Observation on 2/27/18 at 11:50 a.m. of resident 320 revealed: The resident had just returned from working with therapy and was sitting on the edge of the bed. The mattress continued to be: -In the same position as observed above. -Not secured in place by the metal brackets. Observation on 2/27/18 at 3:07 p.m. of resident 320 revealed: He had been lying on his bed resting. The mattress: -Continued to be not secured in place by the metal brackets. -Had shifted further to the left and moved down towards the foot of the bed. --That movement had exposed a larger portion of the bed frame. The head of the mattress had moved down to expose approximately 3 inches of the bed frame. The side of the mattress had shifted further to the left and exposed approximately 4 to 5 inches of the bed frame. Observation and interview on 2/28/18 at 9:45 a.m. with certified nursing assistant (CNA) D regarding resident 320's bed revealed: The resident's bed had been made, and the fitted sheet had been placed over the metal brackets. The mattress had been secured to the bed frame with the fitted sheet over those brackets. CNA D: -Was not aware what the metal brackets were used for. -Had always made the resident's beds that way. -Could not remember being trained on the proper use for the metal brackets. -Confirmed the resident was independent in his room and had been able to transfer himself in/out of the bed. -Agreed the: --Position of the mattress as observed above was a safety concern for the resident. -Resident could have acquired a skin injury from the bed frame or fallen when transferring. Interview on 2/28/18 at 3:26 p.m. with the Minimum Data Set (MDS) assessment coordinator revealed she: Agreed: -The mattresses should have been secured to the bed frames to ensure safety for the residents. -The observation above had created the potential for a skin injury or a fall for the resident. Would not have always assessed the safety of the mattresses. Relied upon the maintenance department to ensure the safety brackets were on the beds and used properly. Was not sure if the maintenance department had put them on a preventative maintenance program for routine checking. Had: -Checked those beds for the resident's who used positioning bars to ensure safe and appropriate use. -Not considered checking those beds and mattresses that did not use the repositioning bars for safety. Interview on 3/1/18 at 7:57 a.m. with the maintenance supervisor revealed: He had not been aware of what the facility was using for bed frames, mattresses, and safety brackets in the TCU. The only time he had checked the beds for proper placement of the mattresses was when he was asked to replace it with an air mattress. He was not sure who should be checking to make sure the safety brackets were in place and had been used properly by the staff. The maintenance department had not placed the safety brackets on a preventative maintenance program to routinely check for proper use and safety. He agreed if they were not used properly any resident would have been at risk for injuries. Interview on 3/1/18 at 8:15 a.m. with registered nurse (RN) F and CNA J who worked on the TCU revealed: They: -Had not been educated on the proper use for the safety brackets attached to the bed frames. -Agreed there was potential for any resident to have obtained an injury if the brackets were not used properly. Interview on 3/1/18 at 10:15 a.m. with the director of nursing (DON) and administrator revealed: The DON was aware the mattresses in the TCU had not been the correct size for those bed frames. The current bed frames and safety brackets had been ordered over a year ago when the TCU first opened. The original mattresses that came with those beds and had concaved edges. The maintenance department had reordered mattresses for those beds, and they came to small. No one had ordered proper fitting mattresses for those beds to ensure safety of the residents. The administrator had not been: -Aware of the above concern. -Sure who should have been responsible for the routine checking for the proper use of the safety brackets and security of the mattresses. Review of the provider's (MONTH) (YEAR) Zenith 5,000 Manufacturer's Instructions for use revealed: The safety brackets, or retainers, could be positioned for an eighty inch or seventy-six inch mattress. The the instructions on how to insert properly into the bed frame. *Important: -Be sure to use a mattress that is properly sized to fit the sleep deck, which will remain centered on the deck relative to State and Federal Guidelines. -Use of an improperly fitted mattress could result in injury or death.	2020-09-01