cms_SD: 98

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
98	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2018-03-01	919	E	0	1	2S8V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, manufacturer's review, and policy review, the provider failed to ensure a consistent process was in place for a multi-use call light system to support the resident's needs had been met in a timely and efficient manner. Findings include: 1. Random observations on 2/27/18 from 8:00 a.m. through 9:50 a.m. in the Transitional Care Unit (TCU) revealed: Most of the residents were out in the dining room eating their breakfast or exercising with the therapists. The residents observed in the dining room wore a long necklace with a square pendant attached to it. -The center of the pendant contained a rubber type material. The residents' rooms all had call lights located by their beds and in the bathrooms. There were no lights above the residents' doors to notify the staff when a resident had turned on their call light. There was a digital board located at the south end of the hall attached to the wall above the exit door. The digital board: -Was approximately 20 feet from the dining room area and the nurses' station. -Made a loud beeping noise whenever a resident would push their call light for assistance. -Would only beep once for each call light. -Had large red digital numbers that would run across the board to indicate which resident's room had their call light on. -The room numbers on the board would keep running until staff answered the resident's call light. Interview on 2/27/18 at 8:53 a.m. with resident 320 revealed: He had been in his room sitting on the bed. His call light had been clipped to the cord and was hanging against the wall behind the bed's headboard. -That call light was not within his reach. He had worn a pendant around his neck as observed on the other residents in the dining room. He stated: -Its what I use for a call light. -I would rather use this than the regular call light. -We can use both, but I prefer to use this one. -I wear it all the time. Interview on 2/27/18 at 1:13 p.m. with CNAs D and [NAME] regarding the call light system revealed: They confirmed most of the residents preferred to use the pendants on their necks versus (vs) the regular call light. The staff wore pagers at all times to alert them of call lights that were on. -Those pagers would have revealed the resident's room number when they had put on their call light. The digital board was another system in place for the staff to use to when checking the residents' call lights. During the day shift: -Only the CNAs wore a pager. -The charge nurse would not have worn a pager to alert her when a resident put on their call light. During the night shift there was only one CNA and the charge nurse. -Both the CNA and charge nurse wore the pagers during that shift. They were not sure why the day shift charge nurse would not have worn a pager. The CNAs pushed resident 321's pendant to demonstrate how they worked in conjunction with the pagers and the digital board. -The pagers made a vibrating noise, and the resident's room number appeared on it. -The digital board made a beeping noise and revealed the resident's room that needed assistance. They had: -Demonstrated how to clear the resident's pendant. -To manually clear their pagers after they cleared the resident's pendant. Interview on 2/27/18 at 1:20 p.m. with licensed practical nurse (LPN) C regarding the call light system revealed: She confirmed the interviews with CNAs D and E. She did not know why the day shift charge nurses were not required to wear a pager. She stated: - Its always been that way. -We don't even have another one down here. All we have are two pagers. She confirmed the digital monitor: -Could not have been heard when she was down the hall or in another resident's room. -Would have only made one sound for each call light. Unless she had heard the digital monitor or randomly checked it she had no way of knowing when a resident had their call light on and for how long. She agreed that was not a safe process for the residents. Observation on 2/27/18 at 1:30 p.m. with CNA D and resident 320 revealed: The CNA had the resident put his call light in his room. The CNAs pager vibrated and his number appeared on her pager. When he had put his call light on the digital monitor made a loud beeping noise, and his room number was shown on the monitor. -His room number had continued to show on the digital monitor until she cleared his call light. The resident's room number continued to show on her pager until she manually cleared it. Interview on 3/1/18 at 9:13 a.m. with registered nurse (RN) F revealed she: Had not been wearing a pager. Confirmed the above interview with LPN C. Interview on 3/1/18 at 10:50 a.m. with the administrator and the DON regarding the call light system in the TCU revealed: The administrator had not been aware: -The charge nurse was not wearing a pager during the day shift. -There were only two pagers for the staff to use in the TCU. -That had always been their process. The DON: -Had been aware there were only two pagers for the staff to use in the TCU. -Stated: --I never wear one myself when I work down there during the day. --I check with the staff and the digital monitor to see if they need help. --I have never had any problems. -Agreed she could not guarantee all the day shift charge nurses would have checked with the staff or digital monitor to ensure there were no call lights that needed answering. They would not comment on whether the day shift charge nurse should wear a pager to ensure: -The safety and well being for the residents. -The personal and care needs for the residents had been met in a timely manner. The DON stated I don't like that call system. Its not very effective. The pager doesn't clear the room number off of it when you answer the call lights. You have to manually remove the number. 2. Random observations on 2/27/18 from 1:00 p.m. through 4:00 p.m. on the 200 wing revealed: There were no lights above the resident's doors to notify the staff when a resident had pushed their call light. There was a digital board located at the end of the hallway above the exit door. The digital board: -Had large red digital numbers that would run across the board to indicate which resident's room had their call light on. -The room numbers on the board would keep running until the staff answered the resident's call light. Interview on 2/27/18 at 1:00 p.m. with registered nurse (RN) I regarding resident 43's use of her call light revealed: She had a [DIAGNOSES REDACTED]. She neededtotal assistance of two staff with a Hoyer lift for transfers. She used a bed pan for her bladder and bowel needs. -She was watched closely when on the bed pan. -She had the potential for skin break down. She had no use of her extremities. She was able to move her head up and down. She used a soft touch pendant for her call light. She would depress the call light with her chin. Staff would attach the call light to the bed sheet or her clothing. -That would prevent the call light from falling or slipping. When her call light was pushed it would be: -Displayed on the digital board located at the end of the hallway. -The room numbers on the board would keep running until the staff answered the resident's call light. -Displayed on the computer screen at the nurses station located at the beginning of the hallway. Interview and observation on 2/27/18 at 1:50 p.m. with certified nursing assistant (CNA) R regarding the call lights on the 200 wing revealed: That two CNAs were assigned to the 200 wing. When a resident had their call light on the room number would be displayed on the: -Digital board located at the end of the wing above the exit sign. -The room numbers on the board would keep running until the staff answered the resident's call light. -Computer screen at the nurses station located at the beginning of the wing. There had been no alarm or beeping system to alert them of a call light being on. She stated Since we do not have an alarm system we look at the digital board and computer screen frequently. Interview on 2/27/18 at 2:05 p.m. with CNA S regarding call lights on the 200 wing revealed: She was covering on the 200 wing for the CNA's break. She was one of the CNAs assigned to the 400 wing. When a resident put their call light on: -It showed up on the screen at the end of the hallway. Staff had walkie-talkies to use if they needed assistance from other staff. Interview and observation on 02/27/18 at 4:00 p.m. with resident 43 regarding the call lights revealed: She had a [DIAGNOSES REDACTED]. 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 was checked on frequently when put on the bed pan. She did not have use of her extremities. She was able to move her head up and down. She used a soft touch pendant for her call light. She would depress the call light with her chin. Staff would attach the call light to the bed sheet or her clothing. -That would prevent the call light from falling or slipping. Interview on 2/28/18 at 2:30 p.m. with CNA T regarding the call lights on the 200 wing revealed: The digital board at the end of the hallway lite 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 200 wing call lights revealed: The digital board at the end of the hallway light up when: -A resident pushed their call light and stays lite up until the resident's call light was turned on or turned off. The resident's room number would be displayed across the computer screen at the nurses station. She stated she checked the computer screen at the nurses station frequently. To her knowledge that was the only way to know if the resident's puts on their call lights. If she needed help then she had a walkie-talkie to radio for assistance. -She stated one CNA stayed on the hallway at all times. To her knowledge that was the only call system available at the facility. 3. Observation and interview on 2/27/18 at 11:20 a.m. with resident 41 revealed: She had been sitting in her recliner in her room with the TV on. Her left leg was stuck in-between the recliner seat and the foot rest. The gap between the two areas had been approximately four inches. She could not put her call light on when asked to, and she just looked at it. The surveyor put her call light on. The resident grimaced when she attempted to move her leg. No one had come to her room. -An unidentified activities staff member was doing an activity in the common area and was asked if there were staff around who could assist the resident. She stated she was not sure and looked around the area. She then pointed out a certified nursing assistant (CNA) on the south end of the common area. The staff member was asked if she got a page for room [ROOM NUMBER]. She stated she was not wearing a pager. They used the banner at the end of the hall to see what call lights were going off. There had been no alarm sounding in the hallway. There was no light outside the door to indicate the call light had been activated. Interview on 2/27/18 at 1:00 p.m. with certified nursing assistant (CNA) L and CNA M in the 200 hall revealed: CNA L had been employed for one year. CNA M had been employed for one week. CNA L did not have a pager on her person for the call light system. CNA M did not have one and was waiting to get one. -She stated call lights were to be answered in seven minutes. -The use of the pager was optional. They used the banner board at the end of the hall. It was hard to read if one was at the opposite end of the hall. The other option was to go behind the nurses station to read it off the computer. A light ding sounded when the call light was pushed but did not stay on. -The ding could not be heard if you were in another resident's room with the door closed. Currently 203B and 206B call lights were going across the board. -They were still on at 1:10 p.m. Resident council meeting on 2/27/18 at 2:25 p.m. with a group of residents and two family members revealed: They had concerns with the call light wait times. Staff would come in the room, turn off the call light, and say they would come back later. -They would not always come back. The wait times got better for a little while but had gotten bad again. Interview on 2/28/18 at 9:31 a.m. with CNA N revealed: She had been employed for one year and had a pager on her person. She was asked to demonstrate how she knows what room was needing assistance. She stated Bear with me as this is new to me. She had only had the pager a few days. They had not had enough pagers for everyone, and they would run out. The other CNA on the 300 hall was currently on break. There were only two CNAs on that hall. When the other CNA went on break they would have to call over the walkie-talkies to get another CNA from a different hall to help them. Interview on 2/28/18 at 2:25 p.m. with the DON revealed: It was not a requirement to carry pagers. The pagers were old and did not work the best. The room number would not clear off the pager unless it was manually reset on each individual pager. -The CNAs would not know if the resident had already been helped so they would have to take the time to go to the room and check. Pagers are not the problem regarding the call light wait times. She did not like the pagers. They had not looked at pagers or staffing as being a problem with the call light wait times. Interview on 2/28/18 at 3:10 p.m. with the human resources director regarding the call light system revealed: She was responsible for running the call light log reports. The residents could choose to use a pendant call light. If the resident was in the living room or open court area and pushed the pendant the staff would probably check the resident's room first. There was no way to know where the resident was if they pushed the pendant. Interview on 3/01/18 at 3:13 p.m. with the DON revealed: She was not sure if they had the correct pagers that went along with the call light system. She had asked a CNA to bring over their pager to look at. That pager the CNA was carrying was an Apollo AL-924L with a digital paging company label. She again stated she did not like the pagers. Review of the Arial Wireless Communication Systems Installation Manual revealed: The Arial system uses wireless transmitting devices to notify staff members of an incident within the facility. If the paging system is being used, staff members carrying the pagers are automatically notified of the call, without having to return to the Arial CMS. The pager model number was . The paging option allows staff members to be notified of a potential emergency anywhere within the coverage area. The pager informs staff of calls for help and when those calls have been cleared. Review of the provider's (MONTH) (YEAR) Answering the Call Light policy revealed: Staff were to answer the resident's call light as soon as possible. *It had not addressed the use of the call light system and pagers.	2020-09-01