ELM HAVEN WEST NURSING HOME
LOCATED: 1315 S 15th STREET, PARSONS, KS 67357
ELM HAVEN WEST NURSING HOME was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT
LEVEL OF HARM – IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
The facility identified a census of 31 residents, with 4 residents sampled for accidents. Based on observation, interview and record review, the facility failed to thoroughly assess the neurological condition of 2 of the 4 sampled residents. Resident #1, an alert and oriented resident, did not receive neurologic assessments after an un-witnessed fall with self-reported hit to head which resulted in a subdural intracranial hematoma (an accumulation of blood in the subdural space). This deficient practice placed resident #1 in immediate jeopardy, and the resident expired at the hospital. The nurse’s note, dated [DATE] at 8:20 AM, documented the resident transferred to the hospital via facility staff. Review of the nurse’s notes from the time of the fall, on [DATE] at 3:30 PM, to the time of transfer to the hospital, on [DATE] at 8:20 AM, revealed the record lacked any documentation of any thorough neurological assessments.
Continued: Staff H reported the first time in the resident’s room he/she was talking normal, but by the 3rd time he/she wasn’t making any sense and had glassy eyes. Staff H had no idea the resident fell the day before, and was not told to check vital signs more frequently or do any increased visual checks on the resident. Staff H reported while dressing the resident, he/she noticed a fresh bruise on the resident’s back, about 3 inches in size with numerous tiny, pinpoint size purple dots inside the bruise. On [DATE] at 1:53 PM, Administrative Nursing Staff C reported the resident fell on [DATE] around 3:30 PM. The resident took off the personal body alarm and took him/herself to the bathroom, where he/she suffered an un-witnessed fall and struck his/her head, per the resident’s report. Staff C confirmed all post fall assessments should include initiation of neurologic assessments for any un-witnessed fall or if the resident hit their head. Staff confirmed this resident’s record lacked any complete neurologic assessments after the fall, and reported the nurse that worked at the time of the fall should have initiated them. The neurologic assessment should have been done initially to include any change in level of consciousness, resident’s orientation, pain, range of motion, grips of hands and status of pupils (PERRLA). Staff C confirmed that he/she worked the shift after the resident’s fall, beginning at 6:00 PM, approximately 2 hours after the resident’s fall, was aware of the fall and that the resident hit his/her head, and that Staff C also did not initiate neurologic checks on this resident. On [DATE] at 5:15 PM, Administrative Staff confirmed that neurologic assessments should have been initiated by the nurse at the time of the fall and were not done. Staff A confirmed that the next nurse that worked, should have realized that the neurologic assessments were not being done and started them, but did not. Staff A reported that the facility had just received word from the resident’s family that the resident died in the hospital earlier today.
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.
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You can make a difference even if your loved one has already passed away.