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DEPARTMENT OF HEALTH AND HUMAN SERVICES
PRINTED: 10/24/2011
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
______________________
B. WING _____________________________
(X3) DATE SURVEY
COMPLETED
295037 03/04/2011
NAME OF PROVIDER OR SUPPLIER
HENDERSON HEALTHCARE CENTER
STREET ADDRESS, CITY, STATE, ZIP CODE
1180 E. LAKE MEAD DRIVE
HENDERSON, NV 89015
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
ID
PREFIX
TAG
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
F 221 Continued From page 3 F 221
maintained free from physical restraints for 1 of
30 Residents (Resident #11).
Findings include:
Resident #11
Resident #11 was a 52 year old female originally
admitted to the facility on 10/22/10, and last
re-admitted on 2/1/11, with diagnoses including
end stage liver disease with cirrhosis of the liver,
hypertension, hepatic encephalopathy and
chronic pain. The resident was on hospice.
Documentation in the nurse's notes revealed:
- 2/3/11 "Non-self releasing seat belt in use at all
times when on w/c (wheelchair) per order."
- 2/6/11 "Sitting up in w/c with non-self releasing
seatbelt - tab alarm in place."
Resident #11's medical record for the 2/1/11
admission, did not contain a physician's order for
physical restraints or a consent for restraints.
On 3/2/11, the Unit Manager (UM) confirmed
there was no physician order for restraints for
Resident #11. The UM verbalized there was an
order for non-self-releasing restraints for
Resident #11 for her previous admission and the
UM had spoken to the husband to obtain the
consent.
On 3/2/11 The UM called the physician and
obtained an order for self releasing seatbelt for
Resident #11.
On 3/3/11 at 6:30 AM, Resident #11 was
observed in the hallway in a w/c with a non-self
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J8O811
Facility ID: NVS263S If continuation sheet Page 4 of 68