Inspection Reports for NHC HealthCare Murfreesboro
420 North University Street, Murfreesboro, TN, 37130
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 2, 2024
Visit Reason
The inspection was conducted due to complaints regarding the use of physical restraints, inadequate discharge planning, and failure to prevent accidents for residents at Nhc Healthcare, Murfreesboro.
Complaint Details
The complaint investigation focused on allegations of physical restraints being used improperly on Resident #3, inadequate discharge planning and unsafe transfer for Resident #4, and failure to prevent multiple falls and injuries for Resident #3. The investigation included interviews with family members, staff, and review of medical records and incident reports.
Findings
The facility failed to ensure residents were free from physical restraints, failed to complete adequate discharge summaries and care plans for discharge, and failed to provide adequate supervision to prevent accidents, resulting in multiple falls and injuries for Resident #3 and inadequate discharge planning for Resident #4.
Deficiencies (4)
Failed to provide an environment free from physical restraints for Resident #3.
Failed to ensure a discharge summary was completed with needed information for Resident #4 to ensure a safe discharge.
Failed to develop and implement a comprehensive, person-centered care plan that addressed discharge plans for Resident #4.
Failed to provide adequate supervision to prevent accidents for Resident #3, resulting in multiple falls with injuries including a major injury requiring hospital transfer.
Report Facts
Documented falls: 39
Falls in November 2022: 3
Falls in February 2023: 5
Falls in March 2023: 2
Falls in April 2023: 3
Falls in May 2023: 4
Falls in June 2023: 5
Falls in July 2023: 3
Falls in August 2023: 2
Falls in September 2023: 3
Falls in October 2023: 4
BIMS score: 6
BIMS score: 4
BIMS score: 5
BIMS score: 4
Discharge date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant K | CNA | Interviewed regarding Resident #3's fall risk and use of mechanical lift. |
| Licensed Practical Nurse L | LPN | Confirmed staff use of care plans and need for 2 persons for mechanical lifts. |
| Certified Nursing Assistant M | CNA | Reported Resident #3 was restless and tried to get up without help. |
| Certified Nursing Assistant N | CNA | Reported finding Resident #3 on floor after bed alarm sounded. |
| Social Service Director | SSD | Discussed concerns about Resident #3's fall with injury. |
| Medical Director | MD | Discussed Resident #3's medical conditions and fall risks. |
| Social Worker H | Social Worker | Discussed discharge planning and referral for Resident #4. |
| Administrator | Administrator | Interviewed about restraint use, discharge planning, and fall prevention. |
| Physical Therapist | PT | Recommended mechanical lift with 2 persons for Resident #3. |
| Nurse Practitioner | NP | Provided psychiatric progress notes for Residents #3 and #4. |
Inspection Report
Deficiencies: 3
Date: Feb 20, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, abuse prevention, and care plan development following observed deficiencies and incidents.
Findings
The facility was found deficient in honoring resident dignity related to catheter privacy for 1 resident, preventing abuse in a resident-to-resident altercation involving 2 residents, and revising a care plan for 1 resident with behavioral issues. All deficiencies were assessed as minimal harm with few residents affected.
Deficiencies (3)
Failed to treat 1 of 20 residents with dignity by not covering the resident's indwelling urinary catheter drainage bag with a privacy cover.
Failed to prevent abuse for 2 residents involved in a resident to resident altercation resulting in a skin tear and pain requiring an X-ray.
Failed to revise the care plan for 1 of 52 residents to reflect behaviors prior to a resident to resident incident.
Report Facts
Residents reviewed for catheter dignity: 20
Residents involved in abuse incident: 2
Residents reviewed for behavior care plan: 52
BIMS score: 99
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Confirmed Resident #25's catheter bag was not placed in a privacy cover | |
| Director of Nursing | Stated expectations for catheter bag privacy covers and confirmed physical altercation between residents | |
| Certified Nurse Aid (CNA) #3 | Reported hearing Resident #60 yell for help and described the altercation | |
| Social Worker #2 | Confirmed behavioral care plan for Resident #47 was not updated prior to incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 27, 2019
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a nursing home survey completed on 2019-02-27.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 50
Deficiencies: 9
Date: Feb 28, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident safety, grievance handling, accurate resident assessments, care planning, fall prevention, dietary services, and equipment maintenance.
Findings
The facility was found deficient in maintaining a safe and orderly environment in a resident's room due to clutter, failure to address grievances properly, inaccurate hospice assessments, failure to follow care plan interventions resulting in resident harm, failure to update care plans after falls, inadequate fall prevention supervision leading to resident injuries, failure to serve correct food portions, failure to dispose of expired food, and failure to maintain dietary equipment and hood lights in sanitary and operational condition.
Deficiencies (9)
Failed to maintain a safe and orderly environment in 1 resident room due to clutter and narrow access.
Failed to address reported grievances and document investigation findings properly.
Failed to ensure accurate hospice status on Minimum Data Set assessments for 5 hospice residents.
Failed to follow care plan interventions for Resident #81, resulting in a fall and sacral fracture.
Failed to revise care plan for Resident #285 after a fall.
Failed to prevent falls for Residents #81 and #285, resulting in actual harm including head injury and sacral fracture.
Failed to serve food portions as specified on the therapeutic diet spreadsheet for 16 residents.
Failed to dispose of expired food and maintain dietary equipment in a sanitary manner.
Failed to maintain hood lights in operating condition in the dietary department.
Report Facts
Residents affected by clutter deficiency: 1
Hospice residents reviewed: 11
Residents with inaccurate hospice assessment: 5
Residents reviewed for falls: 23
Residents with fall prevention failure: 2
Residents receiving meal trays: 141
Residents with incorrect food portions served: 16
Expired food item date: Feb 17, 2018
Hood lights not operating: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding safety concerns about clutter in resident's room |
| CNA #5 | Certified Nurse Assistant | Interviewed about difficulty caring for resident due to clutter |
| RN #4 | Unit Manager | Interviewed about inability to maintain safe environment due to family refusal |
| Environmental Services Technician #1 | Interviewed about family refusal to allow cleaning of resident's room | |
| Administrator | Confirmed resident's room was not kept in a sanitary, orderly, and safe manner | |
| Social Services Director | Interviewed about lack of grievance documentation | |
| Administrator-in-Training | Confirmed failure to provide grievance summaries and corrective actions | |
| Regional Social Worker | Unable to provide information on grievance tracking | |
| RN #5 | Registered Nurse / MDS Coordinator | Confirmed failure to accurately assess hospice status on MDS |
| LPN #3 | Licensed Practical Nurse | Confirmed resident receiving hospice services |
| CNA #6 | Certified Nurse Aide | Interviewed about transferring Resident #81 alone resulting in fall |
| Director of Nursing | Confirmed failure to follow care plan interventions and transfer assistance | |
| RD #1 | Registered Dietitian | Confirmed failure to serve correct food portions and maintain dietary equipment |
| Certified Dietary Manager | Confirmed expired food and unsanitary dietary equipment | |
| CNA #7 | Confirmed resident found with head laceration after fall |
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