cms_AZ: 34
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 34 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 641 | D | 0 | 1 | 6GPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for two resident's (#66 and #68) accurately reflected their status. Findings include: -Resident #66 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 1, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. However, a physician's progress note dated (MONTH) 11, (YEAR) included the resident remains in chronic vegetative state, non-communicative. A resident interview was attempted on (MONTH) 28, (YEAR) at 1:00 p.m. The resident appeared to be in a vegetative state and was unable to answer questions. A family member was at the bedside and confirmed that the resident was unable to understand questions or communicate in any manner. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m., with two MDS nurses (staff #116 and staff #117). They stated that they did not know why the MDS was coded in this manner, as it was a mistake and that the nurse who did the coding was no longer employed there. -Resident #68 was readmitted to the facility on (MONTH) 7, (YEAR) and discharged on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. The orders also included for [MEDICATION NAME] (antianxiety medication) 1 milligram by mouth two times a day as needed for anxiety. Review of the Medication Assessment Record (MAR) for (MONTH) (YEAR) revealed the resident received Ertapenem Sodium Solution from (MONTH) 8 through 18. Further review revealed that the resident received [MEDICATION NAME] on (MONTH) 11, 12, 13 and 14. However, review of the MDS assessment dated (MONTH) 14, (YEAR), revealed documentation in Section N, that antibiotics had not been administered to the resident. The MDS also included documentation that the resident had only received three days of antianxiety medication. An interview was conducted with the MDS coordinator (Licensed Practical Nurse/LPN/staff #116) on (MONTH) 1, (YEAR) at 9:31 a.m. She stated that in coding Section N of the MDS, she pulls up the MAR and counts the days the resident received the medications during the 7 day look back period. At this time, the MDS was reviewed for antibiotic and antianxiety medication use. She stated that the MDS was inaccurate as the MAR showed that the resident received an antibiotic and had received the antianxiety medication on 4 days. Staff #116 stated the expectation is that the MDS is accurate regarding the care the resident is receiving during the look back period of the MDS. During an interview conducted on (MONTH) 1, (YEAR) at 9:43 a.m. with the Director of Nursing (DON/staff #66), she stated the expectation is that the MDS would accurately reflect the residents status and care. Staff #66 stated that the MDS nurse is to follow the RAI manual in completing the assessment. She further stated that the facility has no policy regarding the accuracy of the MDS, as the facility uses the RAI manual. Review of the RAI manual for the MDS revealed the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The MDS assessment is the basis for the development of an individualized care plan. | 2020-09-01 |