| 43 |
HANDMAKER HOME FOR THE AGING |
35016 |
2221 NORTH ROSEMONT BOULEVARD |
TUCSON |
AZ |
85712 |
2019-01-08 |
641 |
D |
0 |
1 |
ZWO111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#'s 36 and 52). Findings include: -Resident #36 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED].#36 revealed that resident #36 had an onset of pneumonia on (MONTH) 24, (YEAR). Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) revealed documentation of an active [DIAGNOSES REDACTED]. However, review of the clinical record revealed that resident #36 had a history of [REDACTED]. An interview was conducted on 1/8/2019 at 11:23 a.m. with the MDS Coordinator (staff #116). Staff #116 stated the MDS assessments are completed by reviewing each chart, checking the history and physical, reviewing all physician orders [REDACTED]. Staff #116 stated the electronic chart is also reviewed for a 7-day look-back period, which includes all progress notes, current diagnoses, medications and treatments. Staff #116 stated that current [DIAGNOSES REDACTED]. Staff #116 stated if it was a non-active diagnoses, it would not be included on the MDS. An interview was conducted on 1/08/2019 at 1:01 p.m. with the Director of Nursing (staff #160), who stated the expectation for the MDS nursing staff is to ensure that each MDS is accurate and completed within the required timeframe. -Resident #52 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 14, (YEAR), revealed the resident did not receive an antipsychotic medication in the past seven days or since admission. However, the MDS assessment also included the following in the Antipsychotic Medication Review section: since admission the resident had received antipsychotic medications on a routine basis only, and that a Gradual Dose Reduction (GDR) had not been attempted. Review of the physician's orders [REDACTED].#52. Review of the Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 8, 2019 at 11:23 a.m., with the MDS Coordinator (staff #116). She stated the facility follows the instructions in the RAI manual to ensure MDS accuracy. She stated the information in the MDS regarding a resident's medications would come from reviewing the resident's MAR. She stated that since the resident had not received an antipsychotic medication, the Antipsychotic Medication Review section of the MDS assessment should have been coded to reflect that antipsychotics were not received. An interview was conducted on (MONTH) 8, 2019 at 1:01 p.m., with the Director of Nursing (DON/staff #160). She stated her expectation was that each MDS assessment should be accurate. She stated accuracy should be determined by both MDS nurses double checking their work. She stated that if a resident was not taking an antipsychotic, the MDS assessment should record zero days of antipsychotic use, followed by a statement that antipsychotics were not received in the Antipsychotic Medication Review section. She stated that when all three areas of documentation matched, the MDS assessment would be accurate. Review of the RAI manual revealed the following requirements: The MDS assessment must accurately reflect the resident's status; A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. |
2020-09-01 |