cms_HI: 78
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
78 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 657 | D | 0 | 1 | 6SFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to meet professional standards of care that would dictate the care plan be revised/updated to reflect changes in condition and approaches for meeting the needs of two Resident's (R), R44, and R127. Care planning drives the type of care a resident receives. Because of this deficient practice, interventions to promote continuity of care and communication amongst nursing staff to safeguard against adverse events were not identified and documented in a timely manner. Findings Include: RR of R127's medical records revealed that R127 had a reoccurring [MEDICAL CONDITION] of the left thigh. R127's care plan identified the problem at risk for skin breakdown i.e. ulcers, rashes, skin tears, with the goal of extrinsic risk factors for skin breakdown will be reduced or eliminated. 11/15/2018 Physician (MD)1 addendum note for R127, includes: recurrent left upper thigh [MEDICAL CONDITION]/rash of left medial and lateral thigh. The warmth of the room and keeping pt. covered contributes to this .ask if pt (sic) can be kept a little cooler. RR of R127 revealed no evidence of documentation that the care plan had been revised to identify interventions to address the contributing factors to the [MEDICAL CONDITION] (warmth of the room, and keeping the resident covered) identified by MD1. During an interview with RN126 on 11/28/2018 at 02:25 PM who stated, I hadn't seen that entry. Inquired if MD1 had communicated the concern to anyone, and RN126 replied, No, but it should have been in the care plan. RR of R44 revealed a new [DIAGNOSES REDACTED]. There was no evidence of documentation that the care plan for R44 was updated to include appropriate interventions and monitoring to minimize complications related to the Pneumonitis (i.e. shortness of breath, fever, drop in oxygen level). During an interview and RR on 11/29/18 with RN126 who agreed the care plan had not been updated to include the new [DIAGNOSES REDACTED]. It was an oversight. If care planning is not complete or is inadequate, the consequences may negatively impact the resident's quality of life, as well as the quality of care and services received. | 2020-09-01 |