| 38 |
LEXINGTON MANOR SENIOR CARE, LLC |
255091 |
56 ROCKPORT ROAD |
LEXINGTON |
MS |
39095 |
2016-08-17 |
278 |
E |
0 |
1 |
BYHQ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to Activities of Daily Living (ADL) for Residents #1, #9, #10, #12; Hospice Services for Resident #13, for five (5) of 13 MDS assessments reviewed. Findings include: Review of the facility's Minimum Data Set (MDS) 3.0 Assessment Completion, Transmission and Validation policy, dated 07/14, revealed the facility uses an interdisciplinary approach to complete a comprehensive assessment of each resident's functional capacity. Members of the Interdisciplinary Team (IDT) will complete their assigned MDS sections and corresponding Care Area Assessments (CAA) within the specifications and timelines established by the Resident Assessment Instrument (RAI) Manual. Each IDT member is expected to use the RAI Manual as a resource during the assessment coding process. A review of the Centers for Medicare and Medicaid (CMS) RAI 3.0 Manual, dated 10/15, revealed under the section 1.3 Completion of the RAI, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Sources must include the resident, direct care staff on all shifts, the resident's medical record, physician and family. Information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy by the IDT completing the assessment. A review of the RAI 3.0 Manual under Section G0110 Activities of Daily Living (ADL) Assistance, revealed to code total dependence, the resident must be unwilling or unable to perform any part of the activity over the entire 7 day look-back period. Resident #1 A review for Resident #1 revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/16/16. Section G 120 revealed Resident #1 was totally dependent with bathing and required two (2) or more persons for physical assistance. Review of the five (5) day admission MDS assessment with an ARD of 02/24/16 revealed Section G 120 was also coded totally dependent of two persons with bathing. Review of the ADL charting during the seven (7) day look-back period (05/10/16 - 05/16/16) for the quarterly 5/16/16 MDS assessment, revealed Resident #1 required only physical help in part of bathing with assist of one person on 05/13/16. A review of the ADL charting during the 7 day look-back period (02/19/16-02/24/16) for the 2/24/16 MDS, revealed Resident #1 required physical help in part of bathing with one person on 02/20/16. Interview on 08/17/16 at 2:00 PM, with Certified Nursing Assistants (CNA) #6 and #7 revealed that Resident #1 does not assist staff when he gets his bath. CNA #6 stated He is dependent on 2 staff for bathing. Interview on 08/17/16 at 6:00 PM, with egistered Nurse (RN) #1, revealed that she completed the quarterly MDS assessment for Resident #1 and had coded total dependence for bathing with two (2) persons assist. RN #1 confirmed that the RAI Manual is used as a reference guide when completing the MDS assessment. RN #1 further revealed that total dependence cannot be coded unless the resident has required total assist from staff every shift during the 7 day look-back period of the MDS assessment completed. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/17/16, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment with an ARD of 05/16/16, revealed Resident #1 scored 8 on the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognitive skills. Resident #9 Record review for Resident #9 revealed a quarterly MDS assessment with an ARD of 07/05/16. Section G 120 revealed Resident #9 coded as being totally dependent with bathing and required two (2) or more persons for physical assistance. A review of the ADL charting during the seven (7) day look-back period (06/29/16 - 07/15/16) for the quarterly 7/5/16 MDS assessment revealed Resident #9 required physical help limited to transfer only with assist of one (1) person for bathing on 06/30/16; physical help in part of bathing with one (1) staff assist on 07/02/16 and 07/04/16. Interview on 08/16/16 at 8:35 AM, with Resident #9 revealed she is able to wash herself but the CNA washes her back because I can't reach back there. Interview on 08/16/16 at 3:15 PM, with CNA #1 revealed Resident #9 required limited assistance of one (1) person for bathing. CNA #1 further revealed that Resident #9 receives her bath on the night shift. Interview on 08/17/16 at 4:45 PM, with RN #2 confirmed Resident #9 was not dependent for bathing. RN #2 revealed Resident #9 can do a lot for herself. RN #2 stated staff sets up for bathing, stays with her while she bathes, and probably assists with washing areas that she can't reach. Interview on 08/17/16 at 6:05 PM, with RN #1, revealed that Resident #9 was not dependent with bathing and required two (2) staff for assistance. RN #1 confirmed that she completed the MDS assessment for Resident #9. RN #1 further revealed that she codes the MDS assessment for ADL care based on the information that the CNAs chart in the computer. A review of the Face Sheet revealed the facility readmitted Resident #9 on 07/11/13, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment with an ARD of 07/05/15, revealed Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment. Resident #10 A review of the annual MDS assessment with an ARD of 07/11/16, for Resident #10, revealed Section G 120 was coded as total dependent of two (2) of more staff for bathing. A review of the ADL charting during the seven (7) day look-back period (07/05/16 - 07/11/16) for the annual MDS assessment revealed Resident #10 required supervision and setup help only with bathing on 07/11/16. Interview on 08/17/16 at 4:40 PM, with RN #2, revealed Resident #10 was not totally dependent with bathing. Interview on 08/17/16 at 6:08 PM, RN #1 confirmed by stating No regarding whether Resident #10 was totally dependent upon two staff for bathing. RN #1 stated the MDS was coded wrong for bathing. Review of the Face Sheet revealed the facility admitted Resident #10 on 03/17/08 with [DIAGNOSES REDACTED]. A review of the annual MDS assessment with an ARD of 07/11/16, revealed Resident #10 scored 15 on the BIMS, which indicated Resident #10 was cognitively intact. Resident #12: Review of Resident #12's MDS with an ARD of 5/31/16, Section G 120, coded the resident with total dependence with the assistance of two (2) or more persons for bathing. The MDS with an ARD of 3/4/16, coded Resident #12 for total assistance with two (2) or more persons required for bathing. Record review of the Certified Nursing Assistants (CNA) computer documentation during the seven (7) day look-back period for the 3/4/16 MDS, from 2/26/16 through 3/4/16, revealed only three (3) of the seven (7) days reflected total assistance required for Resident #12's bathing. Computer documentation for the Quarterly 5/31/16 MDS, dates of 5/25/16 through 5/31/16, revealed only four (4) days where Resident #12 required two (2) person physical assist with bathing. An observation and interview of Resident #12 on 8/17/16 at 11:30 AM, revealed Resident #12 lying in her bed. She stated she was not feeling well today. She said she is normally up, washes her face before every meal, ambulates about the facility using her walker and usually bathes at the sink herself. An interview on 8/17/16 at 12:00 PM, with Registered Nurse (RN) #2, who serves as Monday through Friday, day charge nurse, revealed Resident #12 likes to stand at the sink and wash her face, brush her teeth and bathe. RN #2 said Resident #12 is not totally dependent upon staff for ADLs most days. In an interview on 8/17/16 at 6:00 PM, RN #1 revealed Resident #12 is not totally dependent for ADLs, and could help with some assistance from staff. She said she had miscoded the MDS for bathing on the Annual MDS assessment dated [DATE] and again on the Quarterly assessment dated [DATE]. The facility admitted Resident #12 on 7/3/12. Resident #12's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 5/31/16, revealed Resident #12 had a BIMS score of 15, indicating the resident was cognitively intact. Resident #13: Record review revealed Resident #13's physician orders [REDACTED].>Review of the MDS assessments with ARDs of 9/30/15 and 12/21/15 did not reflect Hospice Care Services. An observation of Resident #13, with CNA #6 on 8/17/16 at 12:00 PM, revealed the resident sleeping soundly on and air mattress with the head of the bed slightly elevated and several positioning devices noted under her coverings. CNA #6 stated Resident #13 received Hospice services daily Monday through Friday. An interview with RN #1, the MDS Coordinator, revealed her acknowledgment of a coding error on both the 9/30/15 and 12/21/15 MDS submissions. She stated she failed to code Hospice services on both MDS assessments. Review of the facility's face sheet revealed, the facility admitted Resident #13 on 4/4/06. Resident #13's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 5/31/16, revealed Resident #13 had a BIMS score of 3, indicating the resident had severely impaired cognition. |
2020-09-01 |