| 39 |
LEXINGTON MANOR SENIOR CARE, LLC |
255091 |
56 ROCKPORT ROAD |
LEXINGTON |
MS |
39095 |
2016-08-17 |
280 |
E |
0 |
1 |
BYHQ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to revise the comprehensive care plan to reflect the conditions of the resident related to Foley Catheter Care and Oxygen use for Resident #4, and bathing for Residents #2, #9 and #10, for four (4) of the 13 resident records reviewed. Findings include: A review of the facility's Care Plans-Comprehensive policy, dated (MONTH) (YEAR), revealed the facility develops a plan of care through the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Outcome objectives are reflective and the facility staff uses the objectives to monitor the resident's progress. The purpose includes the development and modification based on the resident's status. Review of the facility's Comprehensive Care Plans policy, dated 07/14, revealed the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to a meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the residents ability's to meet his/her objectives. The facility also provided a document signed by the Administrator stating, It is our facility's policy to use the guidance from the CMS RAI manual for care planning. The RAI Manual, dated (MONTH) 2012, provided by the facility, revealed under section 4.4: Facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs. Resident #4 Record review of Resident #4's physician's orders [REDACTED]. An order, dated 7/28/16, noted to irrigate Foley catheter with 30 to 60 milliliters (ml) of sterile water as needed for leakage or obstruction. Review of Resident #4's incontinent care plan with an onset date of 7/05/16, revealed, the elder (resident) is continent of bowel, and had a Foley catheter. A care plan for the Stage 4 sacral wound dated 7/5/16, documented Resident #4's Foley catheter. There was no care plan intervention for providing catheter care daily and as needed or for the irrigation of the Foley for either care plan. Record review of Resident #4's physician's orders [REDACTED]. Review of Resident #4's care plan for shortness of breath, dated 7/5/16, did not reveal an intervention/approach for the resident to have two (2) liters of oxygen by nasal cannula as needed. Interview with Registered Nurse/Minimum Data Set Nurse (RN/MDS) #1 on 8/16/16 at 3:58 PM, confirmed she should have revised the care plans to reflect the physician's orders [REDACTED].#4's condition. She said she is responsible for initiating and updating the residents care plans. Review of the facility's face sheet revealed the facility readmitted Resident #4 on 7/05/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 7/12/16, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 8, indicating Resident #4 had moderate cognitive impairment. Resident #2 Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/11/16 for Resident #2, Section G 120 revealed Resident #2 was totally dependent with bathing and required two (2) or more persons for physical assistance. A review of the comprehensive care plan for Resident #2 revealed a problem related to the resident's need for assistance with Activities of Daily Living (ADL) due to weakness secondary to [MEDICAL CONDITIONS] and [MEDICAL CONDITION],dated 11/5/15. Interventions for this problem did not address bathing. Interview on 08/17/16 at 6:08 PM, with Registered Nurse (RN) #1 revealed the MDS assessment should match the care plan. Review of the Face Sheet revealed the facility readmitted Resident #2 on 01/09/14, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment with an ARD of 07/11/16, revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment. Resident #9 Review of the quarterly MDS assessment with an ARD of 07/05/16 for Resident #9 revealed Section G 120 was coded totally dependent with bathing with two (2) or more persons for physical assistance. A review of the comprehensive care plan for Resident #9, dated 4/11/16, revealed a problem that addressed resident requiring limited assistance with ADL related to weakness. Interventions for that problem did not address bathing for Resident #9. 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 BIMS, which indicated the resident was cognitively intact. Resident #10 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 comprehensive care plan for Resident #10, dated 7/11/16, revealed a problem to address the resident requiring limited assistance with ADLs related to an old [MEDICAL CONDITION]. Interventions for this problem did not address bathing for Resident #10. A review of the Face Sheet revealed the facility admitted Resident #10 on 03/17/08, with [DIAGNOSES REDACTED]. Review of the annual MDS assessment with an ARD of 07/11/16, revealed Resident #10 scored 15 on the BIMS, which indicated the resident was cognitively intact. |
2020-09-01 |