| 43 |
BOYINGTON HEALTH AND REHABILITATION |
255092 |
1530 BROAD AVE |
GULFPORT |
MS |
39501 |
2017-01-13 |
279 |
D |
0 |
1 |
QXQE11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to develop a Comprehensive Care Plan for a Ureostomy for Resident #11, and bowel and bladder incontinence for Resident #8, for two (2) of 21 Care Plans reviewed. Findings include: Review of the facility's policy titled, Care Plan-Comprehensive, dated (MONTH) 2001, revealed the facility would develop a Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs for each resident. The comprehensive care plan had been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes, and identify the professional services that are responsible for each element of care. Resident #8 Review of Resident #8's Plan of Care revealed no Care Plan for bowel and bladder Incontinence was developed. An observation on 1/12/17 at 2:05 PM, revealed Certified Nursing Assistant (CNA) #1 and CNA #6 provided incontinent care for Resident #8 after an episode of incontinence. An interview with the Director of Nursing (DON) on 1/13/17 at 3:00 PM, revealed all residents should have a Care Plan reflective of identified needs. The DON confirmed Resident #8's Plan of Care did not address bowel and bladder incontinence. Review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/31/16, under section H0300, revealed Resident #8 was frequently incontinent of bowel and bladder. This MDS revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #8 was cognitively intact. Review of the Face Sheet revealed the facility admitted Resident #8 on 9/14/15, with the [DIAGNOSES REDACTED]. Resident #11 Record review of Resident #11's Care Plan revealed a Focus initiated on 6/13/2016 for High Risk for Impaired Skin Integrity related to bowel incontinence, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), Diabetes (DM), General Weakness, [MEDICAL CONDITION], Hypertension (HTN), [MEDICAL CONDITION] (HLP), and Presence of a [MEDICATION NAME]. The interventions included change the [MEDICATION NAME] bag and wafer every 5 (five) days, and as needed. There was not a care plan developed with a Focus related to the potential problems for a [MEDICATION NAME] with individualized care, goals, and persons responsible to provide the care/interventions. Review of Resident #11's MDS with an ARD of 12/12/2016 revealed in Section G for Functional Status, Resident #11 required extensive assistance of two staff members for toilet use. Section H for Urinary Continence revealed he had a urinary ostomy. Interview on 01/13/2017 at 2:20 PM, with Registered Nurse (RN) #2 revealed no care plan for the [MEDICATION NAME] had been developed, and the person that had done the original care plan no longer worked there. Review of the facility's Face Sheet revealed the facility admitted Resident #11 on 06/01/2016. His [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 12/12/2016 revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he had no cognitive impairment. |
2020-09-01 |