| 8 |
JEFFERSON DAVIS COMMUNITY HOSPITAL ECF |
255050 |
1320 WINFIELD STREET |
PRENTISS |
MS |
39474 |
2019-09-19 |
657 |
D |
0 |
1 |
S8KJ11 |
Based on record review, facility policy review, and staff interview, the facility failed to revise the Comprehensive Care Plan to reflect a soft wrist splint and interventions, for Resident #3 and the use of an indwelling catheter for Resident #38, for two (2) of 18 care plans reviewed. Findings Include: A review of facility policy titled, Care Plans-Comprehensive, (no date) revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care-Planning interdisciplinary team is responsible for the review and updating of care plans. Resident #3 Record review of the Working Care Plan on the chart, and the most current care plan, initiated 12/12/18, through the review date of 9/30/19, revealed Resident #3's care plan was not revised to include a soft wrist splint and/or interventions related to the splint. Review of an incident report timeline, provided by the facility, revealed Resident #3 had a right wrist splint placed, per Primary Care Provider, on 8/13/19, for a non-displaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. During an interview on 09/18/19 at 11:07 AM, the Director of Nursing (DON) stated, after reviewing the current care plan and the working care plan on the chart, The right wrist splint interventions are not on the Resident's current care plan or on the working care plan in the chart. An interview on 09/18/19 at 11:20 AM, with LPN #1 MDS/Care Plan Nurse, revealed the soft wrist splint and interventions were not care planned, and they should have been. LPN #1 stated, The nurse who checks the orders when a resident returns from an appointment, is responsible to write the order and care plan the order if needed. An interview on 09/18/19 at 1:37 PM, with the DON, revealed, It is the RN Supervisor or the LPN's responsibility to check a resident back in after an appointment and they are supposed to write any orders that return with the resident. Then, whoever writes the order, is supposed do to create or update the care plan specific to the order. Resident #38 Review of Resident #38's comprehensive care plan, with a target date of 11/30/19, revealed a care plan related to the resident's incontinence, however, there was no care plan for an indwelling urinary catheter. On 9/17/19 at 9:19 AM, an observation revealed Certified Nursing Assistant (CNA) #1, assisted by CNA #2, performed catheter care for Resident #38. The resident was observed to have an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview with the Director of Nurses (DON) revealed there was no physician's order or care plan for the indwelling urinary catheter for Resident #38. On 9/17/19 at 11:10 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed a care plan had not been developed for the resident's indwelling urinary catheter. She also stated the current care plan did not reflect the resident's current status regarding the indwelling urinary catheter. During an interview on 09/18/19 at 8:54 AM, Registered Nurse (RN) #3 revealed Resident #38 returned from the hospital (8/19/19) with the catheter and had not had any complications from the urinary catheter. |
2020-09-01 |