| 90 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2019-05-15 |
656 |
D |
0 |
1 |
0E0S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and interviews, the facility failed to ensure comprehensive, resident-centered care plans were developed and/or implemented for three (3) of 48 sampled residents, Residents #37, #89, and #112. Findings include: A review of an undated facility policy titled, Care Plan - Comprehensive, revealed, it is the policy of this facility to develop comprehensive care plans for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. In addition, the policy stated, The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's assessment or within twenty-one (21) days after the resident's admission, whichever occurs first. Resident #37 Record review of the undated care plans for Resident #37, revealed no care plan for the pressure ulcer to the right ischium. There were no interventions or goals related to the care of the pressure ulcer. Review of Resident #37's undated Face Sheet (a document that contains demographic and [DIAGNOSES REDACTED]. Resident #37's [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 5/07/19, revealed Resident #37 scored a 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Further review of the MDS, indicated Resident #37 required limited two (2) staff assist for bed mobility; extensive two (2) staff assistance for transfers, dressing, toilet use and bathing; and extensive one (1) staff assistance for personal hygiene. The MDS documented Resident #37 had one (1) unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar (dead tissue). The MDS indicated the pressure ulcer was present upon admission. Review of the Pressure Ulcer Report, dated 5/10/19, indicated the pressure ulcer to the right ischium measured 3.5 cm (centimeters) by 4.6 cm and was a Stage 3. Observation on 5/14/19 at 10:43 AM, with the RN Wound Nurse, revealed the pressure ulcer was clean and measured 2.8 cm by 4.1 cm and was a Stage 3. During an interview on 5/14/19 at 4:08 PM, the RN Wound Nurse confirmed there was not a care plan for the pressure ulcer to the right ischium for Resident #37. During an interview on 5/15/19 at 4:10 PM, the MDS Consultant confirmed Resident #37 did not have a care plan for the pressure ulcer to the right ischium. Resident #89 A review of Resident #89's, Baseline Care Plan, dated 4/30/19, revealed the resident's care plan identified the following: [NAME] Resident #89's Baseline Care Plan stated, I am at risk for falls related to decreased mobility. The care plan gave instructions for facility staff to ensure the resident's call light was within reach and ensure the resident was wearing appropriate footwear. B. Resident #89's, Baseline Care Plan further indicated, I have an infection. The care plan gave instructions to facility staff to ensure the resident's medication was administered as ordered and observe the resident for worsening symptoms. Resident #89's clinical record did not contain a comprehensive care plan that addressed the residents history of falls or UTI, at the time of the review. The resident's record review was on 5/14/19, 26 days after Resident #89 was admitted to the facility. A review of Resident #89's admission assessment, dated 4/25/19, revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The assessment indicated Resident #89 used a wheelchair for mobility and needed extensive assistance of two (2) persons and a Hoyer lift for transfers. The resident was also assessed to receive antibiotics for a UTI; as well as physical therapy, occupational therapy, and speech therapy services at the facility. During an interview with the Minimum Data Set (MDS) Care Plan Coordinator (CPC) on 5/14/19 at 5:47 PM, the MDS CPC confirmed Resident #89 only had a Baseline Care Plan at the time of the record review, and further confirmed he should have had a Comprehensive Care Plan completed and implemented. The MDS CPC did not provide an explanation for facility's failure to develop and implement a Comprehensive Care Plan for Resident #89. Resident #112 Review of Resident #112's medical records lacked documentation that a comprehensive care plan for falls had been developed and implemented. Review of Resident #112's undated Face Sheet found in the electronic medical record, revealed the resident was admitted to the facility on [DATE]. Review of Resident # 112 's list of Medical [DIAGNOSES REDACTED]. Review of Resident #112's admission MDS assessment, dated 4/26/19, and the resident's Care Area Assessment (CAA) for falls, dated 5/1/19, revealed the facility was to proceed in care planning Resident #112 for falls. Care Areas are triggered by MDS responses and indicate a need for additional assessment or action for the identified care concerns. During an interview on 5/14/19 at 5:40 PM, the MDS CPC stated the resident only had baseline admission care plan. She confirmed the comprehensive care plan should have been completed and should include falls. The resident had been in the facility for 25 days and had no comprehensive, resident-centered care plan with measurable goals to achieve and/or maintain the resident's highest level of well-being. During an interview on 5/16/19 at 11:00 AM, the MDS Consultant confirmed the comprehensive care plan should be completed and implemented no later than 21 days after a resident's admission. |
2020-09-01 |