| 93 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2019-05-15 |
684 |
D |
0 |
1 |
0E0S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policies, and interview, the facility failed to ensure a resident with a [DIAGNOSES REDACTED].#102, in a sample of 24 residents. This had the potential to cause a delay and/or alteration in treatment for [REDACTED]. Findings include: Review of a facility policy, titled Weights; Obtaining and Documenting, dated 12/27/17, revealed .Timing of Weights: 1. Daily; Daily weights should be done if ordered by the physician . Record review of Resident #102's admission Minimum Data Set (MDS) assessment, dated 4/25/19, revealed the resident was readmitted to the facility on that date after an acute hospitalization . The MDS revealed in Section I the resident had [DIAGNOSES REDACTED]. An observation of Resident #102 on 5/13/19 at 9:38 AM, revealed the resident was lying in bed, in her room. Her hands and arms were observed to be [MEDICAL CONDITION] (swollen). During an interview on 5/13/19 at 9:41 AM, Registered Nurse (RN) #2 stated the resident had gone to the hospital recently, and had been [MEDICAL CONDITION] since she came back. Review of the Progress Notes, dated 5/02/19, revealed the Nurse Practitioner assessment, . Chief complaint [MEDICAL CONDITION], inadequate diuresis .resident with recent hospitalization .while admitted had [MEDICAL CONDITION] and put on #30 fluid at the time of discharge. I started her on [MEDICATION NAME] (a diuretic) 40 daily, increasing it to bid (twice a day), she has only lost #3 (pounds) . Plan: D/c (discontinue) [MEDICATION NAME] 40 bid, [MEDICATION NAME] (a diuretic) 1 mg(milligram) one po bid, daily weights . Review of the resident's physician's orders [REDACTED].Daily weight one time a day for fluid retention . Review of the resident's Daily Weight record revealed the resident's weight on 5/03/19 was 197 pounds. There was a lack of documentation of the resident's daily weights for 5/04/19, 5/05/19, and 5/06/19. Review of Resident #102's care plans, dated 8/17/18, revealed I am on diuretic therapy r/t (related to) [MEDICAL CONDITION] .Obtain weight as ordered .I have altered cardiovascular status r/t .HF (Heart Failure) .observe/document/report PRN (as needed) any s/sx (signs and symptoms) of [MEDICAL CONDITION]: [MEDICAL CONDITION] .weight gain . During an interview on 5/14/19 at 1:50 PM, Certified Nursing Assistant (CNA) #5 stated she was a restorative CNA and they were responsible for the daily weights. She stated she weighed the resident on 5/03/19, and at that time the resident was on weekly weights, she was not aware the resident had been put on daily weights until 5/07/19. During an interview on 5/14/19 at 4:00 PM, RN #1, stated she had worked on 5/04/19, 5/05/19 and 5/06/19. She stated she had notified the Director of Nursing (DON) on 5/06/19, that the weights had not been done. The DON had told her to notify the restorative CNA to do the daily weights. |
2020-09-01 |