| 77 |
MINOT HEALTH AND REHAB, LLC |
355031 |
600 S MAIN ST |
MINOT |
ND |
58701 |
2018-08-16 |
641 |
D |
0 |
1 |
B0I611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.15), and staff interview, the facility failed to ensure accurate coding of Minimum Data Sets (MDSs) for 2 of 18 sampled residents (Resident #6 and #46). Failure to accurately complete Section N (Medications) and Section O (Special Treatments, Procedures,and Programs) of the MDS does not allow each resident's assessment to reflect their current status/needs, and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION N: Medication The Long-Term Care Facility RAI Manual, page N12 - N13, stated, . Coding Instructions for N0450A: Code 0, no: if antipsychotic were not received . Code 1, yes: if antipsychotic's were received on a routine basis only: Continue to N0450B, Has a GDR (gradual dose reduction) been attempted? . Code 0, no: if a GDR has not been attempted. Skip to N0450D, Physician documented GDR as clinically contraindicated. Code 1, yes: if GDR has been attempted. Continue to N0450C, Date of last attempted GDR. - Review of Resident #6's medical record occurred on all days of survey and identified a physician's orders [REDACTED]. Review of the (MONTH) Medication Administration Record [REDACTED]. The record also showed the physician rejected a GDR in (MONTH) (YEAR) for the Quetiapine. The quarterly MDS, dated [DATE], failed to identify the use of an antipsychotic. Failure to identify antipsychotic use resulted in the system not triggering staff to identify the physician's rejection of a GDR in (MONTH) (YEAR). During an interview on 08/15/18 at 3:21 p.m., an administrative staff member (#18) confirmed she coded section N0450 incorrectly on Resident #6's 07/22/18 MDS. SECTION O 0100: Special Treatments, Procedures, and Programs The Long-Term Care Facility RAI Manual, page O-3, stated, . O 0100C Oxygen therapy, Code continuous or intermittent oxygen administered via mask, cannula, . delivered to a resident to relieve [MEDICAL CONDITION] (low oxygen in tissues) in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula. - Resident #46's medical record, reviewed (MONTH) 14-16, (YEAR), identified a physician's orders [REDACTED]. Progress notes, dated 07/28/18 at 2:09 p.m. and 07/29/18 at 3:10 p.m. identified the resident receiving oxygen at 2 liters per minute via a nasal cannula. A quarterly MDS, dated [DATE], failed to identify oxygen use. During an interview on 08/16/18 10:30 a.m. an administrative nurse (#18) confirmed she should have coded Resident #46's oxygen use at O 0100C on the 07/29/18 MDS. |
2020-09-01 |