| 41 |
GREENBRIAR HEALTHCARE |
305005 |
55 HARRIS ROAD |
NASHUA |
NH |
3062 |
2018-12-19 |
641 |
C |
0 |
1 |
P2R411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that assessments accurately reflect the resident's status for 25 residents out of the sample size of 40 residents. (Resident identifiers are #7, #13, #18, #19, #22, #25, #27, #74, #80, #84, #88, #89, #91, #94, #109, #112, #118, #135, #140, #177, #190, #204, #210, #212, and #226.) Findings include: Review on 12/19/18 of Resident #7, #18, #22 #25, #74, #80, #84, #88, #89, #91, #94, #109, #112, #118, #135, #140, #177, #190, #204, #210, #212, and #226 MDS (Minimum Data Set) for the month of (MONTH) to (MONTH) (YEAR) revealed that section C0100-C0500 (BIMS (Brief Interview of Mental Status)) was coded not assessed and with no BIMS score. Review on 12/19/18 of Resident #7, #18, #22, #25, #74, #80, #84, #88, #89, #91, #94, #109, #112, #118, #135, #140, #177, #190, #204, #210, #212, and #226 previous MDS dated between (MONTH) to (MONTH) (YEAR) revealed that Section C0100-0500 was coded with BIMS scores. Interview on 12/19/18 at 9:00 a.m. with Staff X (Social Worker) confirmed that above findings. Staff X revealed that they evaluate and document residents BIMS.Staff X states that they started working at the facility the last week of (MONTH) (YEAR) and that many of the BIMS for the month of (MONTH) to (MONTH) (YEAR) were not done and that they are trying to catch up with the BIMS assessments. Review on 12/19/18 of Resident #18, #22, and #88 BIMS assessment revealed that their last documented assessment were 727/18, 9/13/18, and 7/13/18, respectively. Interview on 12/19/18 at 10:47 a.m. with Staff U (MDS Head Coordinator) confirmed that Resident #18, #22, and #88's BIMS were not completed. Staff U states that the BIMS should have been completed. Staff U stated that the social worker evaluates residents BIMS and completed Section C of the MDS and the MDS coordinators electronically signs for the completion of the MDS. Resident #13 Review on 12/18/18 of Resident #13's Minimum Data Set ((MDS) dated [DATE] revealed Section C0100 Should Brief Interview for Mental Status (C0200-C0500) be Conducted? dashes though sections C0100-C0500 with no BIMS score. Review on 12/18/18 of Resident #13's medical record revealed that Resident #13 had a previous Brief Interview for Mental Status (BIMS) score of 15 in previous MDS dated [DATE]. Interview on 12/18/18 at approximately 10:40 a.m. with Staff H (MDS Coordinator) confirmed the above findings and revealed the 9/28/18 MDS sections were completed in error due to no social service worker available to do the work and that Resident #13 should still have a BIMS score. Resident #27 Review on 12/18/18 of Resident #27's MDS dated [DATE] revealed Section J0100 Pain Management revealed that Resident #27 had received no scheduled pain medication in the past 5 days. Review on 12/18/18 of Resident #27's physician orders [REDACTED]. Interview on 12/18/18 at approximately 10:40 a.m. with Staff H confirmed the above findings and revealed the above MDS sections were completed in error. Resident #19 Review on 12/18/18 at 9:34 a.m. Resident #19's medical record shows a 14 day MDS Medicare review completed on 8/9/18 coding section C Cognitive Pattern Section C0500. BIMS with a summary score of 12. Then on 10/31/18 a Quarterly MDS was competed and section C0500 was not completed with prior sections coded as Not assessed . Interview on 12/18/18 at 10:00 a.m. with Staff N (MDS coordinator) confirmed that there was no Social Services personal employed during this time and this area was not completed. |
2020-09-01 |