cms_NM: 35
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
35 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 656 | D | 0 | 1 | GNFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop a comprehensive person-centered care plan for 2 (R #29 and R #69) of 2 (R #29 and R #69 ) residents reviewed for 1) oxygen use and care, and 2) dental care. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are: Resident #29 [NAME] On 10/22/18 at 9:10 am an observation of R #29 revealed that the resident was using oxygen while sitting in assigned room. B. Record review of baseline care plan dated 05/02/18 revealed that R #29 was admitted with oxygen at 2 liters per minute. C. Record review of Care Plan dated 05/30/18 revealed that R #29 had not been care planned for the use of oxygen. D. On 10/26/18 at 11:00 am, during an interview, the MDS coordinator stated, I was looking for orders for the O2 (oxygen), if he didn't have orders for the O2 he wouldn't be care planned. E. On 10/26/18 at 2:34 pm, during an interview Assistant Director of Nursing (ADON) stated, (resident name) does not have an O2 order, the only place I see is on the admission where they started to mark it yes and then marked it no. I am writing an order for [REDACTED]. Resident #69 F. Record review of the facility facesheet for R #69 dated 08/15/17 revealed, an admitted d 08/15/17. Admission [DIAGNOSES REDACTED]. [NAME] On 10/22/18 at 4:21 pm, observation of R #69's teeth revealed, they were brown, worn down and chipped. H. Record review of R #69's Minimum Data Set (MDS) assessment (Center for Medicare/Medicaid assessment tool) dated 07/05/18 revealed no triggers for dental issues. 1. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Pain, discomfort, difficulty chewing. Teeth very poor condition, probable caries broken/missing teeth and refuses dental care. Requires good oral hygiene at least 2 times a day. Will continue to care plan. 2. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Cavity or broken natural teeth, pain discomfort, difficulty chewing. Poor oral dentition related to (r/t) weakness, decreased trunk control and cognitive deficit. Will care plan. I. Record review of the care plan dated 09/19/17 for R #69 revealed, no care plan for dental issues. [NAME] On 10/26/18 at 9:07 am, during an interview, the Director of Nursing stated I don't see it on his (R #69) care plan but I am going to get help. K. On 10/26/18 at 9:40 am, during an interview, the MDS Registered Nurse (RN)stated that the issues with his (R #69) teeth are not care plan. L. On 10/26/18 at 10:05 am, the MDS Licensed Practical Nurse stated that dental issues for R #69 should be on the care plan. | 2020-09-01 |