| 98 |
RIO RANCHO CENTER |
325033 |
4210 SABANA GRANDE SE |
RIO RANCHO |
NM |
87124 |
2019-03-07 |
684 |
D |
0 |
1 |
IVL411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide services for 2 (R #s 12 and 25) of 2 (R #s 12 and 25) residents reviewed for treatment and care in accordance with professional standards of practice. For (R #12) Hospice (end of life care management) Care, the facility staff failed to assure a resident receiving hospice care was being monitored by hospice staff. For R #25, the resident was not repositioned in bed for many hours and in accordance with the guidance on her kardex (document where the tasks a Certified Nurses Aide (CNA) should provide to a resident is delineated). This deficient practice was likely to result in a resident receiving inadequate and/or untimely care and treatment during daily and end of life care. The findings are: Findings for R #12: [NAME] Record review of R #12's face sheet dated 03/06/19 revealed he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. [MEDICAL CONDITION]-Stage 3 (Moderate) (long term decline of kidney function) 2. Acute Kidney Failure (immediate failure of kidney function) 3. [MEDICAL CONDITION] in [MEDICAL CONDITION] (blood red cell abnormalities due to kidney disease) B. Record review of R #12's physician order [REDACTED].#12 was admitted to (name of selected hospice service) under routine level of care. Primary Diagnosis: [REDACTED]. C. Record review of R #12's written progress notes of care provided to R #12 by the selected Hospice service reveals that he was seen by a Registered Nurse, Licensed Practical Nurse or Social Worker from the hospice service on 12/14/18, 12/31/18, 01/18/19, 01/21/19, 01/29/19, 02/01/19, 02/05/19, 02/08/19, 02/12/19 and 02/15/19. There were no other written progress notes available after this date. D. On 03/06/19 at 9:15 am, during interview with the Social Services Director (SSD), stated that hospice nurses were suppose to come weekly. She stated that when the Hospice nurses come they document their visit in the paper chart. The SSD confirmed that the chart had not been updated since 02/15/19 and stated she believed this was an error and that they just forgot to chart for him on his last visit. Findings for R #25: E. On 03/04/19 at 8:40 am, during an observation, R #25 was lying in bed with the head of the bed (HOB) elevated approximately (~) 30 degrees and positioned on her back tilted slightly to her right side. F. On 03/04/19 at 11:15 am, during an observation, the resident was in bed positioned slightly, to the right, with HOB up ~ 30 degrees. [NAME] On 03/04/19 at 12:20 pm, during observation, the resident was slightly on her right side but has slid down in bed about a foot. H. On 03/04/19 at 2:48 pm, during observation, R #25 has slid down a little further in her bed and still slightly to her right side. I. On 03/05/19 at 8:41 am, during an observation, R #25 was positioned with her HOB up ~30 degrees on her back. [NAME] On 03/05/19 at 12:13 pm, during an observation, R #25 remains in bed with the HOB up ~ 30 degrees on her back. K. On 03/05/19 at 12:20 pm, during an interview, CNA #1 who was caring for the resident, was asked if (name of resident R #25) been turned this morning? we will do that at about 1 (pm) when her feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth) is turned off .I've been told not to turn her when her tube feed was turned on. L. Record review of the Kardex for R #25 revealed, Assist resident in turning and reposition every 2 hrs. (hours). |
2020-09-01 |