cms_NV: 53
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 |
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53 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 656 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review ad document review, the facility failed to ensure a comprehensive care plan was completed for use of antidepressant medication for 1 of 12 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Resident #14's annual Minimum Data Set (MDS) 3.0 dated 04/30/19 and Quarterly MDS 3.0 dated 07/31/19, Section D- Mood, revealed the resident had little interest or pleasure in doing things, feeling down, depress or hopeless, feeling tired or having little energy and poor appetite. Resident #14's annual MDS 3.0 dated 04/30/19 and Quarterly MDS dated [DATE], Section I -documented depression as an active diagnosis, and Section N -Medications, indicated resident was taking antidepressant medication. Care Area Assessment (CAA) Summary dated 07/30/19, triggered for [MEDICAL CONDITION] drug use and the care planning decision area documented addressed in the resident's care plan. Resident #14's clinical record lacked documented evidence of a Comprehensive Care Plan for [MEDICAL CONDITION] drug use. On 10/15/19 at 2:00 PM, the Director of nursing (DON) explained the Care Plans were initiated, completed and revised by the DON. The DON confirmed there was no Comprehensive Care Plan developed to address Resident #14's use of antidepressant medication and depression. The Facility policy titled Care Plans, last revised on 03/22/17, documented each resident will have a comprehensive person-centered care plan developed by the interdisciplinary team. These care plans will be updated as the needs of the resident changed. The care plan must include the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. | 2020-09-01 |