| 55 |
PROVIDENCE BENEDICTINE NURSING CENTER |
385018 |
540 SOUTH MAIN STREET |
MOUNT ANGEL |
OR |
97362 |
2017-07-31 |
278 |
E |
1 |
1 |
LC2W11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to accurately code MDS assessments related to resident weights, dehydration, UTIs, terminal prognosis and pressure ulcer risk for 5 of 13 sampled residents (#s 21, 26, 33, 60 and 140) reviewed for nutrition, UTIs, dehydration, pressure ulcers and hospice. This placed residents at risk for unmet needs. Findings include: The RAI 3.0 Manual dated 10/2016 requires the following four criteria be met for coding UTIs as an active Diagnosis: [REDACTED]. - Sign or symptom attributed to UTI, which may or may not include but not be limited to: fever, urinary symptoms (e.g., peri-urethral site burning sensation, frequent urination of small amounts), pain or tenderness in flank, confusion or change in mental status, change in character of urine (e.g., pyuria), - Significant laboratory findings (The attending physician should determine the level of significant laboratory findings and whether or not a culture should be obtained), and - Current medication or treatment for [REDACTED]. The RAI 3.0 Manual dated 10/2016 requires two or more of the following potential indicators when coding for dehydration: - Resident takes in less than the recommended 1,500 ml of fluids daily (water or liquids in beverages and water in foods with high fluid content, such as gelatin and soups). Note: The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards. - Resident has one or more potential clinical signs (indicators) of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, [MEDICATION NAME], blood urea nitrogen, or urine specific gravity). - Resident's fluid loss exceeds the amount of fluids he or she takes in (e.g., loss from vomiting, fever, diarrhea that exceeds fluid replacement). 1. Resident 21 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE] identified the resident as having active [DIAGNOSES REDACTED]. No documentation of an active UTI or dehydration diagnoses, related laboratory findings or signs/symptoms indicated a UTI or dehydration was found in the clinical record. In an interview on 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged the 7/11/17 Quarterly MDS was miscoded. 2. Resident 60 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE] identified the resident as having an active [DIAGNOSES REDACTED]. No documentation in the clinical record indicated dehydration, related laboratory findings or signs/symptoms the resident was dehydrated. In an interview on 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged the 5/7/17 Quarterly MDS was miscoded. 3. Resident 140 admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. The 5/18/17 Significant Change MDS indicated Resident 140 received hospice services. The MDS indicated the resident did not have a terminal prognosis. On 7/27/17 at 12:27 pm Staff 8 (RNCM) acknowledged Resident 140 received hospice service and did have a terminal prognosis. Staff 8 stated the MDS was coded in error. 4. Resident 33 admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. A 2/3/17 Braden Scale For Prediction of Pressure Sore Risk indicated Resident 33 was at risk for pressure ulcers. The 4/21/17 Annual MDS indicated Resident 33 was not at risk for pressure ulcers. On 7/31/17 at 1:21 pm Staff 8 (RNCM) stated Resident 33 was at risk for pressure ulcers and acknowledged the MDS was coded in error. 5. The CMS RAI Manual Section K: Swallowing/Nutritional Status, Coding Instructions for Weight stated, If a resident cannot be weighed .use the standard no-information code (-). Resident 26 admitted to the facility in 8/2010 with [DIAGNOSES REDACTED]. The 12/23/16 Annual MDS indicated Resident 26's weight was zero. On 7/27/17 at 2:17 pm Staff 8 (RNCM) stated Resident 26 was not weighed by facility staff but the resident's arm circumference was measured in order to monitor the resident's nutritional status. On 7/28/17 at 9:24 am Staff 9 (Dietitian) acknowledged the resident's weight was coded inaccurately on the 12/23/16 Annual MDS. |
2020-09-01 |