cms_OR: 56
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 56 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2017-07-31 | 279 | E | 1 | 1 | LC2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to create a comprehensive care plan including measurable objectives, timeframes and services provided for 13 of 22 sampled residents (#s 15, 21, 24, 26, 33, 46, 60, 72, 118, 144, 153, 159 and 167) for whom care plans were reviewed. This placed residents at risk for unmet needs. Findings include: The facility's 4/2017 Resident Care policy states: The nursing department participates in the development of an interdisciplinary resident care plan to assure continuity and individualization of nursing care: 1. The care plan is completed within 21 days of admission by the interdisciplinary team, which includes the resident, nursing, life enrichment, social services and food and nutrition services. 2. The care plan includes problems, goals, objectives and approaches which nursing personnel use as guidelines in giving and recording the results of care. 3. The discipline(s) to initiate or carry out approaches, the frequency of approaches, and appropriate signatures are required on the care plan. 4. The care plan is reviewed and updated at least quarterly at an interdisciplinary team meeting. Residents or designees will be requested to participate. CARE PLAN: The entire resident record is understood to be the plan of care. More specifically, this includes any information that is used to carry out care and services for the resident: - The Bedside Information Sheet - Focus notes: written quarterly or as needed. These identify goals, measurements and descriptions. - physician's orders [REDACTED]. - Clinical monitoring: lab results, flow sheets (meal monitoring, snacks, restorative, etc.), therapy treatment notes - Medication and Treatment Administration Records - Progress Notes Because the entire record represents the care plan, all staff is aware of and engaged in the carrying out the (sic) goals of the care plan on a daily basis. 1. Resident 26 admitted to the facility in 8/2010 with [DIAGNOSES REDACTED]. a. A 10/13/16 Nutrition Assessment indicated Resident 26 was on swallowing precautions. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's nutritional needs. On 7/28/17 at 9:15 am Staff 2 (DNS) acknowledged Resident 26's care plan did not include objectives, timeframes and services provided to meet the resident's nutritional needs. b. The 7/20/17 Bedside Information Sheet indicated Resident 26 had a [MEDICAL CONDITION]. No information was found in the resident's record to indicate objectives, timeframes and services provided for the resident's needs related to the [MEDICAL CONDITION]. On 7/28/17 at 9:15 am Staff 2 (DNS) acknowledged Resident 26's care plan did not include objectives, timeframes and services provided to meet the resident's needs related to the [MEDICAL CONDITION]. 2. Resident 33 admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. a. The 4/21/17 Annual MDS Pressure Ulcer CAA indicated a plan was in place to prevent pressure ulcers and stated, Risks for pressure ulcer addressed in care plan. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's risk for pressure ulcers. On 7/31/17 at 11:47 am Staff 8 (RNCM) acknowledged the resident's care plan did not include objectives, timeframes and services provided to meet the resident's needs related to pressure ulcer risk. b. The 4/21/17 Annual MDS indicated Resident 33 experienced a UTI in the past 30 days. On 7/28/17 at 12:55 pm Resident 33 stated she/he had a long history of UTIs including prior to admitting to the facility. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's risk for UTIs. On 7/31/17 at 11:47 am Staff 8 (RNCM) stated the resident had a history of [REDACTED]. related to UTIs. 3. Resident 15 admitted to the facility in 3/2010 with [DIAGNOSES REDACTED]. The 8/26/16 Significant Change MDS indicated the resident received antipsychotic, antidepressant, anticoagulant and diuretic medication. The 6/2017 and 7/2017 MARs indicated Resident 15 refused antidepressant medication seven times and refused diuretic medication 18 times from 6/1/17 through 7/30/17. On 7/28/17 at 12:58 pm Staff 10 (RN) stated Resident 15 frequently refused medication and staff used a variety of interventions to encourage the resident to take her/his medication. No information was found in the resident's record to indicate objectives, timeframes or services provided related to the resident's high-risk medication and medication refusal. On 7/31/17 at 11:47 am Staff 8 (RNCM) acknowledged the resident's care plan did not include objectives, timeframes or services provided to meet the resident's needs related to high-risk medication and medication refusal. 4. Resident 159 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. a. The resident's 6/1/17 Admission MDS identified the resident had unsteady balance, required one- person limited assistance with transfers and one-person extensive assistance with toilet use. The resident's Person-Centered Bedside Care Plan included the amount of assistance and devices needed for transfers but included no measurable goals for fall prevention. Progress notes indicated on 7/08/17 at 1:43 pm the resident sustained [REDACTED]. The fall investigation dated 7/8/17 indicated the resident was alone in the bathroom at the time of the fall and attempted to self-transfer from the wheelchair to the toilet. On 7/17/17 at 2:01 pm the progress note indicated the resident was found on 7/17/17 at 10:15 am sitting on the floor in front of the toilet in her/his bathroom again. The fall investigation dated 7/17/17 indicated the resident was alone in the bathroom at the time of the fall and attempted to self-transfer from the toilet to the wheelchair. No new fall prevention interventions were identified or added to the care plan until 7/21/17, four days after the second fall occurred. On 7/28/17 at 4:55 pm Staff 16 (RNCM) verified Resident 159's care plan contained no measurable goals for fall prevention and the care plan was not revised related to falls and toileting until after the second fall occurred. b. On 7/25/17 at 10:14 am Resident 159 was observed with a bruise on her/his left elbow and steri-strips on her/his right forearm. Progress notes indicated the resident sustained [REDACTED]. There was no progress note related to the resident's left elbow bruise. The resident's care plan identified the resident had a history of [REDACTED]. The resident's clinical record did not include measurable goals to prevent breakdown or injuries and did not indicate staff responsible to provide the interventions. On 7/28/17 at 5:36 pm Staff 16 (RNCM) verified the resident's care plan contained no measurable goals related to fragile skin or bruising or the staff responsible to provide the interventions. c. The resident's 6/1/17 Admission MDS identified the resident had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter CAA associated with the 6/1/17 Admission MDS included the resident's diagnoses, history of urinary tract infections, urinary catheter use and need for one-person extensive assistance with toileting. A progress note dated 7/8/17 indicated the resident was found on the floor of the bathroom with the catheter drainage bag attached to her/his wheelchair. On 7/09/17 at 11:13 pm the progress note related to the fall with injury indicated the resident had no apparent injuries, denied pain, but a red and irritated skin injury was noted. On 7/17/17 the resident was found again on the floor of the bathroom with the catheter drainage bag attached to her/his wheelchair. The resident's clinical record included the use of the indwelling urinary catheter but included no measurable goals to prevent urinary tract infections or injury related to the catheter and did not indicate staff responsible to provide the interventions. On 7/28/17 at 5:36 pm Staff 16 (RNCM) verified the resident's care plan had no measurable goals related to injuries from pulling of the catheter and did not indicate the staff responsible for interventions. 5. Resident 24 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. A progress note dated 6/22/17 indicated the resident had a 8.5 cm x 7.5 cm bruise on the left upper arm, a history of bruising and took oral blood thinners. On 7/24/17 at 12:14 pm Resident 24 was observed with a bruise on her/his right arm and diffused bruising on the back of both hands. The progress notes included no information or identification of the resident's right arm bruise. The resident's 7/2017 physician orders [REDACTED]. On 7/26/17 the resident's Person-Centered Bedside Care Plan indicated the resident received high risk medications. However, the resident's clinical record did not identify the medication or adverse side effects of the medication. The resident's record identified the resident bruised easily but included no measurable goals or interventions to protect the resident from bruising. On 7/28/17 at 5:00 pm Staff 16 (RNCM) verified the resident's care plan had no measurable goals related to bruising and use of high risk medications. Staff 16 verified the care plan did not indicate the staff responsible for interventions. 6. Resident 21 admitted to the facility in 2014 with [DIAGNOSES REDACTED]. A Significant Change MDS dated [DATE] and a Quarterly MDS dated [DATE] indicated the resident had [DIAGNOSES REDACTED]. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's UTI, Foley catheter or dehydration needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 21's care plan did not include objectives, timeframes and services provided to meet the resident's UTI, Foley catheter or dehydration needs. 7. Resident 60 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE] identified an active [DIAGNOSES REDACTED]. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's dehydration needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 60's care plan did not include objectives, timeframes and services provided to meet the resident's dehydration needs. 8. Resident 72 was admitted to the facility in 6/2011 with [DIAGNOSES REDACTED]. Resident 72's physician orders [REDACTED]. No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's high risk medication needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 72's care plan did not include objectives, timeframes and services provided to meet the resident's high risk medication needs. 9. Resident 118 was admitted to the facility in 8/2015 with [DIAGNOSES REDACTED]. Resident 118's physicians orders dated 6/27/17 revealed orders for [MEDICATION NAME] (sedative), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (anticonvulsant also used for mood), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (blood thinner), [MEDICATION NAME] R (insulin) and [MEDICATION NAME] (insulin). No information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's high risk medication needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 118's care plan did not include objectives, timeframes and services provided to meet the resident's high risk medication needs. 10. Resident 167 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. The resident's Admission MDS dated [DATE] indicated the resident required extensive assistance with transfers and ambulation. The resident's Personalized Bedside Care Plan revised 6/19/17 identified the resident was a fall risk related to medication use, tremors, coordination shuffling and environment. Staff were to assist, supervise and visually check the resident. No further information was found in the resident's record to indicate objectives, timeframes and services provided related to the resident's fall risk needs. On 7/27/17 at 2:29 pm Staff 2 (DNS) acknowledged Resident 167's care plan did not include objectives, timeframes and services provided to meet the resident's fall risk needs. 11. Resident 144 was admitted to the facility in 4/2016 with [DIAGNOSES REDACTED]. The 5/27/17 Annual MDS indicated Resident 144 received antipsychotic and antidepressant medication. The 6/7/17 [MEDICAL CONDITION] Drug Use CAA indicated the resident received antipsychotic and antidepressant medication. Resident 144 had advancing [MEDICAL CONDITION] with behavioral disturbances which had advanced since her/his stroke. It was identified Resident 144 had behaviors including agitation, impulsiveness, frustration and anger. A review of the resident's clinical record revealed no information regarding measurable goals, objectives or timeframes and what approaches would be used to meet those goals related to Resident 144's behaviors and use of [MEDICAL CONDITION] medications. On 7/28/17 at 12:21 pm Staff 4 (RNCM) acknowledged there was no information regarding measurable goals, timeframes or what approaches would be used to meet those goals for Resident 144's behaviors and use of [MEDICAL CONDITION] medication in Resident 144's care plan. 12. Resident 153 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. The 7/14/17 Significant Change MDS indicated Resident 153 was frequently incontinent of bowel and bladder. The resident required two person extensive assistance with toileting. The 7/25/17 Urinary Incontinence CAA indicated Resident 153 had advanced Alzheimer's dementia and was incontinent of bladder and bowel with occasional continent episodes. The resident had difficulty making her/his needs known and staff provided frequent toileting and incontinence care. The family requested Resident 153 receive comfort measures only. A review of the resident's clinical record revealed no information regarding measurable goals, objectives or timeframes and what approaches would be used to meet those goals related to Resident 153's incontinence. On 7/28/17 at 10:31 am Staff 8 (RNCM) acknowledged there was no information in the care plan regarding measurable goals, timeframes or what approaches would be used to meet those goals for Resident 153's urinary incontinence. 13. Resident 46 admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The resident's clinical record did not include measurable objectives, timeframes and staff responsible to meet the resident's medical, nursing, and mental and psychosocial needs. In an interview on 7/28/17 at 8:58 am Staff 2 (DNS) confirmed Resident 46's care plan did not include measurable objectives and timeframes. | 2020-09-01 |