| 67 |
OAK HILL HEALTH & REHABILITATION CENTER |
415027 |
544 PLEASANT STREET |
PAWTUCKET |
RI |
2860 |
2018-06-18 |
842 |
D |
0 |
1 |
NPS511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 2 non-sample residents selected for a medication review (ID #11) and 1 of 22 sample residents (ID #49). Findings are as follows: 1. Resident ID # 11's record revealed that the resident was seen by the Wound Clinic on 5/18/2018 with the following recommendations: a.) Right, Lateral Ankle Wound: wash wound with vashe solution, apply santyl oint nickel thick to wound bed, follow by Algisite M, and dressing. Change dressing daily. b.) Left, Proximal, Anterior Leg Wound: wash wound with vashe solution, apply santyl oint nickel thick to wound bed, follow by Algisite M, and dressing. Change dressing daily. c.) Left, Distal, Anterior Leg Wound: wash wound with vashe solution, apply santyl oint nickel thick to wound bed, follow by Algisite M, and dressing. Change dressing daily. d.) Right Leg Circumference Wound: wash wound with vashe solution, apply durafiber Ag, and dressing. Change dressing daily. Review of the physician's orders [REDACTED].>Review of the Medication Administration Record [REDACTED]. Additionally, the (MONTH) TAR revealed 3 out of 13 opportunities and the (MONTH) TAR revealed 5 out of 15 opportunities where the treatment to the left distal anterior leg was not documented as complete. During a surveyor interview with the Corporate Nurse, staff B, on 6/15/2018 at 10:39 AM, she was unable to explain why one of the four wound clinic recommendations were not ordered nor why two of the wound treatments ordered on [DATE] were not on the TAR. Additionally, she was unable to provide documentation that the treatment to the left proximal anterior leg wound was done on the days it was not signed off. 2. Resident ID #49's record revealed a physician's orders [REDACTED]. An additional order dated 10/25/2017 states, patient to wear left resting hand splint at all times as tolerated except during hygiene cleaning and during therapy check skin integrity. During a surveyor observation on 6/14/2018 at 9:38 AM and 6/18/2018 at approximately 11:15 AM, in the presence of the nurse, Staff A, the resident was not wearing the left hand splint. Staff A informed the surveyor that she has never applied the splint. Review of the (MONTH) (YEAR) TAR revealed that the nurse, Staff A (who had worked the 11-7 shift), signed off that the resident was wearing the splint on 6/14/2018 and 6/18/2018. During a surveyor interview on 6/18/2018, the nurse Staff A acknowledged that she did not see the resident with the splint on during the 11-7 shift and should not have signed off the TAR. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities, they are deficiencies under State Regulations and grounds for licensure sanctions. |
2020-09-01 |