cms_SD: 42
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 42 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 657 | E | 0 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure 6 of 13 sampled residents (5, 21, 33, 37, 41, and 53) had their care plans followed, updated, and revised timely to reflect their current status and care needs. Findings include: 1. Observations, interview, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 5 revealed:*Her 3/27/18 care plan had not been updated timely related to her falls and interventions for them. Refer to F689, finding 2. 2. Observations, interview, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 41 revealed her 3/14/18 care plan had not been: *Updated timely related to her falls and interventions for them. *Updated to reflect her current physician's orders [REDACTED]. *Followed by staff related to her fall and pressure ulcer interventions. Refer to F686, finding 1. Refer to F689, finding 1. Observation, interview, and review of the CNA cheat sheet on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during and following resident 41's personal care revealed: *The resident was wearing compression stockings to both legs and slipper socks on her feet. *She had no dressings in place to both of heel pressure injuries. -CNA I was not aware she was supposed to have dressings on her heels. *She was not wearing the foam boots that morning. -The CNA thought she only needed to wear her boots when she was in bed. *The CNAs used a cheat sheet as a reference for how to take care of the residents. *She was the person who updated those cheat sheets with input from the nurses. *CNAs also had access to review the residents' care plan in the electronic medical record. *She agreed residents' care plans and cheat sheets should have been updated to their current status and needs. *The cheat sheet for resident 41 included: -[NAME] hose on left leg only. -No mention of her pressure injuries or that nurses did a treatment for [REDACTED]. -No mention of the foam boots or when she should have worn them. Observation and interview on 3/13/18 at 11:17 a.m. with registered nurse (RN) [NAME] and licensed practical nurse (LPN) D in resident 41's room following her personal care revealed: *Her care plan was not being followed related to her pressure injuries. *She should have been wearing foam boots at all times, and she had not been wearing them that morning. *She was supposed to have dressings in place to both heels, and those had not been on. *The foam boots to her feet were for pressure relief related to pressure injuries on both of her heels. *They confirmed the CNA's cheat sheet had not reflected the appropriate interventions. *The resident's care plan should have been current to her status and need and followed by staff. 3. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *She had been moved from one room to another on 9/18/17 due to concerns with her rummaging through her roommates belongings. -On 10/5/17 she was involved in an incident with her current roommate where she was being hit by her. *Her [DIAGNOSES REDACTED]. *She had been on an antidepressant ([MEDICATION NAME]) since 11/22/17. -On 3/14/18 another antidepressant ([MEDICATION NAME]) had been ordered as well. Observations on 3/27/18 from 11:45 a.m. through 6:00 p.m. of resident 37 revealed: *She was independently ambulatory throughout the building. *Her overall demeanor appeared pleasant that afternoon. Review of resident 37's 2/7/18 quarterly Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status examination score was eight indicating she had moderate cognitive impairment. *She had no [MEDICAL CONDITION]. *During the lookback period she had: -One to three days of verbal behaviors only. --There was no impact on her or others. -She had rejected care one to three days. Review of resident 37's CNA task documentation related to her behaviors for the previous thirty days revealed:*On 3/23/18 and 3/26/18 she had physical and verbal behaviors. *On 3/26/18 she had social behaviors. Review of resident 37's behavior and other progress notes from her 8/18/17 admission through 3/27/18 revealed:*She was admitted from home and was pleasant and cooperative. -She was brought by her husband and was walking independently without an assistive device. *On 8/23/17 she was packing up clothes and wearing her roommates clothes. *On 8/25/17 an MDS note stated she was eager and friendly, but staff had reported she was rummaging through her roommates belongings and her clothes. *On 9/15/17 she was being moved to another room due to rummaging through items. - .Her new roommate will tolerate that behavior better . *On 10/5/17, CNA overheard this resident tell her roommate 'stop hitting me.' CNA was outside of room and did not witness this resident being hit. Resident states she did not get hurt, assessed and no injury noted. CNA redirected the roommate of this resident out of this area. *On 11/1/17, at pm meal this resident attempted to make her tablemate put his nasal cannula on, telling him that he had to and she knew so because she once worked here. When this nurse intervened to separate this resident and her tablemate this resident became very angry striking out at this nurse then grabbing my arm and trying to yank me around. This nurse to resident 'that's enough, take your hands off me and don't touch me like that, it's not acceptable.' Resident began to yell again that she can do what she wants because she once worked here. Tablemate removed and placed at a different table secondary to this resident would not calm down and quit yelling. This resident struck out at and grabbed this nurse 2 more times. Staff will continue to monitor. *On 11/7/17, At app. (approximately) 1015 this am, this resident was sitting in a chair, and approached by another resident. This resident started yelling at the other resident, telling her to sit down. The other resident did not sit down, so this resident then took her by the hand and physically sat her down in a chair. She then yelled 'I used to work here, and you stay there!' This resident was then educated on not touching others. She kept repeating 'but I used to work here, I was a CNA' I explained to her that she no longer works here, and cannot touch other residents. She then promised that she wouldn't do that again. *On 11/20/17, CNA informed this nurse that resident has been having behaviors of: wandering into other resident's rooms, attempting to help residents out bed (even resident that require extensive/dependent assist), taking items and clothing that do not belong to her. Refusing to change clothes even after wearing same clothes for days. CNA tells me that she become very angry and yells at them when they attempt to correct her and refuses to cooperate. When they attempt to take clothing or items from her and return them to their owner, she will yell and argue saying 'I won that, its mine.' Note left for Dr. (name) updating her. *On 12/17/17 a 8:55 p.m. noted, This nurse heard resident yelling at her roommate .This nurse told this resident that she needed to go back to her side of the room. Resident swung her arm at me and yelled that she was a CNA here and that she could do as she wished. I again told her to go to her side of the room and keep her hands to herself. Resident continued to yell and tried x4 to grab this nurse. Resident did eventually go to her bed and sit down but continued to yell out . *On 12/28/17 there were notes about her moving her roommate's things around in room. *On 12/31/17 she was yelling at her roommate on two different occasions that evening. *On 3/14/17 at 9:16 a.m. a social service (SS) note, SS called (name) (husband) to get verbal consent for behavior assessment ordered by Dr. (name). SS explained that Sharon hit bath aide and Dr. (name) sent order. His response was 'I don't think that is a good idea.' When SS asked him why not, he stated 'I don't want to pay for it.' SS stated that Medicare would cover part or all of it he consented. He also stated that 'hitting is typical for (resident name).' SS sent referral to (facility name) for behavior assessment. -That note occurred during the first week of survey after surveyors had been questioning referrals for other residents with behaviors. --There had been no mention of getting an evaluation prior to that. -That was the same day 3/14/18 a new antidepressant medication ([MEDICATION NAME]) was ordered, but it had not been mentioned in the notes. Review of resident 37's 3/27/18 care plan related to behaviors revealed:*Most interventions were initiated on admission. *Revisions were not done timely to reflect the above incidents and behaviors. *Behaviors specific to her roommate's concerns had not been addressed. 4. Observations, interviews, and record reviews during the surveyor related to resident 53 revealed:*His undated baseline care plan had not been individualized and specific related to his skin concerns. *His 3/13/18 care plan did not have any additional interventions added related to his newly acquired pressure ulcer. Refer to F686, finding 2. 5. Observations, interview, and record review during the survey related to resident 21 revealed her care plan had not been followed or updated related to her activities and grief. Refer to F740, finding 1. 6. Observations, interview, and record reviews during the survey related to resident 33 revealed her care plan had not been updated timely related to her falls and interventions for them. Refer to F610, finding 2. Surveyor: 7. Interview and record review on 03/13/18 at 11:06 a.m. with CNA supervisor I related to care plans revealed: *The CNAs used a cheat sheet as a reference for how to take care of the residents. *She was the one who updated those cheat sheets with input from the nurses. *CNAs also had access to review the resident care plan in the electronic medical record. *She agreed residents' care plans and cheat sheets should have been updated to their current status and needs. *Staff should have been following the resident's care plans. Interview on 3/14/18 at 1:21 p.m. with LPN A and RN G regarding residents' care plans revealed: *Residents' care plans should have been updated to reflect their current status and needs. *Care plans were typically only updated by the Minimum Data Set (MDS) coordinator nurse and the director of nursing (DON). *Nurses could have updated care plans, but most of the time they left that up to the MDS nurse. *Resident care plans should have been followed and updated as changes occurred. Interview on 3/14/18 at 3:05 p.m. with the administrator, DON, MD'S assessment coordinator, and social services coordinator S regarding care plans revealed: *Charge nurses usually did not update or revise residents' care plans. *Most changes and updates to the care plans were being done by the MD'S coordinator with the assistance of the DON. *They agreed residents' care plans should have been updated to reflect the resident's current status and needs. -Updates should have been done as changes occurred. *They expected residents' care plans to have been followed by staff. Review of the provider's revised (MONTH) 2010 Care Plans-Comprehensive policy revealed: *The individualized comprehensive care plan was to have included measurable objectives, and timetables to meet the resident's medical, nursing, mental, and psychological needs. *The comprehensive care plan was to have been based on a thorough assessment that had included but was not limited to the Minimum Data Set assessment. *Each resident's comprehensive care plan had been designed to: -Incorporate identified problem areas. -Incorporate risk factors that had been associated with identified problems. -Build on the resident's strengths. -Reflect the resident's expressed wishes for care and treatment goals. -Reflect treatment goals, timetables, and objectives in measurable outcomes. -Identify the professional services that were responsible for each element of care. -Aid in preventing or reducing declines in the resident's functional status and/or functional levels. -Enhance the optimal functioning of the resident by focusing on a rehabilitative program. -Reflect currently recognized standards of practice for problem areas and conditions. *Care plan interventions were to have been designed after consideration of the resident's problem areas and their causes. *Care plans were to have addressed underlying sources of the problem area. *Assessments of residents were to have been ongoing and care plans were to have been revised accordingly. *The care plan team had been responsible for the review and updating of the care plans at the time of: -Significant change in the resident's conditions. -When desired outcome was not met. -When the resident had been readmitted to the facility from a hospital stay. -Quarterly review. Review of the provider's revised (MONTH) 2006 Using the Care Plan policy revealed:*3. Cans are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved.*4. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and/or the MD'S Assessment Coordinator. Review of the provider's revised (MONTH) 2006 Care Plans - Preliminary Policy revealed: *1. To ensure the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of admission.*2. The Interdisciplinary Team will review the Attending physician's orders [REDACTED]. dietary needs, medications, and routine treatments, etc.), and implement a nursing care plan to meet the resident's immediate care needs. | 2020-09-01 |