| 2675 |
PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR |
115586 |
277 COMMERCE STREET |
HAWKINSVILLE |
GA |
31036 |
2017-09-21 |
279 |
D |
0 |
1 |
V4Q111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to revise or develop the comprehensive care plan for three residents (R#93, R#17, and R#71) by not utilizing the current assessment to reflect the status of each resident. The sample size was 31 residents. Findings include: 1. On 9/20/17 review of the medical record on the initial physician's orders [REDACTED]. She was admitted with PO for [MEDICATION NAME] (an appetite stimulant) 40 milligrams (mg) by mouth (po) three times a day (TID). Her admission weight was recorded on the Weight Change History form as 88 pounds (lbs.) on admission. On 4/25/17 the PO sheet noted an order for [REDACTED].>On 6/7/17, the Weight Change History form recorded R#93's weight as 82 lbs. On 7/11/17, the Weight Change History form recorded R#93's weight as 83 lbs. On 8/31/17, the Weight Change History form recorded R#93's weight as 81 lbs. R#93's 9/2017 (no specific date listed) Blood Pressure and Weight Chart form weight recorded was 79 lbs. On 9/18/17, 9/19/17, 9/20/17 and 9/21/17, various times throughout the day R#93 was observed pacing about the facility on a frequent basis. She ambulated (walked) continuously in her Merry Walker (a device to aid in ambulation) throughout the building. R#93 was alert with confusion noted to place and time confirmed by attempted interview. PO's dated 9/8/17 noted an order to discontinue Ensure daily and begin Ensure Clear with meals and Ensure pudding with meals. The Ensure Clear (a dietary supplement for nutrition) was provided to R#93 on her meal tray for all meals. There was no documentation noted of the percentage of supplement R#93 received for increased caloric intake. Review of the medical record's comprehensive Care Plan for R#93 dated 8/21/17 revealed an identified problem; .at risk for weight changes and nutritional deficits. Identified interventions did not include the dietary supplement nor the appetite stimulant, R#93 had received daily since admission or the recent order to increase the supplement to TID with meals to increase caloric intake and prevent weight loss. The facility failed to revise the care plan to accurately reflect the current interventions in place for R#93 to prevent weight changes and maintain nutritional status. Interview with the Dietary Supervisor (DS) on 9/21/17 at 10:30 a.m., revealed supplement percentage was not recorded separately, it was included as part of the overall meal intake percentage. When asked how she could determine the effectiveness of the supplement provided to R#93 for her weight loss, the DS indicated the Certified Nursing Assistant (CNA) staff working in the dining room would report to her if R#93 did not take her supplement or eat her meals. She continued to indicate nothing had been reported to her, so she assumed R#93 was taking her supplement as ordered by the physician. Interview with the Director of Nursing (DON) on 9/21/17 at 10:05 a.m., revealed the facility did not record percentage of dietary supplement intake separately. She indicated it was included in the total meal percentage intake on the Activity of Daily Living (ADL) sheets documented by the CNAs. She further indicated if a resident was not taking their supplement, the CNAs would report it to the nurses and the dietary manager. After reviewing the care plan for R#93; the DON confirmed the care plan had not been revised to indicate R#93 had been receiving a dietary supplement to prevent weight changes and maintain nutritional status since she was admitted to the facility. 2. Observation of R#17 on 9/19/17 at 9:06 a.m., revealed she had broken and discolored teeth. Covering each of her visible teeth, was debris and a discolored thick substance of buildup. R#17 was interviewable at times, but she did not answer simple questions appropriately. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed R#17 was readmitted to this facility on 5/13/17 with a cognitive impairment, (Section C). The facility coded R#17 as a five out of possible 15 on the Brief Interview for Mental Status (BIMS), which indicated R#17's cognitive status was severely impaired, (Section C). Review of (Section L) for Oral/Dental Status revealed R#17 had obvious or likely cavity or broken natural teeth. Review of the medical record and the hospital record Progress Note(s) revealed R#17 was admitted to the hospital on [DATE] with some respiratory and digestive concerns. The physician documented on his Progress Note dated 5/3/17, R#17 had some periodontal disease. Continued review of the medical record Progress Note dated 5/8/17 revealed the following information: R#17 has oral pain. There is some evidence of thrush here. There is still a marked crusting and evidence of periodontal disease. Peroxide gargle may help. We will start with Magic Mouthwash and [MEDICATION NAME] and watch for improvement. During an interview on 9/20/17 at 9:45 a.m., with a Certified Nursing Assistant (CNA) LL assigned to R#17, revealed she did not assist R#17 with her oral care because R#17 refused help. CNA LL stated R#17 did not brush her teeth, but she was supposed to use a mouthwash after each meal to help with her oral hygiene. Review of the Activity of Daily Living (ADL) care plan dated 6/26/17 revealed the facility failed to develop a goal, approach and interventions to ensure R#17's oral needs could be met. The following information was obtained from R#17's ADL care plan: Problem: .Resident is very unkept and refuses to bathe and brush teeth Goal: .Resident will exhibit less refusal for staff to assist her with ADL's and staff to clean room thru next review. Approaches: .Assist her with grooming as she will allow . The ADL care plan was not specific to R#17's periodontal disease, her prescription mouth wash, how or when to assist her with her oral hygiene needs, or what to do if the resident refused assistance. An interview with the MDS Coordinator, Licensed Practical Nurse (LPN) CC on 9/20/17 at 10:00 a.m., revealed she was aware that R#17 had periodontal disease and had refused care, however she failed to develop a specific care plan relative to R#17's dental and oral needs. 3. Clinical record review of R#71's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's medical record Minimum Data Set (MDS) admission assessment (a comprehensive assessment used in nursing facility's), dated 6/7/17, the resident's weight was 154 pounds (lbs.) on admission. According to the Nutritional Documentation documented by the consultant dietitian, Resident #71 had an 8-lb. weight loss, which was 5.5% in 30 days. R#71's weight on 8/31/17, documented in the resident's Weight Record, was 136 lbs. and on 9/19/17 it was 137 lbs. R#71's medical record Nutrition care plan, dated 6/20/17, revealed interventions to reach a goal of .Nutritional status will be observed for stability for weights within baseline parameters thru (through) next review 9/28/17 for a problem indicated as .Need for observation for identified weight loss concerns. Medical conditions posing impact on weight and nutritional status. The review of the care plan revealed no new interventions to address the residents additional weight loss after admission. According to R#71's medical record physician's orders [REDACTED].%. This new intervention was not noted in the care plan. The resident's Medication Administration Record [REDACTED]. Refer to F325 for further findings. During an interview with LPN CC, who was the MDS Coordinator and developed the care plans, on 9/21/17 at 8:25 a.m., it was confirmed the care plan had not been updated. LPN CC stated she was not aware the resident had the order for the Ensure to be administered into the resident's PEG tube, since she was not responsible for following up on orders that were written. She said the DS who was an LPN, was responsible for that information. During an interview with the DON on 9/21/17 at 8:48 a.m., revealed she expected a change in the resident to be addressed in the resident care plan. |
2020-09-01 |