| 4336 |
PLEASANT VIEW NURSING CENTER |
115411 |
475 WASHINGTON STREET |
METTER |
GA |
30439 |
2016-11-23 |
278 |
J |
1 |
0 |
C00C11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews the facility failed to ensure that the Minimum Data Set (MDS) was coded accurately including pressure sores (PSores), indwelling urinary catheter and weight loss for one (1) resident (R35). The failure of inaccurate coding of the MDS resulted in a lack of care planning. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Record review of the Quarterly MDS dated [DATE] revealed that R35 was coded to have one (1) Stage II PSores. R35 was discharged to the hospital on [DATE] with 1 Stage II PSores. R35 was re-admitted to the facility on [DATE]. Review of the wound physician notes dated 9/7/2016 revealed R35 had five (5) PSores at this time including: two (2) stage II and one (1) unstageable on the coccyx; 2 fluid filled blisters to the heels one each heel. However, review of the re-entry MDS dated [DATE] revealed that only 1 Stage III PSores coded on the MDS, and there was no evidence on the MDS of coding for the weight loss, review of the monthly weight monitoring form revealed that R35 weighed 152 pounds (lbs) on 8/1/16. (Cross refer to F325) Review of the wound physician progress notes [REDACTED]. However, R35 continued to have the following PSore: a stage III w to the central coccyx measuring 3.9 x 3.4 x 0.2 centimeters (cm); a unstageable wound to the right, lateral heel with eschar, measuring 2.9 x 3.5 x not measureable depth and a shear wound to the left, posterior, lateral hip with eschar, measuring 4.5 x 4.5 x 0.1 cm. However review of the 14 day MDS dated [DATE] revealed that the PSore coding was unchanged without additional PSore and no there was no evidence of the weight loss being coded. Review of the monthly weights revealed that on 9/7/16 R35 weighed 115lbs. (Cross refer to F325) Review of the wound physician progress notes [REDACTED]. However, review of the discharge MDS dated [DATE] revealed that the coding was unchanged indicating that R35 had one Stage III PSore and no evidence of weight loss. Review of a MDS dated [DATE] revealed that PSores were not coded although the admission skin assessment revealed R35 had seven (7) PSores and an indwelling urinary catheter coded, nor was the weight loss. Review of the five day MDS dated [DATE] remained unchanged with 1 Stage III PSore, no coding of the indwelling urinary catheter and no coding to indicate the weight loss. Review of the wound physician progress notes [REDACTED]. Review of the discharge MDS dated [DATE] revealed that R35 had 2 Stage II and 3 Stage III PSores, nor was the weight loss coded on the MDS. Review of the re-entry MDS dated [DATE] revealed that PSores were not coded, however review of the re-admission skin assessment dated [DATE] revealed that R35 had 7 PSores. The Wound Physician did not see the resident after re-admission on 11/3/2016 and before discharge on 11/9/2016. R35 was hosptalized on [DATE] with severe dehydration and multiple wounds. The hospital discharge summary, dated 11/3/2016, revealed R35 had a percutaneous endoscopic (PEG) gastrostomy tube (feeding tube) placement and surgical debridement of decubitus wound. R35 was discharged back to the facility on [DATE] with continuous feedings via the PEG tube of Glucerna 1.2 at 40 milliliter (ml) per hour and water flushes, 200 ml, every four (4) hours. Review of the wound physician progress notes [REDACTED]. Review of the wound physician progress notes [REDACTED]. R35 was not seen on 10/26/16 due to hospitalization and on 11/9/2016 R35 was discharged to another facility. Interview on 11/22/2016 at 2:00 p.m. with Licensed Practical Nurse (LPN) EE and the current interim Administrator revealed that the former DON would give her the information to enter into the MDS. LPN EE stated she had no idea that the information was incorrect or that she should be looking at the residents for accuracy of PS, indwelling urinary catheter or weight loss herself to ensure the information was correct prior to finalizing the MDS. |
2019-11-01 |