| 160 |
CARLYLE SENIOR CARE OF AIKEN |
425014 |
123 DUPONT DR NORTHEAST |
AIKEN |
SC |
29801 |
2018-11-30 |
641 |
E |
0 |
1 |
JLSM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure the accuracy of assessments for 7 of 23 sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments (Residents #23, #52, #57, #66, #67, #70, and #135) and for 2 of 2 residents noted on the MDS 3.0 Missing OBRA Assessment report (Residents #40 and #60). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the 8-29-18 Admission/5-Day and the 9/7/18 14-Day MDS assessments on 11/29/18 at 11:23 PM revealed the following: (1) Section B of both assessments noted that the resident was sometimes understood and sometimes understands. However, the Section C Brief Interview for Mental Status (BIMS) and the Section D Mood interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) The 9/7/18 14-Day assessment only had one fall coded. Review of Incident/Accident Reports on 11/30/18 at 9:34 AM revealed the resident had sustained 2 falls during the 7-day look-back period (on 9/1/18 and 9/5/18). During an interview on 11/30/18 at 10:19 AM, the MDS Coordinator stated that Sections C and D were completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record, verified the falls noted in the Nurses Notes and on the Care Plan, and confirmed that the number of falls coded on the 14-Day MDS was incorrect. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Hypertension, [MEDICAL CONDITION], Dementia, Aspiration Pneumonia, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux Disease, B-12 Deficiency, and Multiple [MEDICAL CONDITION]. Review of the 2-6-18 Significant Change and the 10-21-18 Quarterly MDS assessments on 11/27/18 at 7:48 PM revealed the following: (1) Section B of both assessments noted that the resident was usually understood and sometimes understands. However, the Section D Mood and Section F Preferences for Customary Routines and Activities interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) On the 2/6/28 MDS, J1400 was coded that the resident did not have a life expectancy of less than 6 months. Record review on 11/29/18 at 12:32 PM revealed physician's orders [REDACTED]. During an interview on 11/29/18 at 3:05 PM, the MDS Coordinator stated that Section D was completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record and verified that J1400 should have been coded that the resident's life expectancy was less than 6 months. S/he stated that Section F, usually completed by the Activity Director, should have been completed with the resident's/family's input as the spouse came 3 times per week. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of the 10-21-18 Annual MDS assessment on 11/29/18 at 11:43 PM revealed the following: The Section F Preferences for Customary Routines and Activities interviews were not conducted. The reason recorded was that the resident was rarely/never understood. Section B noted the resident was usually understood and understands. During an interview on 11/30/18 at 11:46 AM, the MDS Coordinator confirmed that the Section F interviews had not been conducted and that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of the 6-3-18 Quarterly and the 10-26-18 30-Day Quarterly MDS assessments on 11/26/18 at 1:59 PM revealed the following: (1) The 6-3-18 Quarterly MDS noted that the resident had both a weight loss and a weight gain. (2) The 10-26-18 30-Day Quarterly MDS noted that there was a weight loss but that the resident was on a physician prescribed weight loss program. During an interview on 11/30/18 at 11:51 AM, the MDS Coordinator confirmed that the resident had no significant weight gain during the period in review by the 6-3-18 MDS and that the resident had never been on a physician prescribed weight loss program. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Review of the 12-3-17 Annual and the 11-2-18 Significant Change MDS assessments on 11/27/18 at 6:22 PM revealed the following: (1) The pain interviews in Section J were not conducted for either assessment. (2) The 12-3-17 Annual MDS noted the resident's weight at 221 pounds and indicated s/he was on a physician prescribed weight gain program. (3) The 11-2-18 Significant Change MDS noted the resident's weight at 198 pounds and indicated s/he was on a physician prescribed weight loss program. During an interview on 11/29/18 at 03:13 PM, the MDS Coordinator verified that the pain interviews had not been conducted. S/he stated that the resident had not been on any physician-prescribed weight loss or gain programs. During an interview on 11/29/18 at 4:20 PM, the Dietary Manager stated s/he had hit the wrong button. The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11-15-18 Admission/5 day MDS on 11/28/18 at 9 AM revealed the following: (1) [DIAGNOSES REDACTED]. (2) Inattention, disorganized thinking, and physical behavior toward others were not coded for this resident. The resident was admitted with information from the hospital stating that s/he was exit-seeking and incapable of reality-based thinking. Review of Nurses Notes on 11/28/18 at 10:07 AM revealed the resident was combative when redirected, aimlessly ambulated in the hall, and remained seated for short times only. S/he struck another resident while s/he was asleep on 11-15-18. During an interview on 11/29/18 at 03:30 PM, the MDS Coordinator verified that the [DIAGNOSES REDACTED]. S/he also noted that the resident-to-resident abuse should have been coded because the incident occurred on the assessment reference date. Review of the MDS 3.0 Missing OBRA Assessment report with the MDS Coordinator on 11-29-18 revealed that (1) the facility had completed/transmitted an assessment for Resident #40 with the wrong gender, and (2) for Resident #60, the facility had entered the wrong birth date. The facility admitted Resident # 66 on 6/9/17 with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 11/27/18 at 1:13 PM revealed that on 8/9/18 the facility placed a self-release lab belt restraint on the resident, related to many falls. On 8/14/18 the facility had the resident evaluated for hospice services. The resident started hospice care on 8/15/18. The Minimum Data Set (MDS) reviewed on 11/27/18 at 2:39 PM indicated that the MDS coordinator conducted a significant change assessment on 8/15/18. However, s/he did not note the restraint or hospice services. During an interview on 11/28/18 at 9:38 AM the DMS coordinator confirmed the above findings. |
2020-09-01 |