| 183 |
WHITE OAK MANOR - LANCASTER |
425017 |
253 CRAIG MANOR ROAD |
LANCASTER |
SC |
29720 |
2017-06-15 |
278 |
D |
0 |
1 |
HKAH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assure that 2 out of 3 residents reviewed for nutrition, 1 out of 3 residents reviewed for activities of daily living, dental, vision, and accidents and 1 out of 1 resident reviewed for pressure ulcers received accurate assessments. Residents #18 and #48. The Findings Included: Review of the medical record conducted on 6/14/2017 revealed that the facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review of Resident #18's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/25/2017 on 6/14/17 revealed Section B (Hearing, Speech Vision) item B1200 (Corrective lenses) was coded 0=no. Further review of medical record revealed documentation on Daylight IQ Assessments (COMS) entered on 5/20/2017 at 6:19 PM and 5/22/17 T 12:58 am which both reflects EENT Vision Corrective: Glasses indicating that resident utilized corrective lenses during the 7 day assessment window prior to the ARD of 5/25/17 of the Comprehensive MDS. During group interview on 6/14/17 at 3:45 PM, when asked if Resident #18 wore glasses when awake, Licensed Practical Nurse) LPN #1, LPN # 2, and Certified Nursing Assistant (C.N.[NAME]) #1 all replied Yes. When LPN #1 was asked if s/he could recall how long Resident #18 has worn glasses, s/he replied as long as I can remember. During an interview on 6/15/17 at 10:00 AM, MDS Nurse #1 agreed that item B1200 (corrective lenses) was incorrectly coded as 0=no and should have been coded as 1=yes. Additional record review on 6/14/2017 of Resident #18's Annual Comprehensive MDS assessment with ARD of 5/25/2017 revealed Section G (Functional Status) items G0110A2 (Bed mobility: support provided), G0110H2 (Eating: support provided), and G0110I2 (Toilet use: support provided) were all coded as 2=one person physical assist and item G0110H1 (Eating: self-performance) was coded as 2=limited assistance-resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight- bearing assistance. Further review on 6/14/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #18 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 5/19/17-5/25/17 for Comprehensive MDS with ARD of 5/25/17. Review of documentation revealed 7 episodes where Resident #18 received 2+ persons physical assist for bed mobility, and 5 episodes where Resident #18 received 2+ persons physical assist for toileting. Review of the documentation for the amount of assistance and support provided for eating for 5/19/17-5/25/17 revealed 8 episodes where resident was independent with only set-up help provided, 4 episodes of supervision with only set-up help provided, and 1 episode of supervision with no set-up or physical help from staff provided. When asked where s/he looks in the resident's record/ documentation to gather information regarding ADL assistance and support provided during interview on 6/15/17 at 10:22 AM, MDS Nurse #1 stated the ADL flowsheet. When asked if the ADL flowsheet is the ADL Assistance and Support report, s/he indicated that it was the same report. MDS Nurse #1 further verified during interview that using the ADL flowsheet for (MONTH) (YEAR) for Resident #18, items G0110A2 (bed mobility: support provided), G0110H2 (eating: support provided), and G0110I2 (toilet use: support provided) were incorrectly coded as 2=one person physical assist. Using the ADL flowsheet, MDS Nurse #1 verified that G0110A2 (bed mobility: support provided) and G0110I2 (toilet use: support provided) should have been coded as 3=2+ persons physical assist and G0110H2 (eating: support provided) should have been coded as 1=set up help only. Additionally, MDS Nurse #1 verified that G0110H1 (eating: self-performance) was incorrectly coded as 2=limited assistance when the ADL flowsheet reflects 9 episodes with resident identified with self-performance independent (0) with eating and 5 episodes of self-performance level of supervision (1) with no episodes of any other levels of self-performance identified. S/he further agreed that item G0110H1 was incorrectly coded when following the ADL self-performance coding instructions regarding the rule of 3 in Chapter 3 page G-6 in Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.14 updated (MONTH) (YEAR). MDS Nurse #1 further stated that she does not agree with the information documented on the ADL Flowsheet for self-performance and support provided for eating during the assessment period of 5/19/17-5/25/17 and that is why s/he coded G0110H1 as 2=limited assistance and G0110H2 as 2=one person physical assist, however, when asked where the additional supportive documentation to reflect that Resident #18 received limited assistance on at least three occasions during assessment period and one person physical assist at least on one occasion during the assessment period of 5/19/17-5/25/17, s/he verified that there was no documentation in record to support what was coded regarding eating self-performance and support provided. Ongoing record review on 6/14/2017 of Resident #18's Annual Comprehensive MDS assessment with ARD of 5/25/2017 revealed that Section L (Oral/ Dental Status) item L0200B (Dental: no natural teeth or tooth fragment(s)) was not checked and item L0200Z (Dental: none of the above) was checked. Additional review of documentation on 6/14/17 revealed Daylight IQ Assessments (COMS) entered on 5/8/17 at 11:44 AM which identifies Dental Condition: no natural teeth or tooth fragment(s). Further review of Nutritional Screening Review completed by Registered Dietitian (RD) #1 on 5/19/17, revealed under staff comments: .Resident with no natural teeth or dentures . MDS Nurse #1 verified that Section L (Oral / Dental Status) was incorrectly coded and that L0200B (Dental: no natural teeth or tooth fragment(s)) should have been checked instead of L0200Z (Dental: none of the above) during interview on 6/15/17 at 10:00 AM. Review of Resident #48's medical record revealed that s/he was admitted to facility with [DIAGNOSES REDACTED]. Record review on 6/13/107 of Resident #48's Comprehensive MDS assessment with ARD of 10/20/2016 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance) and G0110IA (Toilet use: self-performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Further review revealed that in Section L (Oral/ Dental Status) Item L0200B (no natural teeth or tooth fragment(s) (edentulous) was not checked, and Item L0200Z (none of the above) was checked. Further review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 10/14/16-10/20/16 for Comprehensive MDS with ARD of 10/20/2016. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on three occasions, extensive assistance with bed mobility on three occasions, and was totally dependent with bed mobility on fifteen occasions. Further review of this documentation reveals that Resident #48 received extensive assistance with eating on one occasion and was totally dependent with eating on sixteen occasions, and s/he received extensive assistance with toileting on two occasions with total dependence documented on 13 occasions during assessment period of 10/14/16-10/20/16. Additional review of Resident #48's Care Plan page 1 of 20 revealed that Resident #48 was identified to have no teeth or dentures as a part of the second approach. MDS Nurse #1 was interviewed on 6/15/17 at 10:22 AM. When MDS Nurse #1 was asked where s/he looks in the resident's record/ documentation to gather information regarding ADL assistance and support provided, s/he stated the ADL flowsheet. When asked if the ADL flowsheet is the ADL Assistance and Support report, s/he indicated that it was the same report. MDS Nurse #1 also verified that the documentation on the (MONTH) (YEAR) ADL Flowsheet for Resident #48, during the dates of 10/14/16-10/20/16 reflected that limited assistance was provided with bed mobility on three occasions and extensive assistance was provided with bed mobility on three occasions. Additionally, s/he verified that the documentation on the ADL flowsheet for (MONTH) (YEAR) during the dates of 10/14/16-10/20/16 reflected that extensive assistance was provided with eating on one occasion, and extensive assistance was provided with toileting on to occasions. When asked if there was any additional documentation in the record that would indicate that the information documented on the ADL flowsheet was identified as incorrect and should not be used as a source for calculation of the ADL self-performance/ support provided during the assessment period of 10/14/16-10/20/16, MDS Nurse #1 replied that there was no additional documentation. When asked if the coding was incorrect for items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance), and G0110IA (Toileting: self-performance) which all indicated 4=total dependence when using the ADL flowsheet as supportive documentation, MDS Nurse #1 agreed. S/he further stated that s/he did not agree with the information on the ADL flowsheet, but verified that there was no documentation in the record that identified any disputed entries on the ADL flowsheet as incorrect and that with information available, the MDS was incorrectly coded for G0110A, G0110HA, and G0110IA when following the rules in Chapter 3 page G5-6 of the (MONTH) (YEAR) RAI Manual. Additional review of Resident #48's Care Plan page 1 of 20 revealed that Resident #48 was identified to have no teeth or dentures as a part of the second approach. During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that Resident #48 did not have any natural teeth and that item L0200B (no natural teeth or tooth fragment(s)/ edentulous) should have been checked instead of L0200Z (none of the above). Further record review on 6/13/107 of Resident #48's Quarterly MDS assessment with ARD of 1/19/17 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110GA (Dressing: self-performance) and G0110HA (Eating: self-performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Additionally, items G0400A (ROM limitation: upper extremity) and G0400B (ROM limitation: lower extremity) were both coded as 1=impairment on one side. Additional review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 1/13/17-1/19/17 for Quarterly MDS with ARD of 1/19/17. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on one occasion, extensive assistance with bed mobility on three occasions. Further review of this documentation reveals that Resident #48 was independent with eating on one occasion, received extensive assistance with eating on three occasions, and s/he received extensive assistance with toileting on three occasions during assessment period of 1/13/17-1/19/17. Further review of Narrative Notes from Daylight IQ (COMS) completed 1/15/17 at 1:42 PM revealed that Resident #48 was noted to have FROM impairment on both upper and lower extremities. During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that G0110A (bed mobility-self performance), G0110GA (Dressing: self-performance) and G0110HA (eating: self-performance) were incorrectly coded and with the supportive documentation available, should have all been coded as 3=extensive assistance using the guidance in the (MONTH) (YEAR) RAI Manual regarding the rule of 3 in chapter 3 on page G-6. S/he also verified that items G0400A & G0400B (functional limitations in range of motion in upper and lower extremities) were incorrectly coded and (1=impairment on one side), and both G0400A and G0400B should have been coded as 2=impairment on both sides. Additional review of medical record on 6/13/107 of Resident #48's Quarterly MDS assessment with ARD of 3/30/17 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance), and G0110I1 (Toileting-self performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Additionally, items G0400A (ROM limitation: upper extremity) and G0400B (ROM limitation: lower extremity) were both coded as 1=impairment on one side. Further review revealed that in Section M (Skin Conditions) that Item M0300B1 (Stage 2 pressure ulcers: number present) was coded as 1 and Item M0300B3 (Stage 2 pressure ulcers: date of oldest) was coded as 2/13/2017. Item M0300C1 (stage 3 pressure ulcers: number present) was 0 and Items M0610A, M0610B, and M0610C were all Blank Additional review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 3/24/17-3/30/17 for Quarterly MDS with ARD of 3/30/17. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on one occasion, and extensive assistance with bed mobility on two occasions. Further review of this documentation reveals that Resident #48 required supervision with eating on one occasion, and s/he received extensive assistance with toileting on one during assessment period of 3/24/17-3/30/17. Ongoing review revealed that on Daylight IQ Assessment (COMS) completed on 3/27/17 at 12:18 AM that Resident #48 had FROM limitations in both upper and lower extremities. Additional record review revealed a Wound Care *Skin Integrity* Evaluation completed on 3/24/17 which identified Wound 1 on sacrum which had an onset date of 2/14/17 was identified as a pressure ulcer-stage III (3). During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that G0110A (bed mobility-self performance), G0110HA (Eating: self-performance) and G0110HI (Toileting: self-performance) were incorrectly coded and with the supportive documentation available, should have all been coded as 3=extensive assistance using the guidance in the (MONTH) (YEAR) RAI Manual regarding the rule of 3 in chapter 3 on page G-6. S/he also verified that items G0400A & G0400B (functional limitations in range of motion in upper and lower extremities) were incorrectly coded and (1=impairment on one side), and both G0400A and G0400B should have been coded as 2=impairment on both sides. Additionally, MDS Nurse #1 verified that M0300 (current number of unhealed pressure ulcers at each stage), M0610 (dimensions of unhealed stage 3 or 4 pressure ulcer .), and M0700 (most severe tissue type for any pressure ulcer) were all incorrectly coded on the quarterly MDS assessment with ARD of 3/30/17. |
2020-09-01 |