cms_AK: 4
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 278 | E | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure MDS (Minimal Data Set), a Federally required nursing assessment, were accurately completed to reflect the status of 3 residents (#s 4, 5 and 6) out of 6 residents who's MDS's were reviewed. This failed practice resulted in inaccurate information about 3 residents and placed them at risk for inaccurate care planning and care. Findings: Resident #4 Record review from 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of Resident #4's Medication Administration Record [REDACTED]. Review of the discontinued and completed medication lists from 10/16/16 to 5/18/17 revealed no antipsychotic medications were listed. Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE], revealed the assessment coded the Resident as receiving antipsychotic medications during the last 7 days. During an interview on 5/17/17 at 2:30 pm the MDS Coordinator stated Resident #4 had not taken any antipsychotics should not have been coded as taking them on the 2/15/17 MDS assessment. Resident #5: Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, [MEDICAL CONDITION], depression, recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Initial/Admission Assessment: Review of the MDS assessment, an admission assessment, dated 2/14/17, revealed the Resident was coded as dressing did not occur under the activities of daily living (ADLs). In addition, the Resident was coded as having an unstageable pressure ulcer that was not present on admission and taking antipsychotic medication during assessment period. During an interview on 5/17/17 at 1:34 pm the MDS Coordinator stated the ADL dressing did occur and it was a miscoding. The MDS Coordinator further stated the Resident did have a pressure ulcer on admission and the MDS was miscoded. The MDS Coordinator reviewed the medication the Resident took during the admission assessment period and confirmed the Resident did not an antipsychotic medication. Quarterly Assessment: Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed Resident #5 was coded as not toileting. Further review revealed the Resident was coded as have taken antipsychotic medications during the quarterly assessment review period and had a [MEDICAL CONDITION]. During an interview on 5/17/17 at 1:34 pm, the MDS Coordinator stated the ADL toileting was miscoded as not occurring. In addition, the MDS Coordinator confirmed the Resident was not taking antipsychotic medications during the quarterly assessment review period. The MDS Coordinator further stated the Resident did not have a [MEDICAL CONDITION]. Resident #6 Record review from 5/16-19/17 revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 3/20/17 revealed the discharge [DIAGNOSES REDACTED]. Review of the nurse's progress note dated 3/22/17 revealed .dressing to stage 1 pressure injuries . No Stage 2 pressure injuries were identified. Review of the care plan for the problem Alteration in skin integrity revealed Document comprehensive description of pressure ulcer .Stage 1 x3, lt (left) hip, lt heel, and sacrum . Review of the admission MDS assessment dated [DATE], revealed the Resident was coded as having 3 - Stage 1 pressure injuries. During an interview on 5/18/17 at 10:00 am, Licensed Nurse (LN) #3 stated pressure injuries are never downgraded. The LN stated the pressure injury on the sacrum should have been identified as a Stage 2. Review on 523/17 of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.14, dated (MONTH) (YEAR), Chapter 3 Section M Page 1, revealed Review the medical record for the history of the ulcer .Review for location and stage at the time of admission/entry or reentry . Review on 5/23/17 of the National Pressure Ulcer Advisory Panel (NPUAP) website at http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf, revealed, .The numerical staging system does NOT imply linear progression of pressure injuries from Stage 1 through Stage 4, nor does it imply healing from Stage 4 through Stage 1 .The NPUAP has long maintained this position and issued a position statement recommending against down staging as early as the year 2000. One of the unintended consequences of identifying numerical stages of pressure injuries is that it invites the misinterpretation that stage implies a progression (forward or backward). NPUAP's system implies no progression . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.14, dated 10/2016, revealed It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the (Interdisciplinary Team) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .The RAI process, which includes the Federally-mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated . | 2020-09-01 |