cms_AK: 61
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
61 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 642 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a MDS (Minimum Data Set) assessment was completed accurately in accordance with standards set forth by Center for Medicare and Medicaid Services (CMS). Specifically, the facility failed to review five subsections of the MDS for the full 7-day look back period for 1 resident (#10) out of 8 sampled residents. This failed practice placed the resident at risk for improper care planning and denied the resident an accurate assessment of his or her current health care status. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. He/She has a history of bilateral [MEDICAL CONDITION] that left her wheelchair bound. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed Assessment Reference Date (ARD) refers to the last day of the observation (or 'look back') period that the assessment covers for the resident .Most of the MDS (Minimum Data Set) 3.0 items have a 7-day look back period. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed the following sections required a 7-day look back review: C1310; E0100; E0200; E0500; E0600; E0800; E0900; J1100; J1500; J1800; K0100; K0510; P0100; and P0200. Review of the admission MDS (Minimum Data Set) assessment, dated 10/11/17, revealed the Social Worker signed Sections C and [NAME] as completed on 10/10/2017 under Section Z (a day before the last day of review). Additional review revealed LN#3 signed Sections J, K and P as completed on 10/10/17 under Section Z (a day before the last day of review). During random interviews on 4/25-27/18, LN #3 stated he/she was unable to explain why Sections C, E, J, K and P were signed before the ARD date of 10/11/17. The LN further stated that some sections can be done early. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed the rationale for Section Z was To obtain the signature of all persons who completed any part of the MDS. Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response. Each person completing a section or portion of a section of the MDS is required to sign the Attestation Statement .The importance of accurately completing and submitting the MDS cannot be over- emphasized. | 2020-09-01 |