6 |
COOSA VALLEY HEALTHCARE CENTER |
15010 |
260 WEST WALNUT STREET |
SYLACAUGA |
AL |
35150 |
2017-04-06 |
278 |
D |
0 |
1 |
0F3P11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #2's height was coded on RI #2's 2/25/16, Initial Minimum Data Set (MDS) assessment, 2) RI #4's height and [MEDICAL TREATMENT] status was coded on RI #4's 7/22/16, Significant Change MDS assessment, and 3) RI #5's catheter was coded on RI #5's 10/21/16, Annual MDS assessment. These deficient practices affected RI # 2, RI #4 and RI #5, three of 15 residents whose MDS assessments were reviewed. Findings Include: 1) RI #2 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #2's Admission Assessment, dated 2/15/16, revealed RI #2 had an admission height of 64 inches. A review of RI #2's Initial MDS assessment with an Assessment Reference Date (ARD) of 2/25/16, revealed RI #2's height was not captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI (Employee Identifier) #8, the MDS Coordinator. The surveyor asked EI #8 should there be a weight and height on the MDS. EI #8 replied, Yes. That is asked on all of them. The surveyor asked EI #8 was RI #2's height coded on RI #2's Admission MDS assessment dated [DATE]. EI #8 said RI #2's height was not on the MDS. EI #8 said the area had 0's and she did not know why. The surveyor asked EI #8 should RI #2's height be on the MDS. EI #8 replied, Yes Ma'am. The surveyor asked EI #8 was RI #2's 2/25/16 MDS assessment an accurate assessment. EI #8 said no, it would not be accurate without the height being on it. 2) RI #4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #4's [MEDICAL TREATMENT]/[MEDICAL CONDITION] care plan, no date, revealed RI #4 started [MEDICAL TREATMENT] 8/2014. A review of RI #4's Significant Change MDS assessment with an ARD of 7/22/16, revealed RI #4's height nor [MEDICAL TREATMENT] status was captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 was RI #4's height recorded on RI #4's Significant Change MDS dated [DATE]. EI #8 said no, there were 0's on the MDS. The surveyor asked EI #8 should the height be recorded. EI #8 replied, Yes Ma'am, it should be recorded. The surveyor asked EI #8 was RI #4 on [MEDICAL TREATMENT]. EI #8 said yes. EI #8 said RI #4 had been on [MEDICAL TREATMENT] since 2014. The surveyor asked EI #8 should RI #4, being on [MEDICAL TREATMENT], have captured on the 7/22/16 MDS. EI #8 said yes. The surveyor asked EI #8 did she see where the [MEDICAL TREATMENT] status captured on the MDS. EI #8 said she did not. The surveyor asked EI #8 was this MDS assessment an accurate assessment for RI #4. EI #8 replied, no, not with the [MEDICAL TREATMENT] not being on the MDS. 3) RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's most recent annual MDS with an ARD of 10/21/2016, revealed RI #5's Foley catheter status was not captured during this assessment period. The Foley was placed on 8/22/16, and should have captured on the 10/21/16 MDS. On 4/16/17 at 4:10 p.m., the surveyor and EI # 8 had a discussion on when RI #5's Foley catheter was placed. It was agreed from reviewing the resident's chart that the catheter was placed on 8/22/16. The MDS dated [DATE] was reviewed. In section H, Bladder & (and) Bowel, Field H0100, [NAME] Indwelling catheter was coded, 0, On 4/16/17 at 4:25 p.m., an interview was conducted with EI #8. EI #8 was asked who was responsible for coding the MDS. EI #8 replied, she was. EI # 8 was asked was RI #5's 10/21/16 MDS coded correctly in regards to the catheter. EI #8 replied, no ma'am. EI # 8 was asked why the catheter was not checked on 10/21/16 in Section H0100. EI #8 replied, an error, an oversight. EI #8 was asked when should it be coded if a person was using a catheter. EI #8 replied, on the assessment that was due. EI #8 was asked why should a catheter be coded if a resident was using a catheter. EI #8 replied, it tells you they have a catheter and it was important to know that. EI #8 was asked why was it important to code correctly on the MDS. EI #8 replied, the MDS gives you a picture of the resident. EI #8 stated when looking at the MDS, you should be able to know everything about the resident. |
2020-09-01 |