cms_AZ: 14
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
14 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2019-01-25 | 655 | D | 0 | 1 | YXH311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, the facility failed to ensure a summary of the baseline care plan was provided to one resident (#63). Findings include: Resident #63 was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a form titled Baseline Care Plan Summary, this form included the resident's goals during his admission, medication orders, and diet orders. This form included a space for the resident to sign. However, there was no resident signature documented. Further review of the clinical record revealed no evidence the resident was provided with a summary of his baseline care plan. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. During an interview conducted on (MONTH) 22, 2019 at 12:28 p.m. with the resident, he stated that the staff do not include him in his care. An interview was conducted on (MONTH) 25, 2019 at 10:04 a.m. with a unit coordinator/ registered nurse (RN/ staff #40). She stated baseline care plans are developed within two days after admission and include resident diagnoses, activities of daily living needs, and dietary status. She stated baseline care plans and goals are reviewed with the resident and a copy is offered to the resident. The RN stated that the resident will sign on the baseline care plan summary that a copy of the baseline care plan was provided to them. After reviewing the clinical record, she stated the baseline care plan summary for resident #63 was not signed but that she reviewed the care plan with the resident. An interview was conducted on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). He stated baseline care plans are developed within 48 hours after admission. He stated the baseline care plan includes medications, high risk concerns, and activities of daily living. The DON stated a final summary of the baseline care plan is given to the resident or the resident's representative. He stated on the baseline care plan summary form the resident will sign indicating the resident received or refused a copy of the baseline care plan. He stated that it is the facility's expectation that a copy of the baseline care plan is given to the resident or the resident's representative. The DON also stated that the facility does not have a policy for baseline care plans. | 2020-09-01 |