cms_AZ: 26

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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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
26 DESERT TERRACE HEALTHCARE CENTER 35014 2509 NORTH 24TH STREET PHOENIX AZ 85008 2019-03-08 641 D 0 1 QDGY11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#382 and #81). The sample size was 31. This deficient practice could affect residents' continuity of care. Findings include: -Resident #382 was admitted on (MONTH) 21, 2019, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The orders also included blood sugar accuchecks before meals and at bedtime. Review of the Medication Administration Record [REDACTED]. A Nursing Progress Note dated (MONTH) 22, 2019, revealed the resident threw her medications when the medications were placed in her hand per her request. Review of the MAR indicated [REDACTED]. The admission MDS assessment dated (MONTH) 28, 2019 revealed a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The assessment also included the resident had no behaviors during the seven day look-back period which included no verbal or other behaviors directed towards others, and no rejection of care. An interview conducted on (MONTH) 7, 2019 at 12:55 p.m. with the Certified Nursing Assistant (CNA/staff #57) who had completed the section of the MDS assessment for behavior. She stated that she was aware the resident had refused medications and treatments and had slapped and scratched the nurse. The CNA stated that she did not include the behaviors on the MDS assessment because she understood why the resident had those behaviors. She stated that it was a communication problem. An interview was conducted on (MONTH) 8, 2019 at 9:43 a.m. with the Licensed Practical Nurse (LPN/staff #22) MDS Coordinator and the MDS resource Registered Nurse (RN/staff #128). Staff #22 stated that she did not review the behavior section of the MDS assessment. Staff #22 further stated that if she was completing the behavior section for this resident, she would ask the resource nurse how to code this resident's behaviors. The RN stated that her instructions would be to include the resident's behaviors in the behavior section of the assessment and develop a care plan for the behaviors. They both agreed that they use the RAI Manual as the policy and procedure guide for coding the MDS assessment. The RAI manual revealed the behavior section of the MDS assessment focuses on the resident's actions, not the intent of the resident's behavior. The RAI Manual also included that once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. -Resident #81 was admitted on (MONTH) 15, 2019, with a [DIAGNOSES REDACTED]. Review of the closed record revealed a discharge summary progress note dated (MONTH) 24, 2019 that the resident was discharged home on (MONTH) 24, 2019. However, review of the discharge MDS assessment dated (MONTH) 25, 2019, revealed the resident was discharged to an acute care hospital on (MONTH) 24, 2019. An interview was conducted on (MONTH) 7, 2019 at 1:23 p.m. with the MDS coordinator (staff #22). The MDS coordinator stated the resident was discharged home and not to the hospital. Staff #22 also stated that the discharge MDS assessment regarding the resident's discharge location was an error. An interview conducted on (MONTH) 8, 2019 at 8:20 a.m. with the Director of Nursing (DON/staff #56). She stated the resident was discharged home and that the MDS assessment was coded incorrectly. The DON stated that they follow the RAI manual for coding the MDS assessments. The RAI manual instructs to review the medical record including the discharge plan and discharge orders for documentation of discharge location and select the code that corresponds to the resident's discharge status. The RAI manual also included that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessments cannot be over-emphasized. 2020-09-01