| 65 |
SERENITY REHABILITATION AND HEALTH CENTER LLC |
95015 |
1380 SOUTHERN AVE SE |
WASHINGTON |
DC |
20032 |
2018-07-20 |
657 |
D |
0 |
1 |
L7I811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interview for three (3) of 56 sampled Residents, the facility failed to update the care plan to include goals and approaches to address one (1) resident with a low [MEDICATION NAME] level, one (1) resident nutritional diet change, and one (1) resident that sustained a fall. Resident #6, #158 and #327. Findings included . 1. Facility staff failed to update the care plan to include goals and approaches to address Resident #6 low [MEDICATION NAME] level. Resident #6 admission was on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MONTH) 6, (YEAR), section I Active [DIAGNOSES REDACTED]. Observation on (MONTH) 11, (YEAR), 10:30 AM showed Resident #6 on the way to [MEDICAL TREATMENT], accompanied by a staff member with the communication medical record binder. Review of the Nutrition Progress Note on (MONTH) 20, (YEAR), at 3:00 PM showed the RD (Registered Dietitian) received a consult notice from RNP (Registered Nurse Practitioner) and [MEDICAL TREATMENT] regarding marginally low [MEDICATION NAME] reading. Resident's [MEDICATION NAME] was 3.4 gram per deciliter on a 3.5-5.5 gram scale. [MEDICAL TREATMENT] goal is 4 gram. The resident will receive 30 milliliters of Pro Source by mouth every day until the next [MEDICATION NAME] reading. A review of the resident's Nutrition/[MEDICAL TREATMENT] care plan lacked evidence that the facility updated the care plan with goals and approaches to reflect a low [MEDICATION NAME] level. During a face-to-face interview on (MONTH) 19, (YEAR) at 3:15 PM, Employee#19 reviewed the care plan and acknowledged the findings. 2. Facility staff failed to update the care plan to include goals and approaches for Resident #158 nutritional diet change. Resident #158 admission was on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set, dated dated dated (MONTH) 19, (YEAR), Section K0310 Nutritional Approaches under C showed Mechanically altered diet - require a change in the texture of food or liquids. A review of physician order [REDACTED]. A review of the Resident's care plan showed a care plan for Nutrition Problem: Mastication difficulty related to medical state as evidenced by mechanical soft diet order date initiated (MONTH) 15, (YEAR). The Resident's care plan lacked evidence that the facility updated the care plan with goals and approaches to reflect Regular diet, Regular texture, Nectar consistency, Nectar thick liquids Double Portion entree per meal every shift when the diet order changed on (MONTH) 20, (YEAR). During a face-to-face interview on (MONTH) 19, (YEAR), at 3:15 PM, Employee#19 reviewed the care plans and acknowledged the findings. 3. Facility staff failed to update the care plan to include goals and approaches to address Resident #327 fall. Resident #327 initially admitted on (MONTH) 4, (YEAR), and hospitalized briefly. On (MONTH) 7, (YEAR), Resident #327 was readmitted with [DIAGNOSES REDACTED]. During a resident representative interview on (MONTH) 11, (YEAR), at 3:33 PM, the resident responsible party stated the staff told her that the resident had fallen and has a bruise on the back and left arm. Review of the admission Minimum Data Set, dated dated dated (MONTH) 11, (YEAR) showed Resident #327 was severely cognitively impaired as coded in Section B Cognitive Status C0500. Brief Interview for Mental Status (BIMS) Summary Score of three (3). In addition, the resident's self-performance required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene as coded in Section G Functional Status Activities of Daily Living Assistance (ADLs) as three (3); and support from staff for activities of daily living provided by staff was coded as one (1) one person physical assist. A review of Nursing Notes showed Resident #327 fell on (MONTH) 9, (YEAR), at 9:15 AM, in dayroom and was later observed on the floor of his room at 11:00 AM. A review of the resident's care plan showed a care plan for Potential risk for falls related to limited mobility initiated (MONTH) 7, (YEAR). However, Resident #327's care plan lacked evidence that the facility updated the goals and approaches to address the falls Resident #327 sustained on (MONTH) 9, (YEAR). During a face-to-face interview on (MONTH) 19, (YEAR), at 3:15 PM, Employee#19 and Employee #3 acknowledged the findings. |
2020-09-01 |