| 69 |
SERENITY REHABILITATION AND HEALTH CENTER LLC |
95015 |
1380 SOUTHERN AVE SE |
WASHINGTON |
DC |
20032 |
2018-07-20 |
685 |
E |
0 |
1 |
L7I811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for four (4) of 56 sampled residents, facility staff failed to assist Resident #3 to obtain services that would include complete hearing evaluation to determine the extent of her hearing loss; and obtain a hearing device to correct and/or improve the resident's ability to hear if necessary; and for two residents (2) needing assistance with scheduling appointments for vision services Resident # 68 and Resident# 96 and to assist Resident #127 in obtaining glasses (which she needs for reading) to replace her broken glasses and failed to ensure residents received proper treatment to maintain vision abilities by failing to schedule ophthalmology appointments for two (2) residents. Residents' #3, #68, #96 and #127. Findings included . 1. Resident #3 was admitted to the facility on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. On (MONTH) 11, (YEAR) at approximately 11:00 AM I attempted to interview Resident #3 without success. Employee #9 had advised me prior to the interview that I needed to face the resident and yell loudly; as she (the resident) had difficulty hearing. However, the resident looked at me when I spoke, slapped her right ear intermittently and uttered no verbal response to the questions I asked. A review of the resident's annual minimum data set (MDS) with an Assessment Reference Date (ARD) of (MONTH) 1, (YEAR) Section B0200 (Hearing) shows the resident coded as a two (2) indicating that the resident has moderate difficulty hearing (speaker has to increase volume and speak distinctly). In B0300 (Hearing Aid) the resident wears no hearing aid or hearing appliance. Under B0600 (Speech Clarity) speech is unclear with slurred or mumbled words. Under B0700 (Makes Self Understood) she has difficulty communicating some words or finishing thoughts and under B0800 (Ability to understand) she misses some part/intent of message. A review of the resident's clinical record showed a neurologist's report which provided the following information. Hearing is markedly lost with tuning fork examination. Under Assessment the neurologist documented that the resident was markedly hard of hearing and under Plan he stated that the resident needs to see an audiologist for possible Hearing Aids. However, Resident #3's clinical record lacked evidence that she received an audiological evaluation. A face-to-face interview was conducted with Employee #5 at approximately 11:00 AM on (MONTH) 13, (YEAR). In response to the question of whether the resident received an audiological evaluation the employee stated that she thought that the resident had received the evaluation. However, she was unable to provide a report of the evaluation. At approximately 2:00 PM on (MONTH) 16, (YEAR) Employee #5 presented a faxed copy of a report of a Diagnostic Audiology Visit. The date of the visit was (MONTH) 05, (YEAR). The date printed on the bottom of the report was 07/16/2018 13:10 EDT indicating that the report was printed on (MONTH) 16, (YEAR) at 13:10 Eastern Daylight Time. The recommendation of the audiology evaluation is listed below: It is recommended that the patient return for Auditory Brainstem Response (ABR) testing under the influence of sedation, if medically/legally permissible, to further determine hearing status as today's findings are suggestive of some degree of hearing loss and patient was unable to perform behavioral tasks. Patient should be sedated to the point of sleep for 1-2 hours of testing if medically and legally permissible. After I reviewed the report I asked the employee whether the ABR testing was was ever conducted. She stated that the test was never done and added that she will make arrangements to have the test completed as soon as possible. Facility staff failed to assist Resident #3 to obtain services that would include complete evaluation and obtaining hearing device to correct and/or improve the resident's ability to hear. Employee #5 acknowledged the finding. 2 Facility staff failed to assist resident with scheduling an eye exam. Resident #68 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record on 7/10/18, showed a Compressive Minimum Data Set (MDS) dated (MONTH) 18, (YEAR), Section B Hearing, Speech and Vision (B1000). Vision ability to see in adequate light (with glasses or other visual appliances), the code entered is 1 which indicates Impaired-sees large print, but not regular print in newspaper/books. (B1200) Corrective lenses (contacts, glasses or magnifying glass) used in completing (B1000), Vision the code entered is 0, which indicates no. During a Resident interview on 7/10/18, at 4:15 PM, Resident# 68 stated she has problems with vision and the facility is aware. During an interview with Employee# 4 on 7/11/18 at 3:30 PM Employee #4 the employee reviewed the medical record and stated the record lack evidence of a completed or scheduled eye appointment. Employee#4 requested additional time to look into the matter. In follow-up on 7/17/18 at 1:00 PM Employee# 4 stted as a result of being unable to locate a record of an eye appointment the facility completed a Request for Medical Care Senior Vision Services dated 7/17/18, for Resident #68. The medical record lacked documented evidence the facility assisted the resident in making an appointment to obtain vision services. Facility staff failed to ensure the resident with impaired vision received proper treatment to maintain vision ability by failing to schedule an eye appointment. During a face-to-face interview on at 7/17/18 at 3:00 PM, Employee# 4 acknowledged the finding. 3. The facility staff failed to schedule an opthamology consult for a resident with [MEDICAL CONDITION] in accordance with the physicians order. Resident# 96 was admitted to the facility on [DATE] (initial admitted ) with [DIAGNOSES REDACTED]. A review of the medical record showed Review of the medical record on showed a Compressive Minimum Data Set ((MDS) dated [DATE], Section B Hearing, Speech and Vision (B1000). Vision ability to see in adequate light (with glasses or other visual appliances), the code entered is 1 which indicates Impaired-sees large print, but not regular print in newspaper/books. (B1200) Corrective lenses (contacts, glasses or magnifying glass) used in completing B1000, Vision the code entered is 0, which indicates no. During a resident interview on 7/10/18 at 3:00 PM , Resident #96 stated that the facility stopped administering [MEDICAL CONDITION] eyedrops, vision is blurry and he has not had an eye exam. Physician order [REDACTED]. The medical record lacked documented evidence the Opthamology was perforemed as ordered. Further review Resident#68 showed interventions to include Resident has impaired visual function related to [MEDICAL CONDITION], Intervention: Vision Consult. During an interview with Employee# 4 on 7/11/18 at 2:00 PM Employee# 4 sates there was no evidence the resident was seen for the Opthamology consult. During an interview with Employee#4 on 7/17/18 at 4:00 PM Employee #4 stated the physician was notified about the Opthamology consult for Resident # 96 and another was obtained. During a face-to-face interview on 7/17/18 at 4:30 PM Employee# 4 acknowledged the finding. 4. Facility staff failed to assist Resident #127 in obtaining glasses (which she needs for reading) to replace her broken glasses. On (MONTH) 10, (YEAR) Resident #127 showed me what she uses to read. The resident demonstrated her broken glasses. There was no shaft on either side to enable the resident to wear the glasses. The resident held the bridge with the lens on either side to demonstrate to me how she attempts to read. She stated, I try to read like this but it is difficult. I love to read and miss not being able to do so. Resident #127 was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. Review of section G (Functional Status) in G0110 Activities of Daily Living (ADL) assistance, the resident is coded as a zero (0) for bed mobility, transfer, locomotion, toilet use, personal hygiene, indicating that she performs these activities independently. In section G0 300 Balance During Transitions and Walking; moving from seated to standing, walking, turning around, and moving on and off toilet she is coded as a one (1) indicating that she was not steady but able to stabilize without staff assistance when completing these tasks and used an assistive device when walking. Under section G0 400 Functional Limitations in Range of Motion she is coded as a two (2) for upper and lower extremities indicating that she has impairments on both sides. Review of the care plans and progress notes showed no documentation about the resident's broken glasses. A face-to-face interview was conducted with Employee #5 at approximately 10:00 AM on (MONTH) 18, (YEAR). During the interview the employee was asked about the lack of documentation about the resident's glasses. The employee acknowledged that she was unaware of the broken glasses and that the facility staff failed to assist Resident #127 in obtaining glasses for reading. |
2020-09-01 |