| 77 |
SERENITY REHABILITATION AND HEALTH CENTER LLC |
95015 |
1380 SOUTHERN AVE SE |
WASHINGTON |
DC |
20032 |
2018-07-20 |
773 |
D |
0 |
1 |
L7I811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, the facility faied to obtain a urine analysis, culture and sensitivity as per the nurse practitioners recommendation for one (1) resident, and failed to ensure one (1) resident's lab work was completed in accordance to the physician orders [REDACTED].#1 and #44). Findings include: Facility staff failed to obtain a urine analysis and culture and sensitivity as per the nurse practitioners recommendation for Resident #1. Resident #1 was readmitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. In addition, the resident has a suprapubic catheter in place. The Health Status note dated (MONTH) 12, (YEAR), at 10:55 AM read, Asked to resident's medication list due to repeated falls .[NAME] known dementia with repeated falls due to? H/o (history of) UTI (urinary tract infection) - SP (status [REDACTED]. P (plan).Check UA (urinalysis) and urine C/S (culture and sensitivity in AM for F/U (follow up) UTI. A review of the clinical record lacked evidence that the urinalysis and the culture and sensitivity of the resident's urine was completed as recommended by the Nurse Practitioner. During a face-to-face interview with Employee #5 on (MONTH) 17, (YEAR), at approximately 3:00 PM, she acknowledged the urinalysis and urine culture was note done. 2. Facility staff failed to ensure that Resident #44's lab work was completed in accordance with the physician's orders [REDACTED].>Resident #44 admitted on (MONTH) 26, (YEAR), with a [DIAGNOSES REDACTED]. A review of Physician orders [REDACTED]. (2) UA(urinalysis & (and) Urine C/S (culture /sensitivity) by I/O (in/out) Cath (catheter) on 2/17/18 AM Dx (diagnoses) R/O (rule/out) UTI (urinary tract infection). A review of the Clinical Records showed that the Resident had no labs drawn to be reported on since his admission to the facility (MONTH) 26, (YEAR), to (MONTH) 19, (YEAR), indicating the labs were not done. A review of the Nurses Progress Note dated (MONTH) 16, (YEAR), called responsible party to inform her of worsening UE (upper extremities) weakness and lab work ordered by NP (nurse practitioner). Responsible Party stated her needs to speak with NP (nurse practitioner) before the lab work is to be done . NP and notified her of Responsible party request to speak with her before the lab work is to be done. The evidence show facility staff failed to contact the (Hospital Name) lab and transport Resident #44 for CBC (complete blood count), CMP (comprehensive metabolic panel), Magnesium level, TSH, Free T4, Phosphorous level, Vit (vitamin) B12, Folate level, UA & C/S to ensure lab work was completed. A face-to-face interview conducted on (MONTH) 19, (YEAR), at 10:00 AM with Employee #19. She stated RP refused facility doing blood work only what she gave permission for, the resident must go to the (Outside hospital). She acknowledges the findings The labs were not done. |
2020-09-01 |