| 26 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2018-12-06 |
770 |
D |
1 |
1 |
H65F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews and review of facility documents as indicated, it was determined that the facility failed to meet the needs of three (R15, R85 and R99) out of 54 sampled residents with regard to the quality and/or timeliness of providing laboratory services. Findings include: 1. Cross refer, F684 example #1 Review of R85's clinical record revealed: 9/19/18 at 11:13 PM - A physician's phone order was entered for an H&H to be drawn on 9/21/18 for R85. Review of R85's clinical record lacked evidence of results for the 9/21/18 H&H. Review of the Lab Form Book on the second floor showed names of residents who needed lab work drawn for 9/21/18. R85 was listed, and it stated she needed an H&H drawn that day. The form was initialed by the laboratory technician and dated 9/21/18, indicating that the lab was drawn. On 12/4/18 at 1:50 PM during an interview, E2 (DON) stated that when the lab results were requested by the surveyor, the facility contacted the lab responsible for doing the lab work for R85 on 9/21/18. E2 stated that the lab had no evidence that the technician had actually drawn blood from R85 for the ordered lab work. The facility failed to obtain laboratory services to meet the needs of R85. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). 2. Cross refer, F684 example #2 Review of R99's EMR revealed the following: 9/7/18 - A physician's orders [REDACTED]. 9/14/18 - Review of laboratory results revealed that the ammonia level, ordered on [DATE], was not drawn. 9/14/18 3:59 pm - A nurse's progress note stated the resident was due for an ammonia level, but the draw was not completed because the test was not ordered. The progress note stated the lab was called and rescheduled the ammonia level for 9/15/18. 9/15/18 - Review of the Lab Form Book revealed that although an ammonia level was entered to be drawn for R99, it was not signed off by the laboratory technician as completed. A notation stated Must be called in for Monday 9/17/18. 9/17/18 - An ammonia level was drawn 3 days after it was ordered to be drawn. The results revealed the level was 133 (range 0-60). The facility failed to ensure that laboratory services met the needs of R99 and that they were performed timely. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). 3. Review of R15's EMR revealed the following: Review of R15's laboratory (lab) results for a BMP (set of eight tests that measure blood sugar and calcium levels, kidney function, and chemical and fluid balance), dated 11/30/18, had handwritten notes from the physician that stated, Encourage fluids x 3 days and Repeat BMP 12/3/18. R15's BUN (blood test to measure kidney function) was elevated at 47 (normal range 10-26). Review of R15's EMR revealed there were no BMP results for 12/3/18 and there were no other BMP results for R15 as of 12/5/18. 12/5/18 12:35 PM- findings were reviewed with E3 (ADON). E3 stated that the BMP on 12/3/18 was not entered into the EMR as a physician order, it was not written in the lab book and it wasn't done. When asked whose responsibility it was to ensure MD or NP orders were input to the EMR, E3 stated after the MD or NP signs the lab results, the unit manager or another nurse on the floor should review the signed lab result and put the order(s) in the EMR. The facility failed to obtain laboratory services as per physician order [REDACTED]. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3, and E14 (QA). |
2020-09-01 |