| 2618 |
AUTUMN BREEZE HEALTH AND REHAB |
115580 |
1480 SANDTOWN ROAD SW |
MARIETTA |
GA |
30008 |
2018-03-09 |
656 |
D |
0 |
1 |
UXT911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review. observation, and Interview the facility failed to implement a Comprehensive Care Plan for three (3) residents (R) #16 related to smoking, R#72 related to helping the resident with daily oral care, and R#82 related to ensuring the resident's medication goals and interventions to meet resident needs. This deficient practice had the potential to effect residents who smoke, residents that require assistance with Activities of Daily Living (ADL) care, and residents that have a daily drug regimen. The facility census was 84, and the sample size was 21. Findings Include: Record Review revealed the resident (R) #16 was admitted the facility on 6/7/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] section C-cognitive patterns; the resident has a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident has moderate cognitive impairment. Further review of the quarterly MDS of section J- health conditions sub-section J1300 tobacco use; indicates the resident uses tobacco. Review of the comprehensive care plan initiated 6/8/17 for R#16 does not indicate the resident is care planned for tobacco use or smoking. Observation of R#16 smoking on 3/6/18 at 11:00 a.m. while in the designated smoking area revealed the resident smoking with a smoke apron that was torn and not fitting properly, and a large white plastic industrial size bucket half filled with water is noted for disposal of the resident's ashes and cigarettes after smoking. Observation of R#16 smoking on 3/8/18 at 2:00 p.m. while in the designated smoking area revealed the resident wearing a torn smoking apron not fitting properly, a large white plastic industrial sized bucket is used for the disposal of the resident's ashes and cigarette's after smoking. Interview on 3/8/18 at 1:09 p.m. with the MDS Coordinator revealed when a resident is admitted to the facility a smoking assessment is completed on admission and then annually. Interview revealed if the resident is assessed to be a smoker; a care plan is completed to note the residents is a smoker with goals and interventions in place. Interview on 3/9/18 at 2:53 p.m. with the Director of Nursing (DON) revealed when a resident is assessed on admission to be a smoker; staff are expected to develop and implement a comprehensive care plan for the resident to meet the goals and interventions to ensure the resident is smoking safely. During the interview the DON revealed his expectation is for staff to follow the facility's smoking policy and procedures, and ensure the smoking residents have the proper materials such as smoke aprons and ashtrays for safe smoking. Review of the facility's policy and procedure titled Smoking revealed; metal containers with self-closing cover devices into which ashtray can be provided in all areas where smoking is permitted. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #82 Record Review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current medications listed: [MEDICATION NAME] 100 units/ml vial sliding scale per accu check before meals. [MEDICATION NAME] 100 units/ml give 35 units at night and 15 units in the morning. [MEDICATION NAME] 0.25 mg TID as needed for anxiety; Discontinued 2/14/18, donepezil 10 mg at bedtime, [MEDICATION NAME] 10 mg daily, Eliquis 5 mg twice daily, [MEDICATION NAME] powder 17 gm in 8 ounces (oz.) of liquid, [MEDICATION NAME] 20 mg daily, and potassium 10 MEQ daily. Review of annual Minimum Data Set ((MDS) dated [DATE] section C- cognitive patterns; revealed the resident has a Brief Interview for Mental Status score (BIMS) of 15, indicating the resident is cognitively intact. Review of section N- medications indicates the resident receives injections for insulin, insulin solution, opioids, and antipsychotic medications. Further review of the annual MDS section V- Care Area Assessment (CAA) revealed the R#82 triggered for [MEDICAL CONDITION] drug use, falls, pressure ulcer, and nutritional status, with the issues to be addressed in the resident's care plan. Review of the Care Plan initiated 11/17/17 revealed there is no care plan related to the residents' antidepressant or antipsychotic drug use to reflect person centered goals and interventions. Interview with the Director of Nursing (DON) on 3/9/18 at 2:47 p.m. revealed if a care area for the resident triggers to be addressed on the person-centered care plan; the responsible staff is expected to place the area of concern on the residents' person-centered care plan with goals and interventions to be implemented daily. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed. Review of the annual Minimum Data Set (MDS) assessment of 2/12/18 revealed R#72 had [DIAGNOSES REDACTED]. No behavioral symptoms such as rejection of care was documented. Under the Care Area Assessment Summary (CAAS) of the assessment, ADL/Functional rehab triggered and the decision was made to complete a plan of care for that area. Review of the plan of care initiated 2/26/17 for assistance with all ADLs secondary to weakness, intellectual disability, and [MEDICAL CONDITION] revealed interventions which included mouth care daily and as needed. During an interview on 3/6/18 at 9:17 a.m., R#72 said she was unable to brush her own teeth, but staff did not always assist in brushing her teeth. In fact, staff had failed to, regularly, brush her teeth for several weeks, even months. Observation of the resident's oral cavity at the time of the above interview revealed teeth that were stained a dark yellow and had an extensive amount of plaque and food. Review of dental progress notes for the resident from 3/17/17, 9/28/17 and 12/11/17 revealed the resident's oral hygiene was described as having heavy calculus, plaque, and food. Observation of the resident's mouth on 3/7/18 at 12:30 p.m. and again on 3/8/18 4:35 p.m. revealed her teeth to have the same appearance - dark yellow with extensive plaque and food build-up. Interview on 3/9/18 at 7:16 a.m. with Licensed Practial Nurse (LPN) DD revealed he works the 7:00 p.m. to 7:00 a.m. shift on the resident's hall. The Certified Nursing Assistants (CNAs) that work the 11:00 p.m. to 7:00 a.m. shift are responsible for completing ADL tasks for each resident as needed. The nurse on the unit is responsible for overseeing the CNAs' work and ensuring that the ADLs are completed. R#72 is totally dependent on staff for ADL care such as oral hygiene. The nurses rely on the CNAs to accurately report that ADLs are completed for the resident, but the nurse is also responsible for checking the resident's oral status during the administration of medications or during other interactions with the resident; Observation of the resident's oral area on 3/9/18 at 7:29 a.m. with LPN DD in attendance revealed the resident's teeth had been recently brushed. The teeth were still discolored, but appeared to have no build-up of food or other materials. Interview again with LPN DD at the time of this observation revealed that the resident's oral care/condition is affected by the CNA assigned to the resident on any given day. Some CNAs are meticulous with the resident's oral hygiene; for others (from another hall for example), oral care may be done in a careless manner or not at all. CROSS-REFERENCE TO F677 |
2020-09-01 |