| 4052 |
CAMBRIDGE POST ACUTE CARE CENTER |
115771 |
2020 MCGEE ROAD |
SNELLVILLE |
GA |
30078 |
2018-09-27 |
698 |
D |
0 |
1 |
0V3G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain communication with a [MEDICAL TREATMENT] center to coordinate care for one Resident (R) #328 of two residents reviewed for [MEDICAL TREATMENT]. The sample size was 31. The findings include: Review of the medical record for R#328 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No mood or behaviors were noted. R #328 was assessed to requires limited assistance of two people for bed mobility, transfers, and toileting. The resident was assessed for having occasional mild pain and receiving scheduled and as needed pain medication. Resident was documented no for receiving [MEDICAL TREATMENT] while a resident and not a resident. Review of the physician orders [REDACTED]. - [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday, with a chair time of 9:15 a.m. - Renal, carbohydrate-controlled diet, regular texture, thin liquids consistency. - Remove pressure dressing from site four hours after returning from [MEDICAL TREATMENT]. - Check graft for positive bruit and thrill every shift. - No blood pressure (B/P) or blood sticks to left arm (graft site). Review of the admission care plan revealed a problem identified with the need for [MEDICAL TREATMENT]. Interventions included: - Check and change dressing daily at access site and document. - Check for bruit and thrill as ordered and per facility protocol. - Do not draw blood or take B/P in left arm with graft. - Monitor for dry skin and apply lotion as needed. - Monitor /document/report to doctor (MD) as needed any signs/symptoms of infection to access site, redness, swelling, warmth or drainage. - Obtain vital signs and weight per protocol. Report significant changes in pulse, respiration and B/P immediately. - Work with resident to relieve discomfort for side effects of the disease and treatment. Interview with R#328 on 9/24/18 at 3:15 a.m., in his room, revealed the resident leaves very early to go to [MEDICAL TREATMENT] and doesn't get back until after lunch in the afternoon. R#328 stated They won't send any medication with me out of the facility and I go all day in pain. The resident denied any knowledge of how the facility communicates with the [MEDICAL TREATMENT] center to assess his need for pain medication. On 9/25/18 at 8:30 a.m., R#328 was observed on an ambulance gurney coming out the front door of the facility going to the [MEDICAL TREATMENT] center. An observation and interview were conducted with R#328 on 9/26/18 at 8:55 a.m. R#328 was sitting on the side of the bed with breakfast remains on the bedside table. R#328 stated [MEDICAL TREATMENT] went well yesterday, and I didn't have any problems. I been going for years to the same place, but I have to change for a little while because they are renovating the center. Review of the electronic medical record for R#328 revealed one form titled [MEDICAL TREATMENT] Information Transfer Form dated 9/18/18. The form contained information for the resident's vital signs prior to transfer and that the resident refused breakfast that morning. The section of the form titled [MEDICAL TREATMENT] Facility Information: Renal Care was blank. Interview with Assistant Director of Nursing (ADON) AA, at the D Hall desk, revealed the facility does not usually get any information back from the [MEDICAL TREATMENT] center. ADON AA stated We don't call them if the resident is stable but if there was a problem then we would call the [MEDICAL TREATMENT] center and get information. Interview with the Director of Nursing (DON) on 9/27/18 at 10:30 a.m., in the front business office, revealed the facility utilizes an electronic communication form for [MEDICAL TREATMENT]. The nurse fills out the pre-[MEDICAL TREATMENT] information and prints the form to send with the resident. The [MEDICAL TREATMENT] center sends the form back and then it is scanned into documents. If the [MEDICAL TREATMENT] center doesn't send the form back, then the nurse is to call and get the information. The DON stated, The resident may have some documents that haven't been scanned back in yet and the DON indicated she would try and locate them. The DON was not able to provide any additional [MEDICAL TREATMENT] communication sheets for R#328. Interview with Licensed Practical Nurse (LPN) HH on 9/27/18 at 11:50 a.m., at the D Hall desk revealed she has not cared for R#328 before but she has another resident who goes out for [MEDICAL TREATMENT]. LPN HH revealed her procedure is to take the vitals and document the information on the transfer form. In addition, she would document the last time the resident ate, any medications given, and any changes in condition since their last [MEDICAL TREATMENT] visit. LPN HH stated the form goes with the resident and the [MEDICAL TREATMENT] center then sends it back with their information for what occurred during the residents' [MEDICAL TREATMENT] session. If the [MEDICAL TREATMENT] center doesn't send the information back, then she would call to get the information, if she can get the center to answer the phone. LPN HH revealed some [MEDICAL TREATMENT] centers are better than others about communicating with the facility. Review of the agreement titled Nursing Home [MEDICAL TREATMENT] Transfer Agreement signed and dated 8/09/2016 revealed the following: Designated Resident Information - Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center. This information, shall include, but is not limited to, where appropriate, the following: (a) Designated Resident's name, address, dat3 of birth and Social Security Number; (b) Name, address and telephone number of the designated Resident's next of kin; (c) Designated Resident's third part payor data and copies of cards or certificat4s evidencing same; (d) Appropriate medical records, including history of the Designated Resident's illness, including laboratory and x-ray findings; (e) Treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition (physical or mental). change of medication, diet or fluid intake; (f) Name, address and telephone number of the nephrologists with admitting privileges at Center referring the Designated Resident to Center; (g) Any advance directive executed by the Designated Resident; and (h) Any other information that will facilitate the adequate coordination of care, as reasonably determined by Center. Medical Records - Center shall maintain reports of all services rendered by Center in accordance with its usual medical records procedures. The ownership and right of control of all such reports, records, and supporting documents prepared in connection with the services shall rest exclusively in Center. Facility shall have the right to photocopy any such reports, records or documents for inclusion in its records. Review of the facility provided policy titled [MEDICAL TREATMENT], Care of the Resident Receiving [MEDICAL TREATMENT] Treatment dated (MONTH) (YEAR) and revised (MONTH) 2, (YEAR) revealed the following: Policy Statement; To prevent complications such as fluid overload, infection or clotting of the access area, or hemorrhage in residents receiving [MEDICAL TREATMENT]. Standard of Practice; 8. Arrange for [MEDICAL TREATMENT] as ordered. Send [MEDICAL TREATMENT] Information Transfer Form with resident. Bag lunch will be sent with resident. 9. Resident that is diagnosed with [REDACTED]. There was no additional information for communicating with the [MEDICAL TREATMENT] center to coordinate the resident's care. |
2020-09-01 |