cms_MT: 1044
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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1044 | LAUREL HEALTH & REHABILITATION CENTER | 275111 | 820 3RD AVE | LAUREL | MT | 59044 | 2019-10-10 | 842 | D | 1 | 0 | TUEN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 (#1) of 4 sampled residents. Findings include: During an interview on 10/10/19 at 12:00 p.m., staff member C stated she did not know why a weekly skin check on a treatment record would be blank. Staff member C stated she generally, over-charted, when something was refused or missed. She stated she initialed the box, and then circled her initials. Staff member C stated she would then write a note describing the circumstances of the refusal or the missed treatment or medication. Staff member C stated that not all of the nurses documented the same way. During an interview on 10/10/19 at 2:35 p.m., staff member [NAME] stated she did not think there was a consistent method for documenting missed or refused medications or treatments. But, she did feel something should be documented, either on the treatment record or in the nursing notes. Review of resident #1's Wound TAR, dated (MONTH) 2019, showed: - wound treatment of [REDACTED]. - wound treatment of [REDACTED]. - wound treatment of [REDACTED]. - wound treatment to right calf cluster every day shift - showed blank dates without nursing notes providing an explanation for the blank dates: 5/23/19, 5/24/19, and 5/26/19 - wound treatment to scrotum every day shift - showed blank dates without nursing notes providing an explanation for the blank dates: 5/23/19, 5/24/19, and 5/26/19 - wound treatment to right hip and right knee M and F - showed blank dates without nursing notes providing an explanation for the blank dates: 5/20/19 and 5/24/19 Review of the facility Aseptic Dressing Technique Competency, dated (MONTH) 2014, showed, .sign TAR, document on skin grid if appropriate. | 2020-09-01 |