| 30 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2018-03-21 |
657 |
E |
1 |
0 |
U1E811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review, the facility failed to update the care plan to accurately reflect the current status for 3 (#s 1, 5, and 6) of 11 sampled residents. Findings include: 1. During an interview and observation on 3/19/18 at 1:20 p.m., resident #1 stated she took care of herself, and did not need any assistance from the staff. The resident sat up in bed without assistance and sat at the edge of the bed to speak. During an observation on 3/20/18 at 11:05 p.m., resident #1 was walking without assistance or a device, to the nurses station. She stated she was going out to lunch that day. She was dressed up, had makeup on, and stated she had dyed her hair purple that morning. Review of resident #1's Care Plan, dated 7/28/17, showed the resident required guided maneuvering of extremities, verbal cueing and sufficient time to perform and/or assist during dressing and other ADL's as needed; transfer with walker and supervision; encourage resident to participate in ADL tasks as able. Review of resident #1's Care Plan, dated 7/28/17, showed she was at high nutritional risk. Review of resisdent #1's Weight sheet showed a severe weight loss of 13 percent from (MONTH) (YEAR) to her present weight of 95.6 pounds and was not identified on the care plan. Review of resident #1's discharge summary from the hospital, dated 1/2/18, showed the resident was diagnosed with [REDACTED]. The risk for dehydration with interventions and monitoring, was not addressed on the care plan. During an interview on 3/19/18 at at 1:30 p.m., resident #1 stated she smoked, and kept the cigarettes and lighter in her room, because the supplies kept disappearing. Review of resident #1's Care Plan showed she needed to check out smoking materials, and the supplies could not be kept in her room. During an interview on 3/20/18 at 1:20 p.m., staff member B stated she was not sure which staff member was to update resident care plans. Staff member B stated at times she updated the care plans, and at other times, the MDS Coordinator or the floor nurse updated the plans. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident needed total assistance of two staff for bathing. During an interview on 3/19/18 at 3:30 p.m., resident #5 said he wanted, and was getting, two showers a week. Resident #5 said NF1 and himself had addressed concerns with the provision of showers with the facility, repeatedly (refer to F550). The resident voiced concerns with not having showers provided, per his preference. Review of resident #5's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. 3. During an interview on 3/21/18 at 7:45 a.m., resident #6 said she liked to have at least two showers per week due to her bowel incontinence issue. Resident #6 said she did not like to smell of body odor, feces or to have greasy hair. Resident #6 said she had made the facility aware of her preferences. Review of resident #6's Quarterly MDS, with an ARD 10/3/17, showed the resident needed total assistance of 1 staff for bathing. Review of resident #6's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. A review of the facility's policy, Comprehensive Care Plans, Protocol, showed, 5. The care plan is reviewed with the first Comprehensive MDS Assessment is and revised to reflect personalization and resident specific preferences. |
2020-09-01 |