cms_ND: 48
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 48 | MINOT HEALTH AND REHAB, LLC | 355031 | 600 S MAIN ST | MINOT | ND | 58701 | 2019-06-11 | 580 | E | 1 | 0 | HFFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information received from the complainants, record review and staff interview, the facility failed to notify the resident's physician and/or family member of a change in condition for 2 of 16 sampled residents (Resident #3 and #16) and 2 discharged residents (Resident #17 and #18) reviewed during the complaint survey. Failure to notify the physician of a resident's change in condition may result in complications to the resident and prevented the physician from evaluating the effectiveness of the current treatment plan. Findings include: Information provided by the complainants indicated facility staff failed to consistently notify them of changes in their family members' condition. Upon request, the facility failed to provide a copy of their policy addressing physician and/or family notification of a change in the resident's condition. - Review of Resident #3's medical record occurred on all days of survey. The current care plan stated, Diagnosis . unspecified dementia without behavioral disturbance . muscle weakness . repeated falls . At risk for falls due to: history of falls . Review of progress notes showed the following: * 02/28/19 at 2:20 p.m., Resident found on floor . Family has been notified . Will update MD (medical doctor) at this time . * 03/13/19 at 1:50 p.m., Will update MD and family. Resident had a missed fall . * 05/28/10 at 2:05 p.m., Late entry. Will update MD and family. Resident had a witnessed fall . - Review of Resident #16's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included, [MEDICATION NAME] (insulin) 20 units two times a day and [MEDICATION NAME] (insulin) 10 units three times a day. A physician's orders [REDACTED]. [MEDICATION NAME] . Inject as per sliding scale . 426+ = 7 units Call MD for blood glucose less than 50 and greater than 426 . Review of the blood sugars showed a blood sugar reading of 426 on 02/08/19 and 430 on 02/09/19. The facility failed to notify Resident #16's physician of the blood sugar readings. During an interview on 06/05/19 at 3:54 p.m. an administrative nurse (#5) agreed the facility failed to notify the physician of a blood sugar readings that fell outside of ordered parameters. - Review of Resident #17's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The progress notes, dated 10/02/18-05/05/18, identified the following: * 12/06/18 at 7:00 a.m. and 12/07/18 at 10:13 a.m., Will update MD . her second rt (right) toe has a 2 cm (centimeter) wt (width) by 1.2 cm Lt (left) pressure area. Skin is intact and without drainage. Site is red, resident denies sensation or pain . The facility failed to notify Resident #17's family of the pressure area to her toe. * 12/11/18 at 3:26 p.m., This nurse paged (physician) regarding resident sore toe. He ordered Keflex (antibiotic) 500 mg (milligram) PO (by mouth) TID (three times per day) for 10 days. The facility failed to notify Resident #17's physician in a timely manner, paging him five days after they discovered the ulcer on her toe. * 01/12/19 at 9:19 p.m., Resident is on follow up for: Un witnessed fall in her bathroom. Resident is unable to transfer self back and fort (sic) (to) the bathroom. Will update MD . The facility failed to inform Resident #17's physician and family of her fall. * 03/22/19 at 2:42 p.m., Resident returned from appointment with nephrologist . New orders to continue same medications, get a U[NAME] A microbiology report, dated 03/24/19, identified Escherichia coli (E-coli) and Proteus mirabilis (types of bacteria) present in Resident #17's urine. The facility failed to notify the physician and family of Resident #17's positive urine culture. Resident #17's progress notes also identified the following: * 03/31/19, . -7.5% change . Wt (weight) triggers for significant change. She is eating * 03/31/19 at 11:50 a.m., Will update family and MD (physician): Resident was hypoglycemic (low blood sugars) with a blood sugar of 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). She was non verbal, clammy and lethargic. [MEDICATION NAME] administered by this nurse, ambulance called. When ambulance crew arrived, resident sugar level was up to 60 mg/dl (Level 1 [DIAGNOSES REDACTED]). Her vitals was (sic) stable, she verbally refused going to the hospital . The facility failed to inform Resident #17's physician and family of her hypoglycemic episode. * 04/09/19 at 6:03 p.m., Resident's daughter . concerned that resident's right 2nd toe diabetic vascular ulcer is not improving. I note that right 2nd toe has a very thick necrotic black 0.8 cm circular scab dry (and) intact. No drainage. Surrounding toe is slightly red. Right foot is slightly cool to touch with pedal pulses palpable. Resident denies any pain or discomfort to the right foot. Daughter . requests that a f/u (follow up) appointment be made ASAP (as soon as possible) with podiatrist . * 04/17/19 at 2:25 p.m., Made an appointment with . podiatry to see if resident scabbed to her right second toe can be debride (sic). The facility failed to schedule an appointment with Resident #17's podiatrist in a timely manner, contacting his office eight days after the family made their request. * 05/02/19 at 5:45 p.m., Resident is pale (and) diaphoretic. Blood glucose is 52 mg/dl (Level 2 [DIAGNOSES REDACTED]). No emisis or c/o (complained of) nausea. (Physician) on call . paged (and) gave new order to administer [MEDICATION NAME] 1 mg intramuscularly now (and) recheck blood glucose in 15 minutes. Order observed. The facility failed to inform Resident #17's primary physician of her hypoglycemic episode. * 05/03/19 at 1:14 a.m., Resident was found pale, diaphoretic and unresponsive (symptoms of Level 3 [DIAGNOSES REDACTED]). Unresponsive to sternum rub. BS (blood sugar) was 35 (Level 2 [DIAGNOSES REDACTED]). [MEDICATION NAME] 1 mg given. 15 mins later, resident continued to be unresponsive and pale. Her BS was 44. Another [MEDICATION NAME] 1 mg injected. 15 mins later her BS was 85. Nurse gave another sternum rub and resident pushed away hands. (Physician) whom is taking call . gave order to administer the [MEDICATION NAME] 1 mg x (times) 2. Primary MD will be notified via fax. The facility failed to inform Resident #17's primary physician and family of her hypoglycemic episode. * 05/05/19 at 5:00 p.m., Resident was found unresponsive (symptom of Level 3 [DIAGNOSES REDACTED]) to sternum rub. BS was 67 mg/dL . [MEDICATION NAME] 1 mg given. Blood sugar rechecked 15 mins later was 106. Resident was responsive . Informed (Physician) on call . and he ordered to decrease dosage of [MEDICATION NAME] . The Primary MD will be notified . The facility failed to inform Resident #17's primary physician and family of her hypoglycemic episode. - Review of Resident #18's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. Progress notes identified the following: * 08/02/18 at 3:38 p.m., Resident has a firm area to the left lower buttock, it is not raised, it has no discoloration, resident states it is very painful when palpated, (Physician) called . The facility failed to inform Resident #18's family of her skin issue. * 09/12/18 at 4:35 a.m., Nurse was sitting at the nursing station when she heard, 'help I'm slipping.' 'help.' 'help me.' This nurse and other nurse on duty went running into her room. This nurse saw resident slide out of her chair and onto the floor. Faxed communication to MD regarding fall. The facility failed to inform Resident #18's family of her fall. | 2020-09-01 |