cms_ND: 66
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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66 | MINOT HEALTH AND REHAB, LLC | 355031 | 600 S MAIN ST | MINOT | ND | 58701 | 2017-07-26 | 280 | E | 0 | 1 | GH6U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 01/12/17. Based on observation, record review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 4 of 13 sampled residents (Resident #2, #3, #4, and #13). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: - Review of Resident #2's medical record occurred on all days of survey. The record included a fax from the physician, dated 06/22/17, which stated, . Thank you for the update. Please advance diet to regular textured diet . The record also included a fax to the physician, dated 07/05/17, which requested the use of Prevalon (pressure-reducing) boots at night. The physician responded, yes, agree (with) above. Review of Resident #2's care plan on 07/24/17 identified a mechanical soft diet and failed to include the use of Prevalon boots. Observations throughout the survey showed staff served Resident #2 a regular textured diet. - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Medications included [MEDICATION NAME] and [MEDICATION NAME] at bedtime to facilitate sleep. Nurses' notes, reviewed from 01/12/17 to 07/25/17, stated Resident #3 failed to sleep well on multiple occasions. A nurse's note, dated 05/03/17, stated, . not slept . Dr (doctor) increased the [MEDICATION NAME] from 5 to 10 mg (milligrams). Dr wants psych evaluation for anxiety and [MEDICAL CONDITION]. The current care plan stated, . Focus: Resistive/noncompliant with treatments/cares. On Honey Thickened liquids. Focus: At risk for nutritional status change . Nectar thick liquids . Observation throughout the survey showed Resident #3 wore bilateral hearing aids and received oxygen at 2 liters per minute (L/min) per nasal cannula. During an interview on the afternoon of 07/26/17, an administrative nurse (#3) verified Resident #3's care plan failed to include the use of hearing aids and oxygen, and was inconsistent regarding thickened liquids. Resident #3's care plan failed to include problems and/or interventions related to hearing aids, oxygen, and [MEDICAL CONDITION]. The care plan stated inconsistencies related to thickened liquids. - Review of Resident #4's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A physical therapy plan of care, dated 06/29/17, identified, . Weight bearing status, right LE (lower extremity) . current level . non weight bearing . Transfers, bed/chair . total assist (100% assist) . The current certified nursing assistant (CNA) kardex, dated 07/26/17, identified . Transfer with full body sling and full mechanical lift and two staff. Use care with moving right leg. Immobilizer to remain in place at all times. The current care plan stated, . At risk for falls due to weakness, history of falls . Provide assist to transfer and ambulate as needed . Immobilizer to remain in place at all times . Ostomy r/t (related to) . impaired mobility, loss of bladder muscle tone . During an interview on 07/25/17 at 2:40 p.m., a physical therapy manager (#5) verified Resident #4 is currently unable to ambulate due to a [MEDICAL CONDITION] femur. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified Resident #4's care plan focus/intervention regarding ambulation, and ostomy is not appropriate and staff need to update the care plan. The facility failed to review and revise the comprehensive care plan to reflect the resident's current status. - Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current physician order, dated 06/26/17, identified, oxygen @ 2L/NC (liters per nasal cannula) to maintain O2 (oxygen) SATS (saturation level) check each shift. Review of Resident #13's care plan on 07/26/17 showed the facility failed to include the focus and interventions for the oxygen. Observations on 07/26/17 showed: * 12:15 p.m., Resident #13 sat in the wheel chair in the dining room with continuous oxygen on at 2L/NC. * 2:05 p.m., Resident #13 laid in bed with continuous oxygen on at 3L/NC. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified Resident #13's care plan failed to include the focus and/or interventions related to the oxygen. | 2020-09-01 |