| 12840 |
BEAVER CITY MANOR |
285269 |
P O BOX 70, 905 FLOYD STREET |
BEAVER CITY |
NE |
68926 |
2010-07-08 |
278 |
E |
|
|
QLVI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview; the facility failed to ensure residents with indwelling catheters and colostomies were coded on the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) as continent for 2 residents (Residents 11 and 14) and that toileting plans were individualized for 2 residents (Residents 17 and 6). The facility census was 17 and the sample size for review was 8. Findings are: A) A review of Resident 11's record revealed a face sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) dated 7/11/2009 that showed the resident was admitted to the facility on [DATE]. A list of medical [DIAGNOSES REDACTED]. -[MEDICATION NAME] [DIAGNOSES REDACTED] -Diabetes Mellitus Type II -Hypertension -[MEDICAL CONDITION] -Aortic Valve Disorder - Mild Stenosis -[MEDICAL CONDITION] - Stage III -[MEDICAL CONDITION] Bladder A review of the MDSs located in Resident 11's record, dated 8/28/2009 and 5/9/2010, revealed dashes in the section for bowel and bladder continence. Options for coding and the explanations on the MDS, include: 0. Continent-complete control (includes use of indwelling catheter or ostomy device that does not leak urine or stool). 1. Usually Continent-Bladder, incontinent episodes one a week or less; Bowel, once a week 2. Occasionally Incontinent-Bladder, 2 or more times a week but not daily; Bowel, once a week 3. Frequently Incontinent-Bladder, tended to be incontinent daily, but some control present (e.g., on day shift); Bowel, 2-3 times a week 4. Incontinent-Had inadequate control Bladder, multiple daily episodes; Bowel, all (or almost all) of the time Observation of Resident 11 on 7/6/2010 through 7/8/2010 revealed the resident had an indwelling supra-pubic catheter and a [MEDICAL CONDITION] bag with no signs of leakage. A review of the record revealed no documentation of leakage of either device. B. A review of Resident 14's record revealed a face sheet dated 8/21/2007 that showed the resident was admitted to the facility on [DATE]. A list of medical [DIAGNOSES REDACTED]. -[MEDICAL CONDITION] -Urinary Tract Infection -Generalized Weakness A review of the current, undated Care Plan provided by the facility revealed further medical [DIAGNOSES REDACTED]. -Cauda Equina Syndrome with Lower Paralysis -[MEDICAL CONDITION] -Suprapubic Catheter A review of the MDSs located in Resident 14's record, dated 3/5/2010 and 6/4/2010, revealed dashes in the section for bowel and bladder continence. Observation of Resident 14 on 7/6/2010 through 7/8/2010 revealed the resident had an indwelling supra-pubic catheter and a [MEDICAL CONDITION] bag with no signs of leakage. A review of the record revealed no documentation of leakage of either device. In an interview on 7/8/2010 at 1:00PM, the Director of Nursing stated s/he had not read the coding explanations and based on those, (Resident's 11 and 14) should have been coded as continent. C. Review of the medical file for Resident 17 revealed admission to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS for Resident 17, with an assessment reference date of 6/8/2010, under appliances and programs found the resident was on a scheduled toileting plan. Review of the care plan for Resident 17, dated 6/10/2010, found no toilet plan addressed for the resident. D. Review of the medical file for Resident 6 revealed admission to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS for Resident 6, with an assessment reference date of 5/14/2010, under appliances and programs found the resident was on a scheduled toileting plan. Review of the care plan for Resident 6, dated of 5/10/2010 found the statement that read "I have a risk for pressure sores due to my incontinent and will need to be on a toileting schedule". No mention of what was a toileting schedule. Interview with the DON (Director of Nurses) on 7/8/2010 at 10:00 AM confirmed the toilet plans were not on the care plans. The DON confirmed the toilet plans on the care plan were not individualized. |
2014-03-01 |