| 84 |
RIO RANCHO CENTER |
325033 |
4210 SABANA GRANDE SE |
RIO RANCHO |
NM |
87124 |
2018-02-12 |
656 |
D |
0 |
1 |
M2BO11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a comprehensive care plan was developed for one resident (R #76) of 32 residents (R #s 2, 5, 8, 14, 15, 18, 19, 26, 31, 36, 37, 45, 47, 51, 55, 56, 61, 62, 68, 75, 76, 89, 91, 94, 95, 96, 101, 156, 164, 167, 209 & 307) reviewed for care plan accuracy. No items in R #76's care plan addressed his care in the facility related to his [DIAGNOSES REDACTED].) This deficient practice had the potential to result in inconsistent care of the resident, through inappropriate food offerings, and the failure to assess for [MEDICAL TREATMENT]-related complications, such as bleeding. The findings are: [NAME] On 02/05/18 at 2:25 pm, during interview with R #76, he stated, I'm a diabetic and damned near everything here is sweet. I don't take any meds (medications) - I control it through diet. I don't know how you can control your sugar when everything is sweet. B. Record review of R #76's electronic medical record found: 1. that he was admitted to the facility on [DATE], and discharged on [DATE]. 2. that his listed medical diagnoses included [MEDICAL CONDITION], dependence on renal (related to the kidneys) [MEDICAL TREATMENT], [MEDICAL CONDITION] (a liver disease), and gastrointestinal hemorrhage (bleeding in the digestive system.) No [DIAGNOSES REDACTED]. 3. a care plan dated 1/22/18 that did not have focus sections related to diabetes management or [MEDICAL TREATMENT] procedures. 4. a physician's orders [REDACTED].> a. that the resident had [MEDICAL TREATMENT] scheduled for each Tuesday, Thursday and Saturday. b. that interventions to assess the [MEDICAL TREATMENT] were ordered. c. that the resident was ordered for a regular/liberalized diet. d. that no fluid restrictions were ordered. e. no checks of the resident's glucose levels were ordered. 5. that a nutritional assessment dated [DATE] did not acknowledge the resident's diabetes. It stated that the resident had declined a renal diet, in favor of a regular diet. 6. that an Admission MDS (Minimum Data Set, a data collection tool) assessment, dated 01/22/18, stated, Diabetes mellitus: No. 7. that the Treatment Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) showed no tasks related to diabetes management. C. Record review of a physician's History and Physical document for R #76, dated 01/18/18, indicated that DM 2 (Type II Diabetes Mellitus) was among his diagnoses in the History of Present Illness section. [MEDICAL CONDITION] and a history [MEDICAL CONDITION](stroke) were additional diagnoses listed on the document. The resident's diabetes was not mentioned in the Plan section of the document, though there was a statement indicating his chronic medical conditions are stable. D. On 02/09/18 at 1:24 pm, during interview with the Director of Nursing (DON), she confirmed that diabetes and [MEDICAL TREATMENT] were not addressed in R #76's care plan. She acknowledged that a complete care plan, including all information necessary to care for the resident, should have been completed within 21 days of his admission. E. On 02/08/18 at 10:07 am, during interview with the facility's Dietician, she stated I probably didn't know that he was diabetic (when I did his nutritional assessment.) If I had known he was diabetic, I definitely would have put it in my assessment. Sometimes I do my assessment before they're seen by the doctor, so the History & Physical wouldn't be available. F. On 02/08/18 at 3:13 pm, during interview with Nurse Practitioner #1, she stated that liberalized diets for diabetics are intended to reduce sweets, not eliminate them entirely. She indicated that it would have made sense, given the liberalized diet, that his blood sugar should have been checked, maybe every morning. |
2020-09-01 |