| 28 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2019-01-10 |
712 |
E |
0 |
1 |
0DP411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure physician visits occurred within the required time frames for 5 of 12 sampled residents (Resident #8, #14, #15, #17, and 18). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's clinical record lacked documented evidence a physician visit occurred between 01/23/18 and 05/16/18. On 01/10/19 at 11:46 AM, the Assistant Director of Nursing (ADON), confirmed the facility lacked documented evidence a physician visit occurred for Resident #8 between (MONTH) (YEAR) and (MONTH) (YEAR). Resident #14 Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #14's clinical record lacked documented evidence a physician visit occurred from 08/20/18 to present. On 01/10/19 at 11:46 AM, the ADON confirmed the facility lacked documented evidence a physician visit occurred for Resident #14 after 08/20/18. Resident #17 Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/10/19 at 10:00 AM, the ADON confirmed the facility lacked evidence a physician visit occurred for Resident #17 between 09/2018 and present. Resident #15 Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/10/19 at 10:02 AM, the ADON confirmed the facility lacked evidence a physician visit occurred for Resident #15 from admission to 01/02/19. The ADON confirmed a physician visit was required every 30 days for the first 90 days after admission and every 60 days after the first 90 days. Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/10/19 at 11:15 AM, Resident #18 verbalized she did not see her doctor for a long time and she would not have refused a physician visit. Resident #18's Minimum Data Set (MDS) 3.0 , section C - cognitive patterns, dated 11/09/18, documented a Brief Interview of Mental Status (BIMS) summary score of 15, meaning an intact cognition. Resident #18's clinical record revealed a physician visit progress note dated 02/22/18. A nursing progress note, dated 11/30/2018, documented a physician assessment. On 01/10/19 at 11:30 PM the ADON verbalized documentation of additional physician visits were not found in the electronic medical record for this resident. The ADON verbalized Resident #18 refused the physician visits, although the facility lacked documentation of the resident's refusal to be seen by a provider. The facility lacked documented evidence Resident #18 had a physician visit between 02/22/18 and 11/30/18. The facility policy titled, Physician visits and medical orders, effective 11/17, documented the attending physician had to visit the resident in accordance with the resident's needs, but at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter and as needed. |
2020-09-01 |