| 46 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2017-10-12 |
387 |
F |
0 |
1 |
Z18S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure residents' received physician visits within the regulated time frames for 8 of 10 residents sampled (Resident #6, #9, #7, #8, #1, #4, #10, and #5). Findings include: Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6's clinical record revealed physician's visits dated 10/7/16, 08/9/17 and 09/20/17. On 10/11/17 in the afternoon, the Director of Nursing (DON) indicated documentation of additional physician's visits were not found in either electronic medical record for this resident. Resident #9 Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #9's clinical record revealed physician visits were conducted on 10/14/16, 10/15/16, 10/26/16 (specialist eye physician), 03/20/17 and 08/31/17. On 10/11/17, the DON indicated documentation of additional physician visits were not found in the electronic medical record for this resident. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1's clinical record revealed physician visits dated 11/03/16 and 02/14/17. On 10/11/17 at 9:32 AM, the Unit Secretary confirmed Resident #1's clinical record lacked documented evidence of physician visits after 02/14/17. The Unit Secretary explained it was her responsibility to track physician visits for the facility. Resident #7 Resident #7 was admitted on [DATE] and readmitted on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. Resident #7's clinical record revealed physician visits dated 11/21/16 and 05/10/17. On 10/12/17 at 10:03 AM, the Director of Nursing (DON) confirmed Resident #7 had not had a physician visit between 11/21/16 and 05/10/17 as required. The facility policy titled Progress Notes by Medical Providers, effective 10/04/11, documented physician progress notes [REDACTED]. Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #4's clinical record lacked documented evidence of a physician visit within the first 30 days after admission. On 10/11/17 at 10:28 AM, the Unit Secretary verbalized Resident #4 did not have a physician visit within the first 30 days after admission. On 10/12/17 at 9:44 AM, the Director of Nursing (DON) confirmed Resident #4 was not seen by a physician within the first 30 days after admission. Resident #8 Resident #8 was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #8's clinical record for the last 12 months lacked of documented evidence of a physician visit for the following dates: 12/20/16, 04/20/17, 06/20/17 and 08/20/17. On 10/12/17 at 9:40 AM, the DON confirmed Resident #8 was not seen by a physician on the above dates. Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #5's progress notes revealed notes were documented, dated and signed by the attending physician for the physician visits on 08/28/16 and 09/18/17. Resident # 5's clinical record lacked documented evidence of physician visits between 08/28/16 through 09/18/17. Resident #10 Resident #10 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #10's progress notes revealed notes were documented, dated and signed for visits on 10/06/16 by an Advanced Practice Registered Nurse (APRN) and on 08/07/17 by the attending physician. Resident #10's clinical record lacked documented evidence of physician visits between 08/16/16 through 08/07/17. On 10/10/17 at 4:30 PM, the Certified Nursing Assistant (CNA) said physician visits are not done every 60 days. On 10/11/17 in the morning the Director of Nursing (DON) tried to find documentation of physician visits for Residents #5 and #10. The DON could not provide any documentation. The DON also admitted the physician visits were not done every 60 days. |
2020-09-01 |