| 91 |
LAS VEGAS POST ACUTE & REHABILITATION |
295006 |
2832 S. MARYLAND PARKWAY |
LAS VEGAS |
NV |
89109 |
2018-05-11 |
698 |
D |
0 |
1 |
QB3511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to secure written contracts and/or agreements with [MEDICAL TREATMENT] providers, ensure a physician's orders [REDACTED].#40) and post [MEDICAL TREATMENT] assessments were completed for 1 of 18 sampled residents (Resident #57). Findings include: The facility's policy titled Policy and Procedure on [MEDICAL TREATMENT] Care (dated 09/27/18), documented: 1) The Administrator shall secure written contracts and/or agreements with [MEDICAL TREATMENT] Care Centers providing services to residents on [MEDICAL TREATMENT] care and, 2) Written contracts and/or agreements shall contain provisions on how to maintain communication by and between facility and [MEDICAL TREATMENT] centers to ensure proper care is provided to residents e.g. dietary recommendations (from [MEDICAL TREATMENT] center), physician orders, etc. On 05/10/18 at 11:00 AM, the Administrator indicated he could not provide documented evidence of contracts and/or agreements with any [MEDICAL TREATMENT] provider. On 05/11/18 in the morning, the Director of Nursing confirmed the facility currently had two residents receiving [MEDICAL TREATMENT] from [MEDICAL TREATMENT] provider #1 and three residents receiving [MEDICAL TREATMENT] from [MEDICAL TREATMENT] provider #2. Resident #57 Resident #57 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 05/08/18 at 3:28 PM, the resident verified [MEDICAL TREATMENT] treatments were scheduled on Mondays, Wednesdays and Fridays at a nearby [MEDICAL TREATMENT] facility. The resident indicated not missing [MEDICAL TREATMENT] treatments since admission. The facility's policy titled Policy and Procedure on [MEDICAL TREATMENT] Care (dated 09/27/12), documented a licensed nurse shall monitor and document on pre and post [MEDICAL TREATMENT] observations, such as vital signs, bruits, shunt area for color, warmth, redness or [MEDICAL CONDITION], etc. A physician's orders [REDACTED]. On 05/10/18 in the morning, a Licensed Practical Nurse (LPN) indicated pre-[MEDICAL TREATMENT] assessments were documented in the Outpatient [MEDICAL TREATMENT] Record. The LPN explained there is no provision for post-[MEDICAL TREATMENT] assessments in the Outpatient [MEDICAL TREATMENT] Record. The LPN verbalized the post-[MEDICAL TREATMENT] assessments would be found in the nurses notes. The Medical Records Director verified pre-[MEDICAL TREATMENT] assessments would be documented in the Outpatient [MEDICAL TREATMENT] Record and post-[MEDICAL TREATMENT] assessments should be in the nurses notes. The RN confirmed if there was no documentation of pre or post-[MEDICAL TREATMENT] assessments, it would mean the assessment was not done. There was no documented evidence of an Outpatient [MEDICAL TREATMENT] Record for 04/04/18. Clinical records revealed missing post-[MEDICAL TREATMENT] assessments for 04/04/18, 04/06/18, 04/09/18, 04/11/18, 04/13/18, 04/16/18, 04/18/18, 04/20/18, 04/23/18, 04/25/18, 04/27/18, 04/30/18, 05/02/18, 05/04/18, 05/07/18 and 05/09/18. On 05/10/18 in the morning, the Director of Nursing (DON) confirmed this was not acceptable. Resident #40 Resident #40 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 03/2018, revealed the resident received [MEDICAL TREATMENT] three times per week and to administer medications per the physician's orders [REDACTED].>A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The [MEDICAL TREATMENT] Log dated (MONTH) (YEAR), lacked documented evidence [MEDICATION NAME] was administered per the physician's orders [REDACTED].>On 05/10/18 in the morning, a Licensed Practical Nurse (LPN) indicated the resident received [MEDICATION NAME] at the [MEDICAL TREATMENT] center. The LPN explained the [MEDICAL TREATMENT] center tested the resident's hemoglobin once every two weeks. When the resident's hemoglobin level was at a 10-11, [MEDICATION NAME] 30 micrograms was administered to the resident. The LPN indicated the resident's last dose of hemoglobin was on 04/27/18. The LPN indicated the resident's levels were normal since that time and [MEDICATION NAME] had not been administered to the resident since 04/27/18. The LPN acknowledged the resident had not received [MEDICATION NAME] units subcutaneous on Monday, Wednesday, and Friday per the physician's orders [REDACTED].>On 05/10/18 in the morning, the Director of Nursing acknowledged [MEDICATION NAME] was administered to the resident at the [MEDICAL TREATMENT] center. The DON acknowledged the resident had not received [MEDICATION NAME] units subcutaneous on Monday, Wednesday, and Friday per the physician's orders [REDACTED].>There was no documented evidence the facility and the [MEDICAL TREATMENT] center communicated about the amount of [MEDICATION NAME] to be administered to the resident. A facility policy entitled Administering Medications revised (MONTH) 2012, documented medications must be administered in accordance with the physician's orders [REDACTED]. |
2020-09-01 |