| 52 |
PROVIDENCE BENEDICTINE NURSING CENTER |
385018 |
540 SOUTH MAIN STREET |
MOUNT ANGEL |
OR |
97362 |
2016-06-06 |
278 |
E |
0 |
1 |
NQJS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to accurately code MDS assessments for 5 of 7 sampled residents (#s 103, 117, 149, 187 and 226) reviewed for [MEDICAL TREATMENT], hospice, hydration and pressure ulcers. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 103 admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The RAI Manual, Chapter 3, Section J Health Conditions indicates to code dehydration if the resident presents with two or more of the following potential indicators for dehydration: takes in less than the recommended 1,500 ml of fluids daily; has one or more potential clinical signs of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values; or the resident's fluid loss exceeded the amount of fluids she/he took in. Resident 103's 4/14/16 Significant Change of Status Assessment MDS section J1150, Problem Conditions, coded the resident as dehydrated during the assessment period. The clinical record lacked documented evidence Resident 103 consumed less than 1500 ml, had fluid loss which exceeded intake, and lacked an assessment or laboratory values to indicate potential clinical signs of dehydration. In an interview on 6/3/16 at 12:13 pm Staff 4 (RNCM) stated Resident 103 went on hospice, did not want to drink and they had a hard time pushing fluids. Staff 4 was not able to provide documentation to support the coding of dehydration on the 4/14/16 SCSA MDS. 2. Resident 149 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The RAI Manual, Chapter 3, Section J Health Conditions indicates to code tobacco use as yes if the resident or any other source indicated the resident used tobacco in some form during the look-back period. Resident 149's 12/5/15 Admission MDS, completed by Staff 3 (RNCM) was coded to indicate Resident 149 did not use tobacco. On 6/3/16 at 9:20 am Staff 8 (LPN) stated Resident 149 was a smoker since admission. On 6/3/16 at 12:46 pm Staff 3 (RNCM) stated she was aware the resident smoked. Staff 3 stated she determined smoking status by asking the resident or based on chart review. Staff 3 could not state why tobacco use was not coded and acknowledged Resident 149 smoked. b. Resident 149's 12/5/15 Admission MDS, completed by Staff 3 was coded to indicate Resident 149 had one unstageable pressure ulcer (skin covered with slough (yellow,tan or brown tissue) and/or eschar (dead tissue, usually black or dark brown) where the true anatomic depth of soft tissue damage cannot be determined). The corresponding Pressure Ulcer CAA indicated Resident 149 had an unstageable pressure ulcer on the right index finger. A 5/26/16 Weekly Observation Report indicated the resident had a wound to her/his right index finger from a previous cut which slowly healed. On 6/3/16 at 12:37 pm Staff 4 (RNCM) stated Resident 149's finger tip was totally necrotic prior to admission and she did not know the original cause of the injury. On 6/3/16 at 12:46 pm Staff 3 stated she had to review the chart to see why it was coded as pressure. Staff 3 stated she might have asked the resident the cause of the injury, but she could not recall talking to the resident about her/his finger. On 6/3/16 at 2:10 pm Staff 3 stated Resident 149's record indicated the resident was sent to a local hospital and diagnosed with [REDACTED]. When asked if she considered a finger tip as an area for a pressure ulcer, Staff 3 stated only if the resident said it was from pressure, but she could not recall what the resident told her. 3. Resident 117 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The RAI Manual, Chapter 3, Section J Health Conditions indicates to code dehydration if the resident presented with two or more of the following potential indicators for dehydration: takes in less than the recommended 1,500 ml of fluids daily, has one or more potential clinical signs of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values; or the resident's fluid loss exceeded the amount of fluids he or she took in. Resident 117's 4/22/16 Quarterly MDS section J1150 Problem Conditions coded the resident as dehydrated during the assessment period. The clinical record lacked documented evidence Resident 117 consumed less than 1500 ml, had fluid loss which exceeded intake, and lacked an assessment or laboratory values to indicate potential clinical signs of dehydration. On 6/6/16 at 9:22 am Staff 6 (RNCM) stated the resident was unable to eat and had difficulty swallowing and choking. Staff 6 stated the resident had a catheter but she was not sure if intake and output were documented. On 6/6/16 at 10:45 am Staff 2 (DNS) reviewed Resident 117's medical record and acknowledged she was unable to provide documentation to support the coding of dehydration on the 4/22/16 Quarterly MDS. 4. Resident 187 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/6/15 Cognitive CAA revealed Resident 187 was on hospice services. The 11/6/15 SCSA (Significant Change in Status) MDS, Section J Health Conditions, indicated Resident 187 did not have a condition or chronic disease that could result in a life expectancy of less than six months. The 1/15/16 Quarterly MDS, Section J Health Conditions, indicated Resident 187 did not have a condition or chronic disease that could result in a life expectancy of less than six months. The 4/18/16 Quarterly MDS, Section J Health Conditions, indicated Resident 187 did not have a condition or chronic disease that could result in a life expectancy of less than six months. On 6/2/16 at 3:04 pm Staff 6 (RNCM) acknowledged Resident 187 was on hospice and the coding in Section J of the 11/6/15, 1/15/16, and 4/8/16 MDS assessments was incorrect. 5. Resident 226 was admitted to the facility in (YEAR) with a stage II pressure ulcer (Is a partial thickness loss of dermis presenting as a shallow open ulcer with a red and pink wound bed without slough. (MONTH) also present as an intact or open or ruptured blister) of the sacral region. Hospital records dated 1/16/16 through 1/19/16 indicated the resident had a stage II to III pressure ulcer of the presacral /coccygeal area in a T shape pattern that is approximately 8 x 6 cm. Operative report dated 1/19/16 indicated that resident 226 had debridement (A process of removing nonliving tissue) of the sacral area and buttocks. Resident 226's Admission MDS dated [DATE] and Quarterly MDS dated [DATE] indicated the resident did not have any pressure ulcers. The M1041 section of the MDS indicated the resident had a surgical wound and skin tears on both the Admission MDS and Quarterly MDS. Skin wound weekly flow sheets dated 1/24/16 through 5/30/16 indicated Resident 226 was treated for [REDACTED]. On 6/1/16 at 12:50 pm Staff 2 (DNS) confirmed the Initial MDS on 1/27/16 and the Quarterly dated 4/22/16 should have been coded as a Stage II pressure ulcer and not a surgical wound. |
2020-09-01 |