cms_PR: 26
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 26 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 514 | F | 0 | 1 | ZOYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on ten records reviewed (RR), performed on a recertification extended survey from 5/2/ to 5/4/17 from 8:00 am thru 5:00 pm, it was determined that the facility failed to ensure that the professional staff documents in the clinical record accurately information showing the residents' needs and the interventions performed to satisfy these needs, as observed in 2 out of 10 records reviewed (RR #4 and #8). Findings include: 1. Resident #4 is an [AGE] years old male patient who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During RR #4 performed on 5/3/17 at 1:00 pm it was found the following: a. According to observations performed on 5/2/17 at 9:00 am during the morning tour accompanied by the Nursing Supervisor (employee # 4) it was observed that all toe nails show a dark color and lack of brightness, characteristics of feet fungus. During interview with the head physician (employee # 6) performed on 5/4/17 at 8:30 am, he stated: The resident has fungus in his toe nails. I did not placed a consult to the Podiatrist because sending him to an outside office with a consult will cause that resident loose one day of therapy here. I prefer during discharge planning, give to resident's family the order for a Podiatrist evaluation after discharge home. During review of the clinical record, no documentation was found of these descriptions on the nursing progress nor the physician's note. b. It was found on the nurses' notes from 5/2/17 at 5:00 pm that the resident showed respiratory distress characteristics, such as documented by the nurse: resident with abdominal breathing, Respiratory rate: 27. A phone call to the physician was performed and he ordered to transfer the resident to the emergency room . A phone call to resident's son was performed and notified that resident showed changes, he answered that he will go to the emergency room . Transfer performed with a stretcher and oxygen with nasal cannula at 2 liters. On the nurse's note from the night shift, the nurse failed to write in the clinical record the results of the evaluation that was performed at the emergency room and no evidence was found of any recommendations that the physician of the emergency room has ordered for continuity of care. It was not determine the health condition of the resident as soon as he arrived to the skilled nursing facility due to lack of documentation. An interview to the head physician (employee #6) was performed on 5/4/17 at 8:30 am, where he stated: The resident showed fast breathing and dry cough. I ordered to transfer him to the emergency room . After been evaluated at the emergency room , his condition was good. No big issues were found in him. Those changes in his respiratory pattern can be a consequence of the [MEDICAL CONDITIONS] that he suffered few months ago. He can shows a diffuse weakness and it may be manifested with dry cough and changes in the respiratory rate. I ordered him liquid oral medication to control dry cough and respiratory therapy every 6 hours as needed (PRN). The nursing staff failed to write accurate information on the clinical record related to resident changes on his health condition. 2. RR #8 belongs to a male resident of [AGE] years old who was admitted to the facility on [DATE] with a Left shoulder fracture and an infected wound on his left shoulder. During RR#8 performed on 5/4/17 at 1:30 pm it was found on the admission nurse's note from 4/24/17 at 8:00 pm that the resident was placed on an isolation room with contact precautions. However, it was not found on the physician's progress notes nor the nurses 'notes an explanation of why this resident has been put in an isolation room with contact precautions. a. According to interview with the Infection Control Preventionist (employee # 7) performed on 5/4/17 at 3:30 pm, she stated the following: The resident had [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) on the wound located on his left shoulder, during hospitalization . When he arrived to our facility, the wound was closed with no secretions. A wound culture was performed and the results were negative [MEDICAL CONDITION]. We notified the physician and he cancelled the order for isolation room with contact precautions. However, this explanation was not written in the clinical record by the nursing staff, the physician nor by employee #7. At least, 3 days has passed while the culture results arrived to the nursing station but no evidence was found of orientation given to the resident and his family members of the procedures to be performed while the resident was in the isolated room with contact precautions. The infection control problem in the nursing plan of care (P[NAME]) was activated on 4/24/17. However, the nurse failed to include in the P[NAME] the isolation room and contact precautions interventions to ensure compliance with Infection Control guidelines while the physician's orders [REDACTED]. According to the Minimum Data Set (MDS) review on 5/4/17 at 3:30 pm it was found on section I, Active [DIAGNOSES REDACTED]. [MEDICAL CONDITION] infection as a second diagnose was not congruent with the information provided by the Infection Control Preventionist (employee #7), where she stated that the resident arrived this facility without an active infection. This information was corroborated with employee #7 and she said: that is an error. The resident's diagnose is Left shoulder Fracture. The facility failed to ensure that correct information is shared between the interdisciplinary staff and failed to monitor that accurate information of the resident's problems and interventions performed are written in the clinical record. b. During RR #8 performed on 5/4/17 at 3:30 pm it was found that the Vaccine assessment documentation form has incomplete documentation. The physician failed to place a check mark besides one or more contraindications that are mentioned in this form. This lack of documentation allows that the clinical record keeps incomplete documentation. This issues have been identified on the quality monitoring activities | 2020-09-01 |