cms_PR: 43
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 43 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2019-03-28 | 658 | E | 0 | 1 | HR5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey observations, review of twelve clinical sample records, nutritional assessment and interviews, it was determined that the facility failed to ensure the appropriateness of resident weight procedures standard of practice for 4 out of 12 resident sample. (Resident R#66, R#69, R#70 and R#115). Residents interview and interview with the Hospital Escort Pool Coordinator Services (employee #3) during a survey process performed from 03/25 /19 thru 03/28/19, from 8:00 am thru 3:00 pm, it was determined that the facility failed to ensure an expedite process to transfer residents between departments for the purpose of the provision of rehabilitation services which affect 2 out of 12 residents (R#1 and R#117) Findings include: 1. A mechanism to ensure that facility had in place a system who guarantee the accuracy of weight taken to residents on wheelchair was not performed accordingly with these findings identified during survey procedures performed from 03/25/19 thru 03/28/19, from 8:00 am thru 3:00 pm: a.Resident #66 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 3/27/19 at 10:18 am and provided evidence that resident was weighted after admission on 03/12/19 while was on wheelchair and was documented to weigh 139 pounds. On the weight registry document it was found that personnel document that wheelchair used by resident weight 51 pounds. Personnel who weight resident perform an arithmetic subtraction of the total weight of the resident 180 (weight of the resident in wheelchair) -51 (weight of the wheelchair) and document as the final weight of the resident 139 pounds. In the arithmetic subtraction 180-51=129, the final weight of the resident must be 129 pounds instead of 139 pounds. The facility failed to maintain best practices when perform and record weight and identify circumstances that could impact weight accuracy. b. Resident #69 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 3/27/19 at 11:00 am and provided evidence that resident was weighted after admission on 03/18/19 while was on wheelchair and was documented to weigh 135 pounds. On the weight registry document it was found that personnel document that wheelchair used by resident weight 49 pounds. Personnel weight resident again on 03/26/19 standing and document as the final weight of the resident 125 pounds. There is a difference of 10 pounds on 8 days from the first weight on wheelchair and the second weight. No information was found documented on the weight chart related with the circumstances were the resident weight was taken while was on wheelchair ( with shoes, clothes, coat ) ( with linens, clothes and without shoes ) There is no explanation for the 10 pounds difference between resident weight on 03/18/19 and on 03/26/19. The resident stated on interview on 03/27/19 at 1:00 pm that she was eating well since his admission and that she does not believe that had been losing weight. The facility failed to maintain best practices when performing and record weight and identify circumstances that could impact weight accuracy. c. Resident #70 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 3/27/19 at 9:00 am and provided evidence that resident was weighted after admission on 03/15/19 while was on wheelchair and was documented to weigh 111 pounds. On the weight registry document it was found that personnel document that wheelchair used by resident weight 49 pounds. Personnel weight resident again on 03/19/19 while was on wheelchair and was documented to weigh 145 pounds. On the weight registry document it was found that personnel document that wheelchair used by resident weight 41 pounds. Personnel took resident weight standing 03/26/19 and document as the final weight of the resident 135 pounds. There is a difference of 10 pounds on 7 days from the first weight on wheelchair and the second weight. No information was found documented on the weight chart related with the circumstances were the resident weight was taken (with shoes, clothes, coat) (with linens, clothes and without shoes) There is no explanation for the 34 pounds difference between resident weight during admission on 03/15/19, the difference of 10 pounds of resident weight on 03/19/19 and 03/26/19 while weight was measure while resident was on wheelchair. Resident stated on interview on 03/27/19 at 9:55 am that she was eating well since her admission and that she does not believe that had been losing weight. d. The facility failed to maintain best practices when perform and record weight and identify circumstances that could impact weight accuracy. Interview was performed with biomedical services technician ( Ciracet Outside Contractor Company ) ( employee # 2) on 3/27/19 at 11:59 am and he stated that scale used to weight residents on wheelchair and standing scale had the preventive maintenance updated and that biomedical personnel performed a weekly revision of the equipment. He also stated that equipment works well and provide evidence of the preventive maintenance. e. The facility had a policy and procedure related with resident weight that was review on 3/27/19 at 2:35 pm. This policy did not include a process step by step who guide the personnel while taking weight on wheelchair accordingly with manufacturers' specifications or manual for use. f. Resident #115- is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 3/26/19 at 10:12 am and provided evidence that resident have a weight of 123 pounds on 3/12/2019 on wheel chair and on 3/19/2019 and 3/26/2019 have a weight of 114 stand up. 2. A mechanism to ensure that facility had in place a system who facilitate resident flow between departments for the purpose of the provision of clinical care, rehabilitation services and maintain best practices while transferring residents in the facility surrounding setting was not promoted, accordingly with the following findings identified during survey procedures performed from 03/25/19 thru 03/28/19, from 8:00 am thru 3:00 pm: R#1 [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 3/25/2019 at 2:46 pm during interview R#1 stated that he think the facility need more escort because they have to wait too long to be transport to therapy. R# 117 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 3/25/2019 at 2:16 pm on interview R# 117 stay that he think the facility need more escorts because sometimes they take long to get us to therapy During interview on 3/27/19 at 1:12 pm Hospital Escort Pool Coordinator Services (employee #3) stated that facility had 4 escort personnel to provide services to all hospital acute departments and the skilled nursing facility residents. She had 2 escorts assigned for day shift and two escorts assigned for night shift from Monday through Friday. As explained by her they had a pool process were the requisitions for escort assistance appear on an electronic (computer system) when the escort transfer the patient or resident to the assigned area, returns to the assigned pool area where is assigned to escort another patient or resident. She also stated that escorts will accompany or transfer acute care patients whenever they are transferred externally to another acute hospital for diagnostic procedure, treatment, ongoing care, specialist care. | 2020-09-01 |