| 1853 |
PRUITTHEALTH-AIKEN |
425145 |
830 LAURENS STREET NORTH |
AIKEN |
SC |
29801 |
2018-08-30 |
657 |
E |
0 |
1 |
H9EX11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to have all disciplines participate in the multidisciplinary care conference for Residents #13, #62, #19, #115 and # 120. Five of 5 residents sampled for care conference participation. The findings included: The facility admitted Resident #13 on 02/02/15 with [DIAGNOSES REDACTED]. On 08/28/18 at 09:16 AM, review of the Multidisciplinary Care Conference Meeting form dated 04/12/18 revealed no indication of attendees. The form indicated information was entered by Activities and reviewed by an LPN (Licensed Practical Nurse). Further review revealed a 02/02/18 care plan conference form that indicated the information was entered by an LPN and there was no documentation of the attendees. No evidence a Registered Nurse (RN) attended or reviewed either care plan. Additional review revealed a care plan signature sheet dated 8/8/18 signed by activities, social services and the Certified Dietary Manager (CDM). There was no evidence the care plan meeting was attended by a RN. On 08/30/18 at 11:28 AM, review of the EHR (electronic health record) IDT (interdisciplinary team) care plan documentation revealed the 08/08/18 care plan information was completed by an LPN. There was no documentation of input from Dietary, Social Services, Registered Nurse or Certified Nursing Assistant. On 06/19/18 the completion of information was conducted by an LPN. There was no documentation of input from a Registered Nurse. The 04/03/18 care plan completion of information was conducted by an LPN. There was no documentation of input from a Registered Nurse. On 01/16/18, the completion of information was conducted by an LPN. There was no documentation of input from Dietary, Social Services, Registered Nurse or Certified Nursing Assistant. During an interview on 08/30/18 at 02:00 PM, RN #1 confirmed there was no documentation that a Registered Nurse (RN) participated in the IDT or was involved in the review of the care plan dated 04/03 or 06/19/18. The RN further confirmed there was no documentation that Dietary, Social Services, a Registered Nurse or Certified Nursing Assistant participated in the IDT or was involved in the review of the care plan on 01/16/18. The facility admitted Resident #62 on 10/25/17 with [DIAGNOSES REDACTED]. On 08/27/18 03:20 PM, record review revealed no CNA (Certified Nursing Assistant) signature on the Interdisciplinary Care Conference Meeting attendance sheet. There was no documentation that a CNA attended the meeting. On 08/30/18 at 11:44 AM, review of the EHR IDT care plan meeting documentation revealed on 07/10/18 the completion of information was conducted by a LPN. There was no documentation of input from or care plan meeting attendance by Registered Nurse. Further review revealed a 04/25/18 a Multidisciplinary Care Conference Meeting form that indicated completion by a LPN. There was no documentation of input from or care plan meeting attendance by Registered Nurse. During an interview at 2:35 LPN #4, stated very seldom did a RN attend the care plan meetings unless a unit manager attended. The nurse stated that the facility now had all RN unit managers and that they were starting to attend the care plan meetings. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of 6-26-18 and 4-10-18 Multidisciplinary Care Conference Meeting forms on 8/30/18 at 2:57 PM revealed no participation in the development of the plans or review by a Registered Nurse. During an interview on 8/30/18 at 4:08 PM, Licensed Practical Nurse #4 confirmed this. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of 5-22-18 and 8-9-18 Multidisciplinary Care Conference Meeting forms on 08/29/18 12:08 PM revealed no participation in the development of the plans by a Certified Nursing Assistant or Registered Nurse. During an interview on 8/30/18 at 4:08 PM , Licensed Practical Nurse #4 confirmed this. The facility admitted Resident #120 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Multidisciplinary Care Conference Meeting forms on 8/29/18 at 3:48 PM revealed no participation in the development of the plans by a Certified Nursing Assistant. During an interview on 8/29/18 at 5:13 PM, Licensed Practical Nurse #4 confirmed this. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the 7-3-18 Quarterly Minimum Data Set Assessment revealed that the resident was cognitively intact with a Brief Interview for Mental Status score of 15. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. Review of the Care Plan on 8/29/18 at 9:22 AM revealed that it had not been updated with the abuse allegation/altercation. During an interview on 8/29/18 at 10:22 AM, the incident was reviewed with Licensed Practical Nurse (LPN) #7 who stated s/he was aware of the incident. S/he reviewed the Care Plan and confirmed it had not been updated with the abuse allegation. When asked, LPN #7 stated that the Care Plan should have been updated by nursing or Social Services. The facility policy titled Care Plans states : 4. Care Plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient's/resident's needs at any given moment. |
2020-09-01 |