cms_SD: 2
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2018-03-29 | 657 | D | 0 | 1 | XF2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to update and revise care plans for 3 of 18 sampled residents (8, 28, and 60). Findings include: 1. Review of resident 60's medical record revealed she had developed a pressure ulcer to her left heel on 3/12/18. Her care plan had not been updated to reflect that information. Refer to F686, finding 1. 2. Review of resident 8's 12/5/17, 2/14/18, and 3/16/18 care plans for skin integrity and pressure ulcers revealed a gap in documentation with no preventative interventions for a resident with a history of pressure ulcers. Refer to F686, finding 2. 3. Review of resident 28's undated care plan revealed she: *Was admitted on [DATE]. *Had two hospitalization s, and her last readmitted was 1/31/18. *Had focus areas for: [MEDICAL CONDITION], anticoagulant therapy, insulin r/t (related to) diabetes, diuretic therapy r/t heart failure, and respiratory distress. *Interventions and tasks such as: -Labs as ordered. -Monitor blood sugar, lab results as ordered by physician. -Administer medication pre physician orders. --Interventions and tasks were not resident specific. --Did not have adequate information to provide interventions and methods to monitor above areas. 4. Interview on 3/29/18 at 7:50 a.m. with the minimum data set (MDS) nurse regarding care plans revealed: *The initial care plan was created from the nurses admission assessment. *The first of the year they had started a new process with the care plans where if a resident was admitted and then discharged upon return to the facility, the care plan had to be completely regenerated. -Previous to the first of the year the care plan could be used from before. *The nurses were not comparing the previous care plan to the current care plan. -Interventions and tasks had not been brought forward. -Care plans were not complete. *She stated resident 25's care plan would be corrected today. *She had been reviewing them upon quarterly review, resident 25 had been in and out of hospital, so her care plan had not been reviewed at this time. *She agreed the areas of insulin/diabetes, anticoagulant therapy, cardiac diagnoses, and respiratory distress did not have adequate information to provide interventions and methods to monitor those areas. Surveyor: Review of the provider's (MONTH) (YEAR) Interdisciplinary Care Planning policy revealed: *The patient's (residents) care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. *It also identifies the types of methods of care that the patient should receive. *The care plan should focus on: -Preventing avoidable declines in function. -Managing patient risk factors. -Preserving and building on patient's strengths. -Patient's goals and individualized preferences. -Evaluating care and progress toward goals. -Respecting the patient's right to decline treatment. -Using an interdisciplinary approach. -Involving the patient and family. -Planning to care to meet the patients needs. -Involving direct care staff. *The care plan should: -Include patient-specific measurable objectives and time frames. -Include collaboration with other agencies that provides services to the patient (i.e. hospice or [MEDICAL TREATMENT]) including who provides that service. -Describe the services that the facility is to provide. -Describe any services that the patient should have, but refuses. | 2020-09-01 |