| 50 |
MONUMENT HEALTH CUSTER CARE CENTER |
435032 |
1065 MONTGOMERY ST |
CUSTER |
SD |
57730 |
2018-03-28 |
842 |
F |
0 |
1 |
CZRE11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to: *Ensure 12 of 13 sampled residents (3, 5, 17, 21, 33, 41, 42, 47, 49, 53, 57, and 58) had complete documentation in their medical records. *Have residents' medical records readily accessible during the survey in a timely manner. Findings include: 1. Review of resident 3's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after four identified falls. Refer to F610, finding 1. 2. Review of resident 5's medical record revealed incomplete or missing documentation related to:*Her falls and interventions implemented related to them. Refer to F610, finding 8. Refer to F689, finding 2 under base statement B. 3. Review of resident 17's medical record revealed incomplete or missing documentation related to: *His behaviors and follow-up to them. Refer to F550, findings 1 and 3. Refer to F600, findings 1, 5, and 7. Refer to F609, finding 4. Refer to F610, finding 6. 4. Review of resident 21's medical record revealed incomplete or missing documentation related to: *Her mental health and grief. Refer to F740, finding 2. 5. Review of resident 33's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after two identified falls. Refer to F610, finding 2. Refer to F657, finding 5. 6. Review of resident 41's medical record revealed incomplete or missing documentation related to: *Details surrounding her multiple falls and interventions. *Her pressure injuries. Refer to F610, finding 10. Refer to F686, finding 1. Refer to F689, finding 1 under base statement B. 7. Review of resident 42's medical record revealed incomplete or missing documentation related to: *His behaviors and the reason [MEDICAL CONDITION] medications had been given. *Details surrounding his falls and investigations into them. Refer to F610, finding 13. Refer to F758, finding 1. 8. Review of resident 47's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after two identified falls. Refer to F610, finding 3. 9. Review of resident 49's medical record revealed incomplete or missing documentation related to: *Follow up and her status after an incident where she was inappropriately touched by another resident. Refer to F550, finding 2. Refer to F600, finding 2 and 3. 10. Review of resident 53's medical record revealed incomplete or missing documentation related to: *Him being verbally abused by his roommate. *His room change and notification to his representative about that room change. *His pressure injuries. *Investigations into his fall and unknown injuries. Refer to F600, finding 5. Refer to F610, finding 11. Refer to F686, finding 2. 11. Review of resident 57's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after two identified falls. Refer to F610, finding 4. 12. Review of resident 58's medical record revealed incomplete or missing documentation related to: *His suicidal thoughts and the follow-up response to them. Refer to F740, finding 3. 13. Review of the provider's (MONTH) (YEAR) Nursing Process and Documentation policy revealed:*H .The patient's response to the nursing care provided and the outcomes of the care are documented in the computerized documentation system.*I. Documentation is done using the current computerized documentation system unless system is down then paper charting needs to be completed.-1. Documentation is the responsibility of the nurse assigned to the patient (resident) each shift and must be objective data entered unless there are subjective resident concerns. -3. The Health Unit Clerk, LPN, or Nursing Assistant, under the supervision of the RN, may record data in the computerized documentation system. Review of the provider's revised (MONTH) 2013 Change in a Resident's Condition of Status policy revealed: *Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. *6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Interviews on 3/12/18 through 3/15/18 throughout the survey with the administrator and director of nursing (DON) revealed: *During the entrance conference on 3/12/18 at 4:30 p.m. the administrator was given a copy of the Entrance Conference sheet. -That sheet indicated the surveyors required access to the residents' electronic medical records (EMR) by the end of the first day of survey. -He was aware the surveyors needed access. *Within the first half hour of survey the DON brought each surveyor a sheet to obtain access to the EMR. -She stated she would send those forms to the information technology (IT) staff and get the access. -She was aware the surveyors needed to be able to readily access any residents' EMRs for review. On day two of the survey (3/13/18) the surveyors attempted to access the EMR with the login in information provided from the DON: *One surveyor was able to log in with their own computer. -Due to a network error once the surveyor logged in to the EMR it would only be open for a minute or two and then go back to the login screen. *The other four surveyors had problems getting logged into the EMR. *The DON and administrator had brought in laptops for the surveyors to use, but the logins did not work. *By the end of day two surveyors had not had access yet to the EMR. *Upon exiting the building at 6:45 p.m. that day the administrator was aware of the lack of access. -He would figure it out, and it would be ready for the next day. On day three of the survey (3/14/18) IT staff spent time with the surveyors for a large part of the morning getting them access to the EMR: *Laptops were brought in for the surveyors to use, but they had to be logged into by facility staff to get to the home screen. *If the surveyors left the laptop logged in with no movement for more than five to ten minutes it automatically logged off. -They would then have to find a facility staff person to log them in again. *The lack of access and problems with being logged out significantly interfered with the survey process and investigations. *The DON and administrator were updated on 3/12/18, 3/13/18, and 3/14/18 of the need for access. -They were aware it was interfering and slowing down the survey. -They verbalized understanding and were trying to work through the concern with the corporate staff. -Printed copies of parts of residents' medical records were requested due to the limited access to the EMRs. Review of the provider's revised (MONTH) (YEAR) Access to Regional Health Information Systems policy revealed:* .Information systems access authorization may be granted to an individual, or to a class of individuals, either on a case-by-case basis, or by policy.*There was no information relating to the timeliness of access to the medical records. |
2020-09-01 |