cms_SD: 74
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
74 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2019-08-07 | 698 | D | 0 | 1 | ILL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the provider failed to ensure communication between a [MEDICAL TREATMENT] center and the provider was documented, that nursing staff were assessing the resident for change of condition, and they were following physician orders [REDACTED]. Findings include: 1. Review of resident 31's medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status assessment score of fifteen indicating she was cognitively intact. *Her [DIAGNOSES REDACTED].>-Type two diabetes. -End stage [MEDICAL CONDITION]. -Dependence on [MEDICAL TREATMENT]. -[MEDICAL CONDITION]. -Heart failure. -[MEDICAL CONDITION]. *She had been receiving [MEDICAL TREATMENT] three times per week. *She had an arteriovenous (AV) fistula place on 7/31/19. *[MEDICAL TREATMENT] post-assessment had not been completed since 7/18/19. Review of resident 31's 7/31/19 nurses note revealed: *She had returned from an appointment for the AV fistula placement. *The dressing was to be removed after forty-eight hours. *She was to do stress ball exercises twenty times every hour while awake. Review of resident 31's last reviewed 6/27/18 care plan revealed a [MEDICAL TREATMENT] post assessment was to be completed on [MEDICAL TREATMENT] days. Interview on 8/7/19 at 10:14 a.m. with registered nurse (RN) B regarding resident 31 revealed: *An assessment was to be done in the electronic medical record when she returned from [MEDICAL TREATMENT]. -She did know how to find and complete assessment. -She did not know where the assessment was to review it after it had been completed. *The resident had a fistula placed a couple days ago on 7/31/19. Interview on 8/7/19 at 10:23 a.m. with resident 31 and her husband revealed that they did not know if a post-[MEDICAL TREATMENT] assessment had been done after her [MEDICAL TREATMENT] treatments. Interview on 8/7/19 at 11:40 a.m. with RN A regarding resident 31 revealed the [MEDICAL TREATMENT] post-assessment should have been completed by a nurse after each [MEDICAL TREATMENT] procedure. Interview on 8/7/19 at 3:19 p.m., at 3:28 p.m., and at 4:19 p.m. with the assistant director of nursing regarding resident 31 revealed: *She had went to an appointment on 7/31/19 for afistula and had returned with new physician orders [REDACTED]. -She could not find the physician orders [REDACTED]. -They would not have documented that stress ball exercises had been completed. *When the resident returned from [MEDICAL TREATMENT] appointments the [MEDICAL TREATMENT] center would send a communication sheet back with her. -The communication sheet had before and after [MEDICAL TREATMENT] run weight and vital signs on it. It would have also contained any new orders. -The nurse reviewed the sheet upon return. -The weights were recorded in the electronic medical record, and then the sheet was shredded. *The resident's treatment record was requested during the interview, but it had not been provided by the end of the survey. *Requested the policy on [MEDICAL TREATMENT] and assessment post-[MEDICAL TREATMENT] treatment. -She stated the provider did not have a policy on that. *She had done a training on [MEDICAL TREATMENT] with staff. -The training material was requested during the interview, but it had not been provided by the end of the survey. Interview on 8/7/19 at 3:43 p.m. with RN I regarding resident 31 revealed: *When the resident returned from the [MEDICAL TREATMENT] center she looked at the dressing and did an assessment. *She reviewed the communication sheet from the [MEDICAL TREATMENT] center. *After she reviewed the sheet she put it in a file to be scanned into the medical record. *She did not document her assessment. *She did not know about the [MEDICAL TREATMENT] post-assessment that was to be completed. | 2020-09-01 |