| 2 |
NHC HEALTHCARE, OAKWOOD |
445002 |
244 OAKWOOD DR |
LEWISBURG |
TN |
37091 |
2019-05-31 |
641 |
E |
0 |
1 |
4KQP11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately assess residents for the use of unnecessary medications and pressure ulcers for 7 of 17 (Resident #4, #24, #27, #30, #45, #51, and #254) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment, and the resident received anticoagulant medications daily during the 7-day look-back period. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 12:48 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 2. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 14, indicating no cognitive impairment, and received anticoagulant medications 5 of the 7 days of the look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED] Interview with the MDS Coordinator on 5/30/19 at 12:50 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 3. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS of 15, which indicated no cognitive impairment, and received antianxiety medications, antidepressant medications, anticoagulant medications, and diuretic medications 5 of the 7 days of the look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 9:59 AM in the Conference Room, the MDS Coordinator was asked if the admission MDS dated [DATE] was coded correctly for antianxiety, antidepressant, anticoagulant and diuretic medications. The MDS Coordinator stated, No. 4. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS of 15, which indicated no cognitive impairment, and received antidepressant and anticoagulant medications 7 days, antibiotics 2 days, diuretics and opioids 6 days of the 7-day look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The quarterly MDS dated [DATE] documented a BIMS of 12, which indicated moderate cognitive impairment, and received antidepressant, hypnotic, anticoagulant, and diuretic medications 5 days of the 7-day look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 9:18 AM in the Conference Room, the MDS Coordinator was asked if the admission MDS dated [DATE] was coded correctly for anticoagulants, antibiotics, diuretics and opioids. The MDS Coordinator stated, No. The MDS Coordinator was asked if the quarterly MDS dated [DATE] was coded correctly for antidepressants, hypnotics, anticoagulants and diuretics. The MDS Coordinator stated, No. 5. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 10, which indicated moderate cognitive impairment, and received anticoagulant medications daily during the 7-day look-back period. Review of the (MONTH) 2019 and (MONTH) 2019 MARs revealed no anticoagulant medication was administered. Interview with the MDS Coordinator on 5/30/19 at 12:51 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 6. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 13, which indicted no cognitive impairment, and was coded for anticoagulant administration daily during the 7-day look-back period. Review of the annual MDS dated [DATE] revealed a BIMS of 14, which indicated no cognitive impairment, and was coded for anticoagulant administration daily during the 7-day look-back period. Review of the (MONTH) 2019 and (MONTH) 2019 MARs revealed anticoagulant medications were not administered. Interview with the MDS Coordinator on 5/30/19 at 10:45 AM in the Conference Room, the MDS Coordinator confirmed the MDS was coded incorrectly for anticoagulant administration. 7. Medical record review revealed Resident #254 was admitted to facility on 5/14/19 with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a BIMS score of 6, which indicated severe cognitive impairment, and was not coded for Unhealed Pressure Ulcers, Other Ulcers, Wounds and Skin Problems. Review of the physician's orders [REDACTED]. Review of the Weekly Wound Assessment Record dated 5/15/19 revealed an Unstageable Pressure Ulcer to the back of the right calf. Review of the Care Plan dated 5/21/19 revealed an Unstageable Pressure Wound to the back of the right calf. Interview with the MDS Coordinator on 5/30/19 at 10:10 AM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to Unstageable Pressure Ulcers and Skin Problems. |
2020-09-01 |