cms_TN: 4812
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4812 | GRACE HEALTHCARE OF WHITES CREEK | 445281 | 3425 KNIGHT DRIVE | WHITES CREEK | TN | 37189 | 2016-07-08 | 281 | E | 1 | 0 | TQUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow the facility policy on Intake and Output for 3 (Resident #1, 3, 4) of 3 residents reviewed; failed to document the use of [MEDICAL CONDITION] (Continuous Positive Airway Pressure) on the Medication Administration Record [REDACTED]. The findings included: Review of the facility policy entitled Intake and Output, Conditions Requiring, revealed .Recording of Intake and Output will be done with the goal of providing continuing assessment information, therefore the Physician and or the Director of Nursing/Nurse Managers may place a resident on Intake and Output or discontinue Intake and Output if the resident's clinical condition deems appropriate . 2. Residents with the following conditions and [DIAGNOSES REDACTED]. Residents with a Foley catheter .d. Residents on fluid restriction .3. Nursing staff will record Intake and Output per facility documentation protocols . Review of the facility policy entitled Fluids, Restricted revealed . It is the policy of this facility to safely provide to the resident the amounts of fluids indicated by the physician's order .Fluids will be provided upon request and at times designated . Fluids consumed by the resident are to be accurately measured and recorded. Intake record should be maintained during the time the resident is on restricted fluids . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 8 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #1 required extensive assist with transfers; was independent with eating; was incontinent of bowel; and had a Foley catheter in place. Medical record review revealed Resident #1 was admitted to the hospital on [DATE] due to shortness of breath which occurred during a physician's appointment. Medical record review of transfer orders dated 11/25/15 revealed Resident #1 was continued on [MEDICATION NAME] (diuretic medication) 80 mg (milligrams) daily and .Fluid restriction 1500 milliliters (ml) . was added to the recapitulation orders after being signed by the physician. Continued review of the orders revealed Resident #1 was readmitted to the facility with a Foley catheter in place. Medical record review of an undated fluid restriction form, which the Director of Nursing (DON) confirmed was applicable to the resident when she returned from the hospital on [DATE], revealed Resident #1 was on a 1500 ml fluid restriction with dietary providing 720 ml at breakfast, 240 ml at lunch, and 240 ml at dinner. Continued review revealed nursing was to give the resident 150 ml fluid during the day and 150 ml fluid during the evening. Medical record review of the Counted Intake and/or Output Roster completed by the Certified Nursing Aides (CNA) revealed documentation of the fluid amounts sent up on each tray by dietary as well as the Foley catheter output. Continued review revealed no documentation of the 300 ml fluids nursing was allowed to give the resident or the amount of fluids administered along with medications. Further review of the form revealed Resident #1 should have received 31,500 ml of fluid from 11/26/15 - 12/16/15 but only received 25,740 ml. Continued review revealed the resident had no fluid intake on 19 occasions when she refused a meal. Medical record review of physician's admission orders [REDACTED]. Continued review revealed an order for [REDACTED]. Interview with the DON on 6/30/16 at 10:45 AM in the conference room, confirmed the [MEDICAL CONDITION] was not reordered when Resident #1 was readmitted to the facility on [DATE]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #3 scored 8 on the BIMS, indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #3 required extensive assistance of 3 people for transfers; required set up assistance for eating; and was occasionally incontinent of bowel and bladder. Medical record review of physician's orders dated 1/11/16 revealed Resident #3 was placed on a fluid restriction of 2000 ml daily. Medical record review of nursing notes dated 1/11/16 revealed dietary would provide the resident with 720 ml with breakfast; 240 ml with lunch; and 240 ml with dinner. Further review revealed there were 800 ml which nursing could administer but there was no documentation in the medical record of fluids administered to the resident by nursing; no documentation of fluids administered with medications; and no record of intake and output. Continued review revealed Resident #3 received [MEDICATION NAME] 80 mg daily. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 scored 12 on the BIMS indicating slight cognitive deficit. Continued review of the MDS revealed Resident #4 required assistance of 1 person with transfers; and had occasional bladder incontinence and frequent bowel incontinence. Medical record review of physician's orders dated 4/12/16 revealed Resident #4 was placed on a fluid restriction of 1500 ml daily. Continued review revealed dietary would provide the resident 720 ml for breakfast, 240 ml at lunch, and 240 ml at dinner. Further review revealed nursing could provide 300 ml to the resident over 24 hours. Continued review revealed Resident #4 received [MEDICATION NAME] 80 mg daily. Medical record review of nursing notes revealed no documentation of the amount of fluids administered to the resident with medications; no documentation of fluids administered by nursing; and no documentation the resident was on a fluid restriction. Interview with the DON on 7/6/16 at 8:20 AM in the DON's office confirmed the facility does not keep intake and output on any residents unless the physician orders it for a special case in spite of the fact the facility policy states MD/DON/Nurse Manager may order Intake and Output. Further interview confirmed there was no documentation of resident intake of fluids allotted to nursing and no documentation of the amount of fluids administered with medications. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 11/20/15 revealed an order for [REDACTED].>Medical record review of the MAR for (MONTH) and (MONTH) (YEAR) revealed no documentation the resident was on [MEDICAL CONDITION] and there was no order to discontinue the [MEDICAL CONDITION]. Interview with the DON on 6/30/16 at 10:45 AM in the conference room, confirmed the [MEDICAL CONDITION] was not reordered when Resident #6 returned to the facility on [DATE] and the use of the [MEDICAL CONDITION] was not reflected on the MAR for (MONTH) or December. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital medication discharge orders dated 5/20/16 and the facility admission (MONTH) (YEAR) Physician Orders recapitulation form, signed by the facility physician on 5/24/16, included the diabetic medication [MEDICATION NAME] ER (extended release) 500 mg (milligrams) 2 tablets by mouth twice a day for 5 days; then increase to 1000 mg twice daily. Further review revealed the hospital discharge orders and the facility recapitulation form included Polyethylene [MEDICATION NAME] 3350 (for constipation) 17 gm (grams) orally every 24 hours. Medical record review of telephone physician orders revealed no changes regarding the [MEDICATION NAME] or the Polyethylene [MEDICATION NAME] medications from admission to 5/23/16. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].administration .except on Mondays and Thursdays . Interview with Licensed Practical Nurse #1 on 6/30/16 at 12:55 PM at the back nursing station confirmed, the Polyethylene [MEDICATION NAME] was not administered as ordered daily after 5/23/16 when the MAR indicated [REDACTED].administer .except on Mondays and Thursdays . Interview with ADON #1 on 6/30/16 at 2:30 PM in the ADON's office confirmed, the ADON had incorrectly changed the [MEDICATION NAME] and Polyethylene [MEDICATION NAME] data entry in the MAR indicated [REDACTED].except on Mondays and Thursdays .and the facility had failed to follow the physician order to administer the [MEDICATION NAME] twice daily and the Polyethylene [MEDICATION NAME] daily. | 2019-07-01 |