| 4439 |
LAKIN HOSPITAL |
5.1e+125 |
1 BATEMAN CIRCLE |
WEST COLUMBIA |
WV |
25287 |
2016-03-10 |
278 |
D |
0 |
1 |
EQIS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete assessments prior to signing and certify the minimum data sets (MDS) were complete. This was found for one (1) of twenty-one (21) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey (QIS). This was true for Residents #95. Additionally, for two (2) of five (5) resident's reviewed for the care area of unnecessary medication, Residents #76 and #90, the facility failed to completed accurate MDSs in regards to active [DIAGNOSES REDACTED]. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #95, #76, and #90. Facility census: 96. Findings include: a) Resident #95 On 03/07/16 at 11:25 a.m., reconciliation of the current residents residing in the facility found Resident #95 was not on the list of residents who had resided or continued to reside in the facility. This resident had resided in the facility since admission date of [DATE]. Review of Resident #95's MDSs on 03/08/15 at 1:00 p.m., found an MDS with an ARD of 02/16/16, was incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. Item Z0400, was signed and dated on 02/26/16 by MDS Coordinator #78 to indicate sections A, B, C, G, H, I, J, L, M, N, and S were completed on 02/26/16. In addition, Item Z0500 - Signature of RN Assessment Coordinator Verifying Assessment Completion, was signed MDS Coordinator #78 on 02/26/16 to certify the assessment was complete. Review of the MDS assessment report for the MDS with the ARD of 02/16/16, found MDS Coordinator #78 had not completed sections A, B, C, G, H, I, J, L, M, N, S, and Z until 03/08/16 at 11:39 a.m The MDS Coordinator had certified the assessment as complete and ready for submission on 03/08/16 at 12:24 p.m. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manuel, Chapter 2, page 16, the assessment must be complete by fourteen (14) calendar days of the ARD date. Interview on 03/08/16 at 2:30 p.m., with MDS Coordinator #78 revealed she thought she had 28 days to complete, certify, and submit the MDS. On 03/08/16 at 3:15 p.m., during a review of the MDS with the ARD of 02/16/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/01/16. She also verified the MDS was completed on 03/08/16, not 02/26/16 as indicated in Section Z by MDS Coordinator #78. b) Resident #76 A review of the medical record for Resident #76 on 03/08/16 at 2:21 p.m., revealed the quarterly MDS assessment with the assessment reference date (ARD) of 12/11/15 did not accurately reflect the [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#76 had orders for [MEDICATION NAME] 0.5 milligrams (mg) daily for anxiety and [MEDICATION NAME] 20 mg daily for GERD. A review of the Medication Administration Record [REDACTED]. In an interview on 03/09/16 at 3:32 p.m., the MDS Coordinator verified Section I - Active [DIAGNOSES REDACTED].#76. c) Resident #90 A review of the medical record for Resident #90 on 03/09/16 at 10:44 a.m., revealed the quarterly MDS assessment with the ARD of 12/28/15 did not accurately reflect the [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#90 had an order for [REDACTED]. An interview on 03/09/16 at 12:10 p.m., with the MDS Coordinator verified Section I - Active [DIAGNOSES REDACTED].#90. |
2019-11-01 |