| 5697 |
PINE LODGE |
515001 |
405 STANAFORD ROAD |
BECKLEY |
WV |
25801 |
2015-01-29 |
272 |
D |
0 |
1 |
WCKU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument Manual, and staff interview, the facility failed to accurately complete comprehensive minimum data (MDS) assessments for three (3) of nineteen (19) residents whose MDSs were reviewed. The MDS for dental status was not accurate for Resident #137. The MDS in the area of skin conditions (pressure ulcers) was not accurate for Resident #75. The MDS was not accurate for Resident #132 in the area of medications. Resident identifiers: #137, #75, and #132. Facility census: 108. Findings include: a) Resident #137 Observation of the resident's oral cavity during an interview in Stage 1 of the Quality Indicator Survey (QIS), at 9:27 a.m. on 01/20/15, found he had discolored, broken, and missing teeth. When asked if he had problems with his teeth, the resident replied, Yes, my teeth are falling out just like an old horse. Review of the annual MDS with an assessment reference date (ARD) of 07/01/14 found Section (L), entitled oral/dental status, identified the resident as having no obvious cavity or broken natural teeth (L0200). At 4:45 p.m. on 01/20/15, the MDS coordinator, Employee #22, examined the resident's oral cavity. She confirmed the resident had discolored and missing teeth. Observation of the teeth on the bottom left revealed several teeth were black and broken at the gum line. She said she had not completed the oral exam herself, but relied on nursing documentation to complete the MDS. An annual nursing assessment completed on 07/01/14 revealed the nurse completing the assessment had checked the teeth located on the upper right, lower right, and lower left were all in poor condition. At 9:15 a.m. on 01/21/15, the director of nursing stated the annual MDS did not capture the resident's dental problems. The director of nursing said the facility would correct this MDS assessment. b) Resident #75 On 01/26/15 at 2:30, a review of Resident #75's admission nursing assessment dated [DATE], revealed the resident had an old surgical scar on the right knee. The medical record revealed two (2) significant change minimum data set (MDS) assessments, with assessment reference dates (ARD) of 09/19/14 and 09/26/14. On 01/26/15 at 1:00 p.m., review of the assessments revealed Item M0100A was coded as the resident having a Stage I pressure ulcer, a scar over a bony prominence, or a non-removable dressing and/or device. Item M0150, was coded to indicate the resident was not at risk of developing a pressure ulcer. Item M0210, regarding unhealed pressure ulcers was coded as the resident not having one (1) or more unhealed pressure ulcer(s) at Stage one or higher. In an interview with MDS Nurse #20, on 01/29/15 at 3:15 p.m., she said this resident did not have a Stage I pressure ulcer, a scar over a bony prominence, or a non-removable dressing and/or device. She acknowledged the two (2) significant change MDSs were incorrectly coded. c) Resident #132 A review of Resident #132's medical record at 10:10 a.m. on 01/26/15 revealed a physician's orders [REDACTED]. A review of Resident #132's medication administration record (MAR) from 12/30/14 through 01/06/15, revealed Resident #132 received this medication daily as ordered by the physician. Further record review, found a Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/06/15, was not coded in Item N0300 - injections to indicate the resident had received injections seven (7) of the seven (7) days in the look back period. Review of the Resident Assessment Instrument (RAI), Version 3.0 Manual, found the coding instructions for N0300 were, Count the number of days that the resident received any type of injection (subcutaneous, intramuscular, or interdermal) while a resident of the nursing home. Record the number of days that any type of injection (subcutaneous, intramuscular, or interdermal) was received in Item N0300. An interview with Registered Nurse MDS Coordinator #103, at 3:32 p.m. on 01/26/15, confirmed she had inaccurately coded Item N0300. She reviewed the MAR and stated, I must have made a data entry error. She confirmed item N0300 was coded as 0 and should have been coded as 7. |
2018-08-01 |