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Tag No.: C0388
On the days of the initial swing bed certification survey based on record reviews, interviews, and review of hospital policy and procedure, the facility failed to ensure the completion of a comprehensive resident assessment for three (3) of three (3) resident records reviewed. (Resident #1, 2, and 3)
The findings included:
On 1/12/10 at 0900, a review of Resident #1's open medical record revealed the fifty-one year old was admitted on 11/15/09 with diagnoses of right middle Cerebral Artery Distribution Stroke with left Hemiparesis, Hypertension, and status post respiratory failure requiring ventilation.
The hospital form, "Minimum Data Set (MDS) for Swing Bed Hospitals" did not include the following required assessment components listed on the form: customary and routine, dental status, activity pursuit, medications, discharge potential, documentation of summary information regarding the additional assessment performed through the resident assessment protocols, and documentation of resident participation in the assessment.
On 1/12/10 at 0945, a review of Resident #2's open medical record revealed the ninety-three year old was admitted on 1/06/10 with diagnoses of status post fall with Pelvic Fracture. The hospital form, "Minimum Data Set (MDS) for Swig Bed Hospitals" did not include the following required assessment components: customary and routine, dental status, activity pursuit, medications, discharge potential, documentation of summary information regarding the additional assessment performed through the resident assessment protocols, and documentation of resident participation in the assessment.
On 1/12/09 at 1300, a review of Resident #3's closed medical record revealed the sixty-two year old was admitted on 11/15/09 with diagnoses of right Basal Ganglia Infarct, Hypertension and Coronary Artery Disease. The hospital form, "Minimum Data Set (MDS) for Swig Bed Hospitals" did not include the following required assessment components:customary and routine, dental status, activity pursuit, medications, discharge potential, documentation of summary information regarding the additional assessment performed through the resident assessment protocols, and documentation of resident participation in the assessment. The findings were reviewed and confirmed in an interview with the Chief Nursing Officer on 1/12/10 at 1430.
Review of hospital policy, "Care for Swing Bed Patients", effective 10/30/09, read, " ... Comprehensive Assessment, Care Plan, and Discharge Planning: The Chief Nursing Officer shall ensure that the Hospital accomplishes a comprehensive, accurate, standardized, and reproducible assessment of each swing-bed resident's functional capacity. The facility may use the State's specified resident assessment instrument, which includes both the Minimum Data Set (MDS) and Resident Assessment Protocols (RAPS) developed by CMS, or create their own assessment tool as long as it provides, at a minimum: 1) Identification and demographic information. 2) A description of the resident's customary and routine ...11) A description of the resident's dental and nutritional status ... 13) A description of the resident's activity pursuit. 14) A description of the resident's medication(s) .... 16) Discharge potential. 17) Documentation of summary information regarding the additional assessment performed through the resident assessment protocols. 18) Documentation of the participation in the assessment...".
Tag No.: C0395
On the days of the initial swing bed certification survey based on record reviews, interviews, and review of hospital policy and procedure, the facility failed to ensure the development of a comprehensive care plan for each resident to include quantifiable and measurable objectives with timetables to meet the residents's needs for three (3) of three (3) resident records reviewed. (Resident #1, 2, and 3)
The findings included:
On 1/12/10 at 0900, a review of Resident #1's open medical record revealed the fifty-one year old was admitted on 11/15/09 with diagnoses of right middle Cerebral Artery Distribution Stroke with left Hemiparesis, Hypertension, and status post respiratory failure requiring ventilation. The Interdisciplinary Plan Care showed staff documented bruising as a problem but staff failed to address the underlying cause of the bruising. Staff documented the expected outcome for the problem of bruising was "no worsening", and the identified intervention was "Implement wound care flow sheet on admission and every three days". The interdisciplinary plan was reviewed weekly at the care team meetings. There was no documentation that the plan was updated to reflect new goals or interventions until the expected outcome was met on 12/27/09. Additional problems identified included impaired mobility, injury prevention, self care alteration, ethical challenges, knowledge deficits, nutritional alteration and personal control but none of the identified problems included measurable goals with timetables identified.
On 1/12/10 at 0945, a review of Resident #2's open medical record revealed the ninety-three year old admitted on 1/06/10 with diagnoses of status post fall with Pelvic Fracture.
The Interdisciplinary Plan Care showed staff documented high risk skin integrity as a problem. The expected outcome for the problem for skin integrity was "no breakdown" and "Offer sufficient nutritional support for prevention of skin breakdown". The identified intervention was "Implement wound care flow sheet on admission and every three days, encourage adequate oral intake, and supplements." The identified goals were not measurable and were without timelines. Impaired mobility was identified as a problem with "See PT (Physical Therapy) for goals" written in the section for measurable goals under interventions. Additional problems identified included injury prevention, alteration in elimination, self care alteration, ethical challenges, knowledge deficits, nutritional alteration, pain, personal control and discharge planning but none of the identified problems included measurable goals and timetables.
On 1/12/09 at 1300, a review of Resident #3's closed medical record revealed the sixty-two year old was admitted on 11/15/09 with diagnoses of right Basal Ganglia Infarct, Hypertension and Coronary Artery Disease. The patient's Interdisciplinary Plan of Care identified rash as a skin integrity problem. The expected outcome for the problem of skin integrity was "no worsening". The identified intervention for the problem was "Implement wound care flow sheet on admission and every three days" but did not include the application of the hydrocortisone cream that was documented in the residents's medical record, as an intervention. Impaired mobility was identified as a problem with "OT (Occupational Therapy) evaluation, see goals. See P.T. (Physical Therapy) evaluation for goals " was written in the section for measurable goals under the interventions. Additional problems identified included injury prevention, alteration in elimination, self care alteration, psychosocial/ cultural/spiritual, nutritional alteration, pain, personal control and discharge planning but the problems did not include measurable goals and timetables.
The findings were reviewed and confirmed in an interview with the Chief Nursing Officer on 1/12/10 at 1430.
Review of hospital policy, "Care for Swing Bed Patients", effective 10/30/09, read, " ... Comprehensive Assessment, Care Plan, and Discharge Planning: ... The Chief Nursing Officer shall ensure that a comprehensive multidisciplinary care plan is developed for each swing-bed resident, that includes measurable objectives and timetables to meet the resident's medical, nursing, rehabilitation, mental and psychosocial needs that are identified in the nursing assessment and the Comprehensive (MDS) Assessment .... ".