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NORTHERN MAINE MEDICAL CENTER
CONTENT OF RECORD: INFORMED CONSENT
Tag No.: A0466
Based on record review and interview with key personnel on November 18, 2014, it was determined that the facility failed to assure that an informed consent was obtained on two (2) of three (3) swing bed residents (Resident A & B) for treatment on the swing bed unit.
Findings include:
A review of the medical records of Resident A and Resident B lacked evidence that an informed consent for treatment was signed prior to or immediately after admission to the swing bed unit. This finding was confirmed on November 18, 2014 at approximately 9:10 AM, with the Assistant Director of Nursing (ADON). The surveyor noted that an informed consent for treatment was obtained after the above finding was confirmed with the ADON.
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on record review and interview with key personnel on November 18, 2014, it was determined that the facility failed to assure that admission orders for swing bed status were written for two (2) of three (3) sampled swing bed residents (Resident B, Resident C).
Finding includes:
A review of the medical records and physician's orders for Resident B and Resident C indicated orders were written to transfer both residents from acute care inpatient status to swing bed inpatient status; however, no admission orders were written to admit Resident B or Resident C into swing bed status. These findings were confirmed by the Assistant Director of Nursing on November 18, 2014 at approximately 9:15 AM.
STAFF ACCESS TO DRUG INFORMATION
Tag No.: A0510
Based on record review and interview with key personnel on November 18, 2014, it was determined that the facility lacked evidence of documentation in the record whether or not the individual has executed an advanced directive for one (1) of three (3) sampled swing bed resident records (Record C).
Findings include:
1. Review of the medical record of Resident C lacked evidence of whether or not the individual had executed an advanced directive.
2. This finding was confirmed by the Assistant Director of Nursing on November 18, 2014 at approximately 9:15 AM.
No Description Available
Tag No.: A1513
Based on record review and interview with key personnel on November 18, 2014, it was determined that the facility failed to assure that resident's participated in care planning and treatment, for one (1) of three (3) sampled swing bed residents (Resident A).
Findings include:
1. Review of the medical record for Resident A lacked evidence of participation in care planning and treatment.
2. The above finding was confirmed by the Assistant Director of Nursing on November 18, 2014 at approximately 9:00 AM.