MANORCARE HEALTH SERVICES -TULSA
LOCATED: 2425 SOUTH MEMORIAL, TULSA, OK 74129
MANORCARE HEALTH SERVICES -TULSA was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO MAINTAIN ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident and staff Interviews, and record review it was determined the facility failed to implement interventions to aid in the prevention of severe weight loss for two (#1 and #4) of six sampled residents who were reviewed for weight loss. This resulted in actual harm for resident #4 who had a severe weight loss of 16.4 pounds (11.2%) in three months, 19.2 pounds (13.1%) in six months, and had developed a stage II pressure ulcer.
A treatment administration record, dated November 2015, documented, “Weekly weights x4 weeks then monthly.” according to the treatment administration record, weights were to be done by the day shift on 11/4/15, 11/11/15, 11/18/15, and 11/25/15.
The weights were reviewed on the treatment record. The admission weight on 11/4/15 was documented as 178.6.
The space for the weight documentation on 11/11/15 was blank.
The space for the weight documentation on 11/18/15 had the initials of an LPN, but no weight.
The space for the weight documentation on 11/25/15 was blank.
On 12/1/15 at 10:10 a.m., the administrator was asked for the weekly weights for the resident. She stated the weights should be documented on the treatment administration record. She then stated she would ask the DON to provide the requested documentation to the surveyor.
At 10:15 a.m., the DON reviewed the November 2015 treatment administration record with the surveyor. The treatment administration record had all four weekly weights recorded in the spaces which were previously blank.
The DON was advised the weights had been added since the previous day. She was then asked who had recorded the weights. The DON provided a blue sticky note which documented, “Wt Weekly … 178.6 … 178.4 … _179.8 … 177.6.”
This was the only documentation on the sticky note. These weights corresponded to the four weights recorded on the treatment administration record. The DON stated she was unaware of who had documented the weights, but would look into it.
At 10:30 a.m. the administrator approached this surveyor and stated she was unhappy regarding the late documentation of weights on the resident and there would be an internal investigation into the situation.
The DON was informed about the resident’s observed weight earlier in the day. She was asked if the resident weighed 178.6 pounds at admission and 154 pounds on 12/2/15, would this be considered severe weight loss. She stated yes, she would call the doctor and notify the family and dietician.
She was asked if accurate weights were obtained as ordered by the physician, could this have prevented the resident’s significant weight loss. . She stated interventions could have been implemented sooner.
Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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