GREENSBORO, GA- LEGACY HEALTH AND REHABILITATION

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35180

Based on observations, record review, resident and staff interviews, and policy review, it was determined that the facility failed to ensure the development of a comprehensive, person-centered, care plan for four residents (R#16, #24, #27, and #20) from a sample size of 18.

Findings include:

Review of the facility policy titled Patient’s Plan of Care with a review date of 12/4/21 revealed each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient’s medical, physical, mental, and psychosocial needs. The comprehensive care plan should be updated as ongoing clinical assessments identify changes.

1. Review of the clinical record revealed R#16 was admitted to the facility on [DATE] with diagnoses of thyroid disease, vitamin A deficiency, hyperlipidemia, dementia, heart failure, Crohn’s Disease, stage III chronic kidney disease, and elder abuse. The assessment for Brief Interview for Mental Status Score (BIMS) was 00.

A review of the Comprehensive Nursing Admission Assessment, dated 7/2/21, revealed that R#16’s vision was adequate with glasses.

A review of the Social Services Assessment, dated 7/8/21, revealed R#16’s vision was adequate with
glasses.

A review of the Activities Initial Assessment, dated 7/12/21, revealed that R#16 required reading glasses.

A review of the MDS OBRA Quarterly Assessment, dated 3/20/22, Section B – Vision, Speech, and Vision revealed the MDS OBRA Quarterly Assessment, dated 3/20/22, revealed R#16’s vision was adequate to see fine detail, including regular print in newspapers and books. Additionally, no contact lenses or glasses were used by R#16.

A review of the medical record revealed the resident was not care planned for vision under any care plan or care area.

During an interview on 8/12/22 at 11:13 a.m. with R#16’s spouse, revealed that R#16 wears glasses to see things up close. He said she used to do puzzles and read but does not do those things anymore due to her dementia, but she required glasses to see things up close.

During an interview on 8/13/22 at 3:35 p.m. with the MDS Coordinator (MDSC), stated she conducted resident assessments through scanned documents, resident interviews, staff interviews, medical record reviews, Social Activity Assessments, Dietary Assessments, Nursing Assessments, laboratory results, and any other assessments in resident’s record. She acknowledged that the Comprehensive Nursing Admission Assessment, dated 7/2/21, and the Social Services Assessment, dated 7/8/21, reflected that R#16’s vision was adequate with glasses. In addition, she confirmed that the Activities Initial Assessment, dated 7/12/21, revealed that R#16’s vision was adequate with glasses. She stated if a resident required glasses to see or read, they would be care-planned for vision. During further interview, she stated she was not working as the MDSC at the time of R#16’s admission, but the MDSC at that time should have care-planned R#16 for vision based on the assessments.

2. Review of the clinical record review revealed Resident #24 was admitted on [DATE] with diagnoses of chronic kidney disease (CKD), anemia, cardiomyopathy, hyperlipidemia, heart failure, atrial fibrillation (A-fib), pulmonary hypertension, essential hypertension, type II diabetes, adult failure to thrive, and gout. R#24 BIMS assessment revealed a score of 08.

Review of the MDS OBRA Quarterly Assessment, dated 5/6/22, Section L – Oral/Dental Status, revealed R#24 reported mouth or facial pain and discomfort or difficulty with chewing during the seven-day lookback period.

Review of R#24’s care plan revealed no care plan for mouth or dental care.

Review of the dental post-op instructions, dated 5/4/22, revealed R#24 had four teeth extracted on 5/4/22.

During an interview with R#24 on 8/13/22 at 7:38 a.m., he stated that he was not asked if he had had any difficulty eating or chewing since the extraction of four teeth. He explained that all four teeth were removed from the bottom left side. He stated as the removed teeth were all next to each other, it was hard to chew meats at times.

During an interview on 8/13/22 at 3:35 p.m. with the MDSC, acknowledged that R#24’s medical record reflected he had four teeth removed on 5/4/22. She stated she should have care-planned R#24 for Dental issues based on the MDS Quarterly Assessment on 5/6/22, and stated it was an oversight.

During an interview on 8/13/22 at 5:00 p.m. with the Administrator, stated it was her expectation for the MDS Coordinator to ensure each resident had a care plan that was self-centered and individualized. She added it was the responsibility of the MDS Coordinator to complete a comprehensive assessment to ensure all care areas were addressed for each resident.
35062

3. Review of the Quarterly MDS dated [DATE] revealed R#20 had a BIMS score of 14 indicating cognition intact. Section N- Medications revealed the resident received a diuretic seven days of the look back period.

Observation on 8/13/22 at 8:30 a.m. revealed R#20 received furosemide (diuretic medication) 40 milligrams (mg) by mouth. The resident bit the pill in half, took half the pill and refused the other half.

Review of the Physician Order (PO) with an original order date of 5/6/21 revealed furosemide 40 mg tablet one tablet by mouth one time per day for pitting edema.

Review of the care plan last updated 7/20/22 revealed no care plan addressing R#20 receiving a diuretic medication.

4. Review of the Quarterly MDS assessment dated [DATE] revealed R#27 had a BIMS of one indicating severe cognitive impairment. Section G – Functional Status documented the resident required two-person extensive assistance with personal hygiene and physical help in part of bathing activity.

Observations on 8/12/22 at 10:48 a.m. and 8/14/22 at 9:42 a.m. revealed R#27 had a lot of facial hair on her chin.

Interview on 8/14/22 at 10:04 a.m. with Certified Nursing Assistant (CNA) BB revealed R#27 will knock you out if they tried to remove the hair off her chin.

Review of the care plan last updated 6/1/22 revealed R#27 has limited mobility and to assist with ADLs as needed. There was no personalized information in the care plan for providing ADL care.

Interview with the Director of Nursing (DON) on 8/14/22 at 1:00 p.m. revealed residents receiving diuretic medication should have a care plan to address the diuretic and care plans should be reflective of the person centered care the resident should receive.