Observations
Based on a review of client records and the Screening, Assessing and Reassessing policy, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in 4 of 5 client records reviewed.The Screening, Assessing and Reassessing policy indicates the CIWA will be completed every 4 hours until the client has scored between 8-10 for a 24-hour period. The COWS will be completed every 4 hours until the client has scored between 5-12 for a 24-hour period. A physician order is obtained to transition from detox.Client # 1 was admitted to detoxification services April 22, 2024, and stepped down to residential services on April 24, 2024, then discharged April 29, 2024. The client record indicates COWS was not completed every 4 hours until the client scored between 5-12 for a 24-hour period. A COWS was documented on April 23 at 11:11am. The next COWS was documented at 8:57 pm. Client # 1 was transferred to residential services on April 24, 2024; however, there was no physician order to transition from detox found in the record. Client # 2 was admitted to detoxification services May 5, 2024, and stepped down to residential services on May 12, 2024, then discharged May 21, 2024. The client record indicates COWS was not completed every 4 hours until the client scored between 5-12 for a 24-hour period. A COWS was documented on April 5, 2024, at 10:06 pm. The next COWS was documented on May 6, 2024, at 7:09am. Client # 4 was admitted to detoxification services on November 8, 2024, and stepped down to residential services on November 11, 2024, then discharged November 15, 2024. The client record indicates CIWA was not completed every 4 hours until the client scored between 8-10 for a 24-hour period. A CIWA was documented on November 9, 2024, at 12:01am. The next CIWA was documented November 9, 2024, at 10:02 am.Client # 5 was admitted to detoxification services on November 15, 2024, and stepped down to residential services on November 21, 2024. They were still an active client at the time of the investigation. There was no physician order to transition from detox found in the record.
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Plan of Correction
At the monthly Nursing department meeting on 12/18/2024, the Director of Nursing will re-train all Nursing staff on the importance of documenting in the electronic medical record system (HCS) and uploading any paper documents. Nursing staff will also be re-trained on the timely completion of chart documentation and on the policy of acquiring COWs and CIWAs. The Director of Nursing will audit charts on a weekly basis for the first 6 months to ensure 100% compliance. After the 6 months, compliance will be monitored through spot checks and also monthly chart audits. The Nursing staff will sign attestation forms acknowledging the education/training they received on these issues. |