Initial Comments:
A focused fundamental survey visit was completed on October 2 and 3, 2024. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was ten, and the sample consisted of three individuals.
Plan of Correction:
483.410(c)(1) STANDARD
CLIENT RECORDS
Name - Component - 00
The facility must develop and maintain a recordkeeping system that documents the client's health care, active treatment, social information, and protection of the client's rights.
Observations:
Based on review of facility records and documentation, and interview with administrative and facility staff, the facility failed to develop and maintain a recordkeeping system that documents the client's health care, that is an accurate, functional representation of the actual experience in the facility, for one of three sample Individuals. This practice is specific to Individual #2.
Findings included:
A review of Individual #2's record was completed on 10/03/2024 from 9:00 AM until
10:30 AM. A review of quarterly nursing assessments for the period 12/14/2023 through current revealed the following:
1. A Quarterly Nursing Assessment dated 06/07/2024 included the following vital signs information as follows: :
-Most recent Temperature
Temperature: 98.9 Date: 06/07/2024
Route: Forehead
-Most Recent Weight
Weight: 141.0 Date: 06/07/2024
Scale: Wheelchair
-Most recent Pulse
Pulse: 84 Date: 06/07/2024
Pulse Type: Regular
-Most Recent Respiration
Respiration: 19 Date: 06/07/2024
-Most Recent Blood Pressure
Blood Pressure: 118/68 Date: 06/07/2024
Position: sitting l/arm
2. A review of a subsequent quarterly nursing assessment dated 08/29/2024 revealed that this document listed the exact same vital signs, and the same date of 06/07/2024 adjacent to each entry, which had been copied to the document dated 08/29/2024. This was evident for all entries to include temperature, pulse, respiration and blood pressure. Only the entry for weight was different from the measurement listed on the document dated 06/07/2024.
Interview with the Assistant Director of Nursing on 10/03/2024 at approximately 10:00 AM confirmed that current vital measurements were not obtained for the 08/29/2024 nursing assessment. When further questioned regarding oversight of accurate completion of these nursing assessments, this interviewee was unable to indicate if a system for such was in place.
Plan of Correction:CE1
A record review will be scheduled for individual #2 by the QIDP. This review will be specific to the medical chart. The current medical chart audit form will be used to ensure all areas related to individual #2 healthcare needs are documented and accurately describe health status, routine nursing review of health, Primary care documentation, information and recommendations of specialists, pharmacy review, nutrition and medications.
All areas identified through audits will have an assigned person responsible for correction and a due date for correction. The meeting and audit forms will be documented and kept on file.
Completion date: 11/30/2024
CE 2
All other facility men will have record review scheduled by the QIDP. This review will be specific to the medical chart. The current medical chart audit form will be used to ensure all areas related to individual #2 healthcare needs are documented and accurately describe health status, routine nursing review of health, Primary care documentation, information and recommendations of specialists, pharmacy review, nutrition and medications.
All areas identified through audits will have an assigned person responsible for correction and a due date for correction. The meeting and audit forms will be documented and kept on file.
Completion date: 12/20/2024
CE 3 / 4
The facility currently uses an electronic health record whereby all health-related information is recorded. A re-training for all nursing staff and Healthcare Coordinators will be conducted during the month of November 2024. This training will review the methods of entering health information, setting due date alerts and real-time accuracy in entering information.
The Director of Nursing/Assistant Director of Nursing will monitor all quarterly documents for the next year. This monitoring will be recorded on an audit form for all individuals residing at the facility.
The Quality Management team will perform a medical chart audit in March and August of 2025
Any missing or erroneous information will be brought to the attention of the Administrator immediately.
Completion Date: 8/30/2025
CE 5
Persons responsible: QIDP, nurse, HCC, DON, ADON, QM team and Administrator
|