Fairview Care Center Of Bethlehem Pike (November 7th)
Based on interviews with staff and review of clinical records, it was determined that the nursing home failed to ensure that the resident assessment accurately reflected the resident’s current status related to restraints for one of 24 residents reviewed. Those findings included the following: Review of the Resident Assessment Instrument Minimum Data Set 3.0 Manual, Section P, Physical Restraints, indicated that if a physical restraint was utilized on a resident during the seven day look-back period, the assessment would identify the type of restraint and the frequency of its use. In review of Resident R138’s current plan of care, it was revealed that the resident’s Broda chair was classified as a restraint. In review of nursing documentation for Resident R138 revealed restraint evaluation and reduction re-assessments were conducted monthly from February 2013, through October 2013. In review of quarterly minimum data sets, dated April 3, 2013, June 24, 2013 and September 30, 2013, it was revealed that Section P on each assessment was coded with zeros, indicating that physical restraints were not used for Resident R138. In an interview with Employee E5, Nurse Assessment Coordinator on November 6, 2013 at 1:45 p.m., confirmed that the quarterly MDS assessments regarding physical restraints were inaccurate for Resident R138.
Based on a review of clinical records and a staff interview, it was determined that the Philadelphia nursing home failed to administer medication and complete laboratory studies as ordered by the physician for two of 24 residents reviewed. Findings included the following: Urine test results, dated October 27, 2013, identified the organism faecalis and trace leukocytes. Notation indicated that no treatment was ordered due to a low count of the organism, and no further elevated temperature or symptoms of a urinary tract infection. Nursing documentation, dated on October 31, 2013, revealed that an elevated temperature was again assessed in Resident R61 that morning, and an order was obtained for a UA C&S. There was no evidence available for review on November 6, 2013, at 9:15 a.m. to indicate that this UA C&S was completed as ordered. This finding was confirmed in an interview with licensed nurse Employee E4 on November 6, 2013 at 10:15 a.m.
A nursing entry for January 21, 2013 at 7:00 p.m. noted that Resident R102 had gone out of the facility for a tooth extraction at 8:30 a.m. that morning, that the resident had returned at 3:00 p.m. and that the resident had been medicated for pain. The resident had a gauze at the extraction site that a previous order stated to hold aspirin 81 milligrams 5 days prior to tooth extraction was documented on the 24 hour report and on Resident R102’s Medical Administration Record. In review of the Dental Consult Sheet dated January 21, 2013, it was revealed that Resident R102 had a surgical extraction, had gauze in his mouth, and that an order was written for Tylenol #3 one tablet every hours as needed for pain. There was no evidence available for review that the Physician had been advised of the consultant recommendations or had been notified that the order to hold the medication had not been followed.