Fairview Care Center Of Bethlehem Pike (November)
Based on interviews with staff and clinical record reviews, it was determined that the nursing home failed to ensure that the resident’s assessment accurately reflected the resident’s current status related to the restraints for one of the 24 residents reviewed. Those findings included the following: Review of the Resident Assessment Minimum Data Set 3.0 Manual, Section P, Physical Restraints, indicated that if a physical restraint was used 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 medical care revealed the resident’s Broda chair was classified as a restraint.
In review of nursing documentation for Resident R138, it was revealed restraint evaluation and reduction assessments were conducted monthly from February 2013 through October 2013. In review of minimum quarterly data sets, dated April 3, 2013, June 24, 2013 and September 30, 2013, revealed Section P 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 interviews with staff and a review of clinical records, it was determined that the 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: Review of Resident’s R61’s clinical records found physician’s orders. Urine test results, dated October 27, 2013, identified the organism faecalis (part of the intestine) and trace leukocytes (white blood cells). Notation indicated that no treatment was ordered due to the low count of the organism, and no further temperature or symptoms of a urinary tract infection. Nursing documentation, dated October 31, 2013, revealed that an elevated temperature was again assessed on 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 revealed 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, and that the resident returned to the facility at 3:00 p.m. The resident had been medicated for pain. The resident had gauze at the extraction site and the previous order stated that the resident to hold aspirin 81 milligrams 5 days prior to the tooth extraction was documented on the 2 4hour report and on Resident R102’s Medication Administration Record.
In review of the Dental Consult Sheet dated January 21, 2013, revealed that Resident R102 had a surgical extraction, a gauze in his mouth, and that an order was written for Tylenol #3, one tablet by mouth, every four hours as needed for pain.