Recent Survey Issues November to May 2019
Resident Council Meetings:
- Residents not aware of Resident Council Meeting is held.
- Complaints in Resident Council not addressed
Weight Loss issues:
- Reason for weight loss not assessed as related to missing dentures
- Advanced dementia not indicated as related to weight loss
Request/Refuse/Treatment/Advanced Directives:
- Resident missing an Advanced Directive
- MD not talking to resident when completing POLST
- No SS documentation of speaking to resident/representative about completing an AD
Environmental/Home-Like Environment:
- No personalized items in long -term resident’s room (photos, artwork, etc)
- Torn bed curtain
Resident Rights/Person Centered Care/Dignity:
- Photo of resident posted on social media
- CNA calling adult brief – “resident’s diaper” in a negative manner
- Resident served food that resident previously indicated she did not want
- No communication board on wheelchair
- No communication board in room
Hospice:
- No CP re: end of life care
- Hospice staff name and phone number not on resident’s chart for easy access
- Lack of IDT communication with hospice agency
Care Planning:
- No Comprehensive Care Plan with 15 days of admission.
- Care Plans not updated as resident condition changed
- Comprehensive Care Plan did not adequately address resident’s foot wound and maggots
- No Comprehensive Care Plan until day 41 of admission
- Care Plans not individualized- computer generated without individualizing
- Problems & interventions realistic?
- Missing care plan for non-English speaking residents
Grievance:
- Grievance reports with no follow-up or resolution
- Grievance reports not completed despite the grievance being addressed and resolved
- SSD not informed of resident grievance
Theft and Loss:
- Two discharged resident’s belongings mixed in with each other’s
- Lack of documentation that resident/representative was satisfied with resolution
- Lack of documenting that resident was informed, in writing, the risk of keeping cash at bedside
Medically-related Social Service:
- Resident failed to receive requested podiatry services.
- Lack of followup or support visit following injury related to alleged abuse.
- SSD asked by Surveyors if she had a “script of questions” when investigating abuse complaints
Behavior Management/Psychotropic Medications:
- Behavior monitored does not match orders.
- No GDR documented
- No documentation of potential triggers prior to medication being prescribed
- Behaviors related to psychiatric diagnosis or symptoms of dementia?
- Justifications for GDRs and no GDRs
- GDR, no individualized reason for no dose reduction
Inventories:
- No Inventory in chart- frequently cited
- Glasses indicated on MDS not listed on Inventory
- Inventory not closed out at discharge
- Items in resident’s room not on Inventory.
- Inventory lacking 2 signatures
Discharge Planning:
- Notice of transfer/discharge not faxed when resident was admitted to hospital- cited frequently
- Lack of SS discharge planning notes- need to demonstrate “sufficient preparation for d/c”
- Ombudsman not informed of resident discharge
POLST:
- POLST indicates No DNR, no order chart.
- MD orders say “follow the POLST”- POLST was not signed by MD.
- No MD signature on POLST
- MD section incomplete
MISC.
- Comprehensive Care Plan not reviewed with resident/representative
- No P & P for vision services, including monitoring appointments
- Residents not aware of where Survey Results are posted
- Resident’s personal food in refrigerator not dated
- Quality Assurance program did not address repeated issues regarding inadequate wound care
- Review of closed charts from 2016 and 2017
- Requested copy of Room Change P & P
- Request for recent SS Consultant Report
- Request copy of Consultant SW License
- Surveyors came in on a complaint, then asked to see charts of two discharged residents
- Face Sheets needs to list alternate MD by name
- Review for Bed Hold Notices in closed charts
