Doctors Community Rehabilitation and Patient Care

In the surveyor’s words

From the most serious findings on record at Doctors Community Rehabilitation and Patient Care, in the surveyor’s own words.

• Actual harm, isolatedF710Apr 30, 2024

  Based on record review and interviews, it was determined that the facility failed to clarify a medication discrepancy on the hospital discharge summary, monitor appropriate dosing of a medication by ordering the correct laboratory testing, and take action on abnormal laboratory results required for accurate medication dosing. This was found to be evident for 1 (#43) out of 6 residents reviewed for Vancomycin administration. This deficient practice resulted in harm to the resident. The findings include: Bacteremia is the presence of bacteria in the blood. Vancomycin is an antibiotic used to treat serious bacterial infections. Proper administration requires blood levels be monitored for accurate dosing. […]

• No harm, potential for more than minimal, patternF583Apr 30, 2024

  Based on surveyor observation, medical record review and staff interview, it was determined that the facility failed to maintain confidentiality of resident medical records as evidenced by accessibility of a laboratory log. This was found to be evident for 7 (Residents #3, 16, 42, 51, 55, 71 and 77) out 7 Residents reviewed for confidentiality of medical records. The findings include: On the initial tour of the nursing unit 400 conducted on 4/15/24 at 8:38 AM the surveyors observed a black binder that sat on the countertop at the nursing station. The review of the black binder revealed a laboratory log that included Residents #3, #16, #42, #51, #55, #71, and #77 names and laboratory information. […]

• No harm, potential for more than minimal, patternF623Apr 30, 2024

  Based on record review, and interviews, it was determined the facility failed to notify the Ombudsman of residents that transferred or discharged . This was found evident of 3 (Resident #17, #90 & 73) of 5 residents reviewed for hospitalization during the survey. The finding include: 1a) On 4/15/24 at 11:56 AM, the surveyor interviewed Resident #17. During this interview Resident #17 stated he/she had recently been hospitalized . On 4/19/24 at 7:47 AM, the surveyor reviewed Resident #17's medical record. The review revealed that Resident # 17 was transferred to the hospital on 3/15/24. On 4/19/24 at 11:33 AM, the surveyor requested documentation that the Ombudsman was notified of Resident #17's March hospitalization . […]

• No harm, potential for more than minimal, patternF657Apr 30, 2024

  Based on observation, interview and medical record review it was determined that the facility failed to: 1) revise residents care plans and 2) to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This was found evident for in 3 (Resident # 42, #75 and #80) and 1 (Resident #322) of 10 residents reviewed for care planning. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). […]

• No harm, potential for more than minimal, patternF677Apr 30, 2024

  Based on observations, review of resident's medical records, and interviews, it was determined that the facility staff failed to provide activities of daily living care in accordance with the Resident's care plan for dependent Residents. This was found to be evident for 5 (Resident #322, #97, #321, #41 and #80) out of 7 reviewed during the survey for activities of daily living. The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. […]