Every finding on record at Park Point Healthcare LLC

A recertification survey was completed on 5/13/21. One deficiency was cited.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure all medications, interventions, treatments and services provided to patients were accurately documented and included within the clinical record for 1 of 4 patients receiving skilled nursing (SN) services (Patient #5), and 2 of 2 patients receiving certified nurse aide (CNA) services (Patients #3 and #8). Findings include: 1. The clinical record for Patient #3 was reviewed on 5/11/21. The Plan of Care for the certification period dated 3/29/21 to 5/27/21, revealed a start of care date of 2/3/20; diagnoses included traumatic brain injury and seizures. The Plan of Care included SN services twice a day Monday through Friday and once a day on Saturday and Sunday for medication administration, tube feedings, vital signs, and assessments and CNA services daily for aspiration precautions, bathing, grooming, dressing, oral care, incontinence care, seizure precautions and a home exercise program. a) The agency failed to ensure patient medications and allergies for Patient #3 were accurately documented within the clinical record. Review of the clinical record for Patient #3 revealed she was taking multiple medications related to her diagnoses including Diazepam, Levetiracetam, and Midazolam for seizures. Further review revealed Patient #3 had no known drug or food allergies. Review of the HHA Basic notes dated 3/29/21 to 5/11/21 revealed documentation that stated "Patient Takes No Medications." 2. The clinical record for Patient #8 was reviewed on 5/13/21. The Plan of Care for the certification period dated 4/26/21 to 6/24/21 revealed a start of care of 7/14/06; diagnoses included multiple sclerosis, type two diabetes, and chronic pain. The Plan of Care included CNA services five days a week, three times a day for grooming, dressing, bathing, positioning, skin checks, range of motion, and laundry. Review of the clinical record for Patient #8 revealed she was taking multiple medications related to her diagnoses including insulin for diabetes. Further review revealed Patient #8 had allergies to Penicillin, Amoxicillin, chocolate, pineapple, and tomatoes. Review of the HHA Basic notes dated 3/1/21 to 4/13/21 revealed documentation that stated "Patient Takes No Medications," and, "Patient has no known allergies or adverse reactions." However, the Plan of Care for the certification period documented all of Patient #8's medications and allergies that included food allergies as well as medication allergies. 3. The clinical record for client #5 was reviewed on 5/13/21. The plan of care for the certification period dated 3/28/21-5/26/21 revealed a start of care date of 6/1/20, diagnosis included type II diabetes with diabetic neuropathy, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic diastolic heart failure; bipolar disorder; post-traumatic stress disorder chronic; adjustment disorder with mixed anxiety and depressed mood; chronic obstructive pulmonary disease; chronic pain syndrome, obesity unspecified, and personal history of pulmonary embolism. The plan of care certification period dated 3/28/21-5/26/21 included SN one time a week for vital signs, physical assessment, pillbox management, assess medication regimen, and update medication list, education on blood glucose monitoring, importance of taking medication as prescribed with no missed doses and how to fill the medication box. a. The agency failed to ensure clinical interventions and treatments provided to client #5 were accurately documented within the clinical record. Clinical record review revealed a missed visit note dated 4/20/21. RN #8 coordinated with patient #5 for a visit. Patient #5 declined the visit and reported she was quarantined due to COVID exposure. Further review of the clinical record revealed a missed visit note dated 4/29/21 by RN #8 where she documented Patient #5 was out of many medications. RN #8 documented, "See communication note for follow up." However, there was no evidence RN #8 made any follow up documentation of Patient #5's medication status. During an interview on 5/13/21 at 12:45 p.m., RN #8 confirmed she did not document further on Patient #5's medication issues and stated Patient #5 had been out of medication a couple of times before, including this time when she also was admitted to the hospital. During an interview on 5/13/21 at 4:30 p.m., the Administrator stated the electronic medical record (EMR) should have been pulling the medication and allergy information from the SN comprehensive assessment and populating the information into the CNA care plans and documentation. She further stated the agency was transitioning EMR systems which should make it easier for patient information to be accessible to all of the staff who need it, and she had no idea the EMR currently in use did not provide the correct information to the CNA's caring for the patients.