FIDELITY CARE CORNER, INC

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provides a resident with assisted living services in the resident's service plan, and documented the services provided in the resident's medical record for two of four residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R3's and R4's medical record revealed a current service plan for personal care services. The service plan, contained a section titled, "Bathing," which indicated R3 and R4 were to receive showers "2 X Weekly."

2. A review of R3's and R4's medical record revealed a document titled, "Activities of Daily Living (ADL)," used for documenting ADLs in the months of April and May, 2024. The records reflected R3 received showers during those months, however evidence of documentation indicating R3 received showers on the following dates was unavailable for review:

April 18, 25, 2024; and
May 2, 9, 16, 23, 27 or 30, 2024.

Further, the ADL record for R4 reflected no evidence of documentation of the service "Bathing" available for review during the month of April, 2024. The ADL record for May 2024 reflected R4 received the service "Bathing," twice weekly through May 15, 2024. However evidence of documentation indicating R4 received bathing services twice weekly after May 15, 2024 was unavailable for review.

R3's service plan also included a section titled, "Skin Care," which indicated "Staff will put cream on [R3's] bottom every brief change to help with psoriasis." Further, the service Plan contained a section titled, "Bladder," which indicated R3 was to receive "incontinence checks every 2 hours," and "Apply skin barrier after each change PRN."

R3's ADL tracking record included a section titled "Check [R3's] Skin daily...," and "Staff to remind [R3] to use restroom before meals and bedtime." However the ADL record contained no other section for documenting the service "Skin Care" or "Bladder" as noted in the service plan. Evidence of documentation to indicate cream was being applied to R3 after brief change or R3 was receiving incontinence checks every 2 hours was unavailable for review.

3. In an interview, E1 acknowledged evidence of documentation to indicate R3 was receiving all services noted in R3's service plan was unavailable for review. E1 agreed the caregivers were not documenting all services provided for R3 and R4.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an emergency and needed medical services, as required per R9-10-818.D.2.

Findings include:

1. A review of facility documentation from January 2024 through June 2024 revealed two incident reports documenting emergencies where 911 was contacted. A review of the incident report dated June 15, 2024 revealed the report involved R2 and contained most documentation required required per R9-10-818.D.2. The report included a section for documenting actions taken to prevent the incident from occurring in the future, however the section was not completed. A review of the incident report dated Jun 30, 2024 revealed the report involved R1 and contained most documentation required required per R9-10-818.D.2. The report included a section for documenting notification of R1's primary care provider as well as actions taken to prevent the incident from occurring in the future, however both sections were not completed.

2. In an interview, E1 agreed the incident reports did not contain all documented required per R9-10-818.D.2.