DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
341503 A. BUILDING __________
B. WING ______________ 		08/18/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AUTHORACARE COLLECTIVE 2500 SUMMIT AVE, GREENSBORO, NC, 27405
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0556      
37615 Based on policy review, clinical record review, and staff interview the nurse failed to timely assess for symptoms of a urinary tract infection (UTI) and to report symptoms for 1 of 1 patient with a UTI (#1). Findings included: A policy, Nursing Services, revised 3/17/22, was provided by Employee #1 on 8/17/22 at 5:15 p.m. The policy stated, "The hospice nurse must ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments. Hospice nursing services include patient assessment, pain and symptom management, identifying and preventing undesirable or secondary symptoms, provision of comfort needs for the patient, patient/family education, collaborating with other IDT [interdisciplinary team] members in the development of the plan of care ...The aide will notify the nurse case manager & IDT of concerns or change in the patient's condition. The nurse is responsible for interpreting information and implementing any needed changes in the Plan of Care." Patient #1 was admitted on 12/24/21 with diagnoses of Alzheimer's disease, moderate protein-calorie malnutrition, and a history of prostate cancer. The Plan of Care for 3/24/22-6/21/22 included orders for skilled nursing one to three times per week for 14 weeks with eight as needed visits; and hospice aide twice per week for one week, three times per week for 12 weeks, and one time for one week. On 6/11/22, the hospice aide conducted a visit and noted, " ...patient urinated and seem [sic] to be in pain emailed patient nurse ..." During an interview with Employee #1 on 8/18/22 at 4:46 p.m., it was revealed that the hospice aide should have called the nurse regarding pain instead of emailing. There was no evidence of nursing follow up regarding the painful urination until the SN visit on 6/8/22. The nurse's note stated, "Wife stated that patient had blood tinged [sic] urine over 2 days, but seemed to be resolving." The visit note did not include a temperature. On 6/17/22, the RN called the patient's spouse. The note stated, "Wife states patient was diagnosed with a UTI per Dr. _____ and has been prescribed generic Bactrim DS [an antibiotic]." The record review revealed Patient #1 was treated for a UTI in April 2022 as well. An interview with Employee #1 and Employee #2 on 8/18/22 at 5:09 p.m. confirmed nurse follow-up should have occurred prior to 6/11/22 since the aide report of pain. An interview with Employee #3 on 6/11/22 at 5:09 p.m. revealed the nurse may not have reported the symptoms after the 6/11/22 visit because hematuria was "resolving." The interview confirmed the patient had a history of UTIs and prostate cancer.