Survey Report for 341528

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	341528	A. BUILDING __________ B. WING ______________	01/04/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF THE CAROLINA FOOTHILLS	374 HUDLOW ROAD, FOREST CITY, NC, 28043
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)
L0671
L0671	41345 Based on policy and procedure, clinical record review, and staff interview the agency failed to maintain accurate documentation of neurological checks for 1 of 1 patients with a fall (#1). Findings include: A policy titled " Inpatient/Residential In-Patient Falls", revised 11/15 was received from the compliance officer on 01/04/22 at 1:43 p.m. The policy stated "patients who choose to remain in the hospice facility and forgo outside treatment after a suspected or possible head injury will be monitored in the following manner: neurological checks will occur every 15 minutes x 4times, every 30 minutes x 2 times, every one hour x 4, then every 4 hours x 6 or until orders for discontinuing the neurological checks are given by the hospice provider". Patient #1 was admitted on 10/05/21 with diagnoses of cerebral atherosclerosis (thickening or hardening of the arteries of the brain), anorexia, abnormal weight loss, unspecified dementia, expressive language disorder, repeated falls, bipolar disorder, and schizophrenia. Review of the plan of care for 12/04/21 had orders for skilled nursing 4 times a day for 14 days. Review of skilled nursing note for 11/16/21 revealed the patient had a fall and hit her head at 5:45 p.m. Review of the neurological flow sheet for 11/16/21 revealed the following information: neurological checks were performed at 7:30 p.m., 7:45 p.m., 8:30 p.m., 9:15 p.m., 9:45 p.m., 10:30 p.m., 11:30 p.m., 12:30 a.m., 4:30 a.m., 5:30 a.m., 12:30 p.m., 4:30 p.m., 8:30 p.m., 12:30 a.m., and 4:30 a.m. Review of skilled nursing note for 12/12/21 revealed the patient had a fall and hit her head at 5:55 a.m. Review of the neurological flow sheet for 12/13/21 revealed the following information: neurological checks were performed at 0630, 0645, 0700, 0715, 0745, 0815, 0915, 1015, 1115, 1215, and 2:15. Interview with the compliance office on 01/14/21 at approximately 3:10 p.m. confirmed the neurological checks were not performed per agency policy and procedure.