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
341546 A. BUILDING __________
B. WING ______________ 		06/09/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MOUNTAIN VALLEY HOSPICE & PALLIATIVE CARE 1427 EDGEWOOD DRIVE, MOUNT AIRY, NC, 27030
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)
L0545      
34981 Based on clinical record review, interviews with staff and caregiver the agency failed to develop an individualized written plan of care which included safety devices related to fall precautions for 1 of 3 charts [#2]. The findings included: Patient # 2 had a Start of Care [SOC] date of 4/28/21 and a terminal diagnosis of Alzheimer ' s Disease with late onset. A review of the Plan of Care for the certification period 4/28/21 to 7/26/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 1 week; 1 time a week for 1 week; 1 time a week for 12 weeks. A review of the clinical record revealed RN # 7 completed the start of care visit on 4/28/21. During the visit RN # 7 identified the patient as a fall risk. [The patient had a score of 4 on the MAHC-10. The MAHC-10 is a multi-factorial fall assessment. A score of 4 or above indicates the patient may be a fall risk]. During a routine visit on 5/4/21 RN # 1 documented Patient # 2 had a fall in the home on 5/3/21. RN # 1 identified a bruise to the forehead of Patient # 2 as a result of the fall. During the routine visit on 5/19/21 RN # 1 documented the following information, " ...Daughter is primary caregiver ...she [caregiver] is exhausted and needs a break ...She has requested a 5 day respite stay from today to 5/24/21 ... " Further review of the clinical record revealed RN # 1 contacted the MSW [medical social worker] and transportation was arranged to take Patient # 2 to ______[name of inpatient hospice]. On 5/19/21 at 5:25 pm RN # 2 documented, " Personal alarm [safety device with a clip attached to the patient ' s clothing which should alarm if the patient attempts to get up from the chair unassisted] placed on patient. Further review of the clinical record revealed during the inpatient stay of 5/19/21-5/24/21 the skilled nurses documented the patient used the following safety devices: 1. Personal alarm 2. Bed alarm [device turned on when the patient is in the bed which should alarm when/if the patient attempts to get up] 3. Door alarm [mat placed in the floor which should alarm if the patient attempts to go outside of doors]. On 5/24/21 at approximately 5:00 am RN # 5 documented, " ...patient found lying in floor on her right side, beside bed ...Checked her for injury, able to MOE [move all extremities] x 4, redness on right hip and right hand is noted ...side rails up and bed exit alarms on ... " A review of the aide flow sheet dated 5/19/21-5/24/21 revealed no mention of what safety device should be used with Patient # 2. On 5/24/21 RN # 6 documented, " 5:47 pm ... " She is here for respite care and is going home today but had an incident at 0500 this am and again at 10:58 [am] when she fell in the hallway this time and was knocked unconscious for a few seconds. She hit her head on the floor ...911 was called ...trying to climb out of bed AGAIN. _______[name of staff member] is sitting with her for safety. " A review of the aide flow sheet for 5/24/21 does not include any mention of a safety device used for Patient # 2. An interview was conducted with RN # 5 on 6/8/21 at approximately 4 pm. During the interview RN # 5 stated, " I was here when she fell the second time. I heard the door alarm go off and I ran down the hall, but she had already fallen by the time I got to her room. She fell face first. " An interview was conducted with RN # 3 on 6/8/21 at approximately 4:30 pm. During the interview RN # 3 stated, " The aides get a verbal report each time their shift starts. We don ' t necessarily put the type of alarm the patient is using on the aide flow sheets, nor do we have a system in place for checking the alarms to make sure the alarms are working. " On 6/9/21 at approximately 12:30 pm an interview was conducted with RN # 4. During the interview RN # 4 confirmed the plan of care did not include what type of safety device should be used with Patient # 2.