What would be your recommendations for overall system evaluation and revision?

You are the consultant for a long-term care facility .that.recently has undergone a long-term care survey in which the facility.received several deficiency notations for noncompliance with.federal.requirements. .The. most significant deficiency involved a noted pattern .(seven of.ten examples .reviewed.in the surveyor. sample).in which comprehensive assessments .(MDS) were not completed within.the required .timeframe. (within 14.days of admission). 1 In addition, the surveyors identified that there was.no.documentation to support.the use of triggered care. areas in.the assessment and care-planning .process. .This resulted in -related quality-of-care .deficiencies. for failure to adequately assess and manage urinary incontinence and psychosocial needs. In three additional examples, the surveyors identified.that residents.had experienced a significant change. in condition without evidence of a new assessment.being done. .Within the statement of deficiencies, the. surveyors noted that the director of nursing stated that she was unaware that assessments.had not been. done. And the nursing staff members stated that they did not understand what the care area triggers. were, and they were unaware of the federal criteria for determining -when a significant change had. occurred. |