KingDom

Business casual. Khaki pants or slacks, and a nice top. And clean, white comfortable sneakers, because you always have to be prepared to RUN!

We're having our annual survey. Surveyor is questioning me on why I coded a lady on anxiousness about health issues and insomnia (I coded less than daily on these 2 items). On the lady's first couple of days at our facility, she confided in the social worker a few times how worried she was that she can get back to prior level of function after her bilateral knee replacement. The social worker charted about this in her notes. However, the nurses notes said nothing about any anxiousness. The MAR showed 2 entries where she was given PRN Ambien for insomnia. The insomnia didn't appear anywhere in narrative form in the nurses notes either, though. I explained to the surveyor that I observed her anxiousness and so did the social worker the first few days. The surveyor replied "well, I'd be anxious, too--wouldn't anybody?" I then told the surveyor that we had to code things we see on section E regardless of the reason. She again stated she could'nt understand why I coded anxiousness and insomnia when it didn't appear in the chart (..."just that little blurb in the social service notes".."and maybe the MAR", in her words) Now I'm questioning myself for coding these things... Do you all think this is worthy of a deficency?

We keep ours under a "care plan" tab in the resident's chart. Kind of a hassle when you need to update the care plan and someone else has the chart, but we've done that for 100 years and sometimes it's hard to change things! :icon_roll

We have an Indian doctor who dictates his assessment to be typed up later. Because of his heavy accent, words are often mispelled. On confused residents he often starts with "significant memory loss", but frequently gets transcribed as "significant mammary loss" :chuckle

We admitted a resident who was in relatively good health (for being in her late 90's). She was no longer safe to take care of herself at home due to weakness and debility. When we asked the physician for an admitting diagnosis when he came in for rounds that day, he simply wrote, "she's old". I wanted to ask him what the ICD-9 code for that was!