The findings of the complaint (Intake #s 28750 and 28772) health survey conducted 3/4/21 through 3/11/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
The sample was comprised of three closed records. The facility had a census of 79 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
DNS: Director of Nursing Services
F: Fahrenheit
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PRN: as needed
PT: Physical Therapist
qd: every day or daily
qid: four times a day
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UTI: urinary tract infection
The findings of the complaint (Intake #28750 & #28772 ) health revisit survey conducted 4/13/21 through 4/14/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part ยง483 Requirements for Long Term Care Facilities.
Based on interview and record review it was determined the facility failed to report an allegation of abuse within the required time frame for 1 of 1 sampled resident (#10) reviewed for discharge. This placed residents at risk of abuse. Findings include:
Resident 10 was admitted to the facility in 1/2021 with diagnoses including cancer and anxiety.
A progress note identified on 2/14/21 stated Staff 10 (CNA) reported a potential incident of abuse to Staff 5 (LPN). According to the note, Resident 10 reported Staff 4 refused to give care and threw clothing at her/him. Staff 5 wrote the resident's statement down and placed it in Staff 2's (DNS) box.
On 3/4/21 at 3:35 PM Staff 2 acknowledged Resident 10's allegation of abuse was not reported to the state agency within the required timeframe. Staff 2 stated she received the report of alleged abuse from Staff 5 immediately after the incident. Staff 2 confirmed she had investigated the accusation and had not reported the incident to the state agency.
On 3/10/21 at 1:26 PM Staff 1 (Administrator) stated he would expect all allegations of abuse to be reported.
It is the policy of this facility to report all alleged violations involving abuse, neglect, exploitation, mistreatment or injuries of unknown source and misappropriation of resident property immediately but no later than 2 hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and no less than 24 hours if it does not involve abuse or serious bodily injury.1. Unable to do corrective action for patient # 10 as she has discharged. For all other patients who have the potential to be affected by the alleged deficit practice. Licensed staff, CNA's and SSD were in-serviced on 3/11/21 regarding reporting requirements, abuse, neglect, exploitation, mistreatment including injuries of unknown source and misappropriation of resident property definitions and what to do if they encounter an incident. 2. Measures/Systemic changes put in place to ensure the alleged deficit practice will not re-occur. Administrator/DNS or designee will review all allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property to the DHS hotline FRI form in an ongoing manner. 3. The plan will be audited monthly x 3 months to ensure proper notification has occurred. Audit will include any reports of alleged violations from staff, patient or family. The results of these audits will be brought to QA X 3 months or until substantial compliance has been achieved.
Based on interview and record review the facility failed to develop and implement an effective discharge planning process to ensure post-discharge care and safety needs were met for 1 of 3 sampled residents (#10) reviewed for discharge. This failure to provide a safe discharge, determined to be an immediate jeopardy situation, placed resident's health and safety at risk, including symptoms of pain, medical complications, hospital readmission and death. Findings include:
The facility's "Transfer or Discharge, Preparing a Resident for" policy, revised 2016, directed a post-discharge plan would be developed for each resident prior to her/his transfer or discharge. Staff were to obtain orders for discharge, recommended discharge services and equipment.
Resident 10 was admitted to the facility on 1/29/21 for skilled nursing care and therapy after a hospitalization related to falls. Prior to the hospitalization, the resident lived at home alone, with no friends or family involved in her/his care. Resident 10's diagnoses included lung cancer, metastasis (cancer spread) to the bone, and two cranial dural lesions (brain tumor) which were recent diagnoses. Other diagnoses included insulin dependent diabetes, hypertension, chronic kidney disease, obesity, history of falls, and anxiety.
Resident 10's care plan initiated on 1/30/21 and continued until 2/19/21, at the time of discharge. The care plan revealed an anticipated discharge plan was to be determined. Interventions included to make arrangements with required community resources to support independence post-discharge and home health to be ordered prior to discharge. Resident 10 had self-care performance deficit and limited mobility related to weakness. She/he required assistance for bathing, eating, mobility, toilet use, and transfers. Resident 10 had bowel and bladder incontinence related to impaired mobility and staff were to check routinely, encourage resident to use bedside commode instead of the floor, briefs were to be worn by the resident and staff were to assist to change. Resident had oxygen therapy related to lung cancer and staff were to change resident position every two hours to facilitate lung secretion movement and drainage. The care plan addressed pain with direction to follow physician orders, which included morphine, topical medication and patches for pain. The resident diabetes was care planned to follow physician orders which included sliding scale insulin. Additionally, the care plan included the resident was at risk of falls related to incontinence and fall history.
Review of the 2/3/21 progress note by Staff 3 (Social Services Director) revealed Resident 10 lived in a single level home with four to five steps to enter the home with no rail. Prior to facility admission, Resident 10 had a care giver for five hours per week and had crutches, oxygen, and life alert (call for help with home/cell phone).
A 2/3/21 at 1:14 PM, therapy progress note by Staff 19 (PT) revealed Resident 10 was confused, disoriented and unable to place her/his nasal cannula (tube for oxygen) back on. Resident 10 had an episode of urinary incontinence and required CNA assistance. When Staff 19 returned after an hour, the nasal cannula was off again, the resident kept pulling it off of her/his self.
The 2/5/21 Admission MDS indicated Resident 10 required extensive assistance (one to two-person assistance) with bed mobility, transfers, dressing, locomotion off unit and toileting. Section Q. Participation in Assessment and Goal Setting, indicated Resident 10 had no family, she/he expected to return to the community, active discharge planning was already occurring for the resident to return to the community and no referral was needed.
A 2/11/21 at 4:48 PM, therapy progress note by Staff 20 (Physical Therapy Assistant) revealed Resident 10 was seated in her/his wheelchair and required moderate cues for focus. Once Resident 10 was able to stand, she/he stated she/he was not able to walk due to pain and discomfort. The resident required an increased amount of time for initiation of each activity.
A 2/12/21 at 6:36 PM, therapy note by Staff 22 (OT) indicated Resident 10 was given an ACL (Allen Cognitive Level) and scored 4.2, which indicated the resident required 24-hour supervision to remove dangerous objects outside of visual field and solve any problems which arose from minor changes in the environment. The SLUMS (St. Louis University Mental Status) score of 17 of 30 indicated dementia.
Progress note on 2/13/21 at 12:05 AM, indicated Resident 10 was found on the floor between her/his bed and the bedside commode. The floor was wet with urine, the resident had stated she/he could not make it to the commode which was about two feet from the bed. Resident 10 was assisted back to bed with a mechanical lift.
The 2/13/21 Fall Risk Assessment indicated Resident 10 fell one to two times in the last month. Resident 10 scored a 19, which indicated a high risk of falls.
Staff 11 (LPN) documented a progress note on 2/13/21 at 9:19 PM, which revealed Resident 10 was alert and oriented, both incontinent and continent of urine and used a bed side commode to void.
A progress note dated 2/14/21 at 8:42 PM, by Staff 15 (LPN) reported Resident 10 was incontinent of urine, poor balance, bedfast most of the time and used a wheelchair. The note indicated the resident wore adult briefs, her/his gait was unsteady, and she/he had poor balance. Incontinent care was provided.
Staff 13 (LPN) entered a progress note, dated 2/17/21 at 6:29 AM, which indicated Resident 10 was paranoid and had delusions. Resident 10 yelled and swung at staff, picked up a lamp to throw and continued to escalate with behaviors. At 4:30 AM, 911 was called and the EMT (emergency medical technician or ambulance technician) fire department, and police arrived shortly after the call and took about 20 minutes to get Resident 10 into the ambulance. Resident 10 would not leave until the clock turned to 5:00 AM and then was taken by stretcher to the hospital at 5:05 AM.
Record review of the 2/17/21 discharge visit progress notes by Staff 6 (Physician Assistant) revealed Resident 10 was expected to discharge on 2/19/21, she/he was paranoid and eager to return home. Nursing staff reported Resident 10 was agitated and combative last night. Resident 10's insight and judgement was poor and she/he experienced anxiety. Resident 10 required a wheelchair upon discharge from the facility and her/his mobility was limited due to weakness. Her/his mobility limitation impaired her/his ability to participate in one or more ADL and could not be resolved with the use of a walker or cane. There were no concerns from staff with the resident's ability to use the wheelchair and she/he had been trained by therapy how to use the wheelchair. The use of a manual wheelchair would significantly improve her/his ability to participate in her/his ADL's. Resident 10 had difficulty ambulating distances even within her/his home and would benefit from a bedside commode to reduce her/his risk of falls, which would reduce the risk of re-hospitalization. Staff 6 reviewed notes from the previous hospital stay which indicated the need to consider palliative or hospice care and the resident's functional status was too poor to allow palliative chemotherapy. Resident 10 was to be discharged home as insurance would no longer cover her/his staff as she/he had plateaued with therapy. Home health and MSW (Master's in Social Work) was ordered. Date signed 2/18/21 at 11:14 AM.
A 2/18/21 at 10:34 PM progress note by Staff 11, indicated Resident 10 had moderate impairment (memory loss), she/he was forgetful and confused, her/his gait was unsteady, balance was poor, she/he was bedfast all or most of the time and incontinent care was provided.
A 2/18/21 at 11:23 AM, progress note by Staff 3 indicated she talked with Resident 10's previous home care worker (Witness 2) about the resident's discharge, on 2/19/21.
A 2/18/21 at 12:56 PM, progress note by Staff 3 indicated she called Resident 10's case manager about the upcoming discharge, 2/19/21, and requested an assessment for resident to get more home caregiver hours.
The 2/18/21 at 4:10 PM, therapy progress notes by Staff 21 (Occupational Therapy Assistant) indicated the discharge summary was completed. Resident 10 had poor insight and recommended increased caregiver hours at home. Resident 10 was unaware she/he was being discharged the next day and was very emotional. Resident 10 requested to speak to the social services staff.
There was no evidence indicating a follow up social services visit was completed for Resident 10's request.
The 2/19/21 Discharge MDS indicated the resident required extensive assistance with bed mobility, transfers, dressing, locomotion off unit and toileting. Section Q. Participation in Assessment and Goal Setting, indicated Resident 10 had active discharge planning to return to the community and no referral needed.
Resident 10's 2/19/21 discharge paperwork indicated the resident needed PT, OT, MSW, home health aide, a wheelchair and a bed side commode for her/his home care. The wheelchair was to be delivered to her/his home. No additional equipment or services were ordered.
In an interview on 3/5/21 at 9:51 AM, Witness 1 (Hospital staff) confirmed she was involved in Resident 10's care for the 2/22/21 hospital admission. The physician documented the resident had no intake by mouth (food or water) since the discharge. The resident was alert and oriented to self and to some locations but not situation, she/he could not answer history questions. At the time of admission, the resident was verbal but had significant word finding problems. Witness 1 reported hospital records revealed the cause of death was metastatic lung cancer, and other contributing diagnoses included dehydration and anemia. Witness 1 reported, in her opinion, it was a mixture of everything, her/his medical condition and the unsafe discharge which contributed to her/his passing. Witness 1 stated even though the resident had several underlying conditions, she believed the weekend trauma without care likely contributed to the resident's death. Witness 1 contacted the Home Health agency from a prior hospitalization to see if they were assigned for the resident's care post discharge (2/19/21 start), the home health agency reported not being contacted for the resident's resumption of care. Witness 1 was concerned the resident was sent home alone with no support, no working phone, not able to care for her/his self and was without the ability to call 911 for help.
In an interview on 3/8/21 at 12:49 PM, Witness 2 reported Staff 3 called her on 2/18/21, for Resident 10's discharge on 2/19/21 and she told Staff 3 she would not be able to go to the resident's home until 2/22/21, three days after discharge. Witness 2 reported Staff 3 stated Resident 10 would still be discharged on 3/19/21. Witness 2 stated Staff 3 was aware she was a home care worker for 5 hours a week, two times per week a little over two hours each time, prior to Resident 10's stay in facility. Witness 2 reported Resident 10 had no working phone as her/his cell phone bill had not been paid while she/he was in the facility. The resident was transferred home from the facility in a cab or wheelchair transport van. Witness 2 found Resident 10 in her/his home on 2/22/21, 3 days after discharge. Witness 2 reported when she opened the door to Resident 10's home, the resident's crutches were inside on floor, blocking the door, the resident was on the floor near the door, nude, covered in feces and urine, confused, unable to rise from the floor, as she/he held a sheet of popped out pills which were also covered in feces. Witness 2 reported the resident was found mostly unresponsive, she/he was really confused and disoriented with expressive aphasia (loss of ability to speak or understand). Prior to the discharge home on 2/19/21, Witness 2 cleaned the home and stocked it with food. When Witness 2 arrived on 2/22/21, no food had been touched, there were broken items that looked like the resident knocked them over, and there were trails of urine and feces. It appeared the resident crawled around on the floor. There were five cats and a dog, there was animal waste as well. Witness 2 called 911 and it took almost an hour to get her/him loaded into the transport. Resident 10 was admitted to the hospital, where she/he died on 3/1/21.
In an interview on 3/8/21 at 3:45 PM, Witness 3 (Case Manager) reported she received the first contact for Resident 10's discharge on 2/18/21 by a voicemail. Witness 3 stated Staff 3 reported the resident needed increased home care worker hours and no additional information was shared. Witness 3 was unaware Resident 10 did not have a working cell phone and attempted to call the resident on 2/19/21. Witness 3 reported, to her knowledge, Resident 10 did not have oxygen at home prior to the facility stay, used crutches, and a cane for mobility assistance and had no wheelchair. Witness 3 reported, although Resident 10 was strong willed she/he would have accepted more services, with the right approach, to allow her/him to stay at home, such as Hospice services.
In an interview on 3/9/21 at 12:21 PM, Staff 7 (CMA) reported she cared for Resident 10 and the resident was very confused most of the time, her/his care needs varied daily, from dependent to independent, possibly due to pain and pain medications, as she/he had routine and PRN pain medication.
During an interview on 3/9/21 at 12:39 PM, Staff 4 (CNA) observed Resident 10's urinary incontinence and the resident seemed to be able to do some things one day and not the next day, example provided was to walk.
In an interview on 3/9/21 at 1:18 PM, Staff 18 (Rehab Manager) reported she attended the weekly UR (utility review) meetings on Wednesdays to report therapy progress of residents in therapy. Staff 18 reported Resident 10 fluctuated in her/his level of participation and performance. On 2/18/21, the day before discharge, Resident 10 was a moderate assist. Staff 18 reported the therapy department recommended Resident 10 go to higher level of care than home, such as an Adult Foster Home or Assistive Living Facility.
During an interview on 3/9/21 at 1:34 PM, Staff 5 (LPN) reported Resident 10's ADLs often varied day to day and hour by hour. Staff 5 reported Resident 10 would not sign the discharge papers and stated "she/he did not come here voluntarily and was not leaving here voluntarily." Staff 5 reported he was told by Staff 2 (DNS) to mark the papers as the resident refused to sign.
In an interview on 3/9/21 at 3:00 PM, Staff 3 was asked where it was documented for home health and medical equipment referrals made on behalf of Resident 10 for post-discharge care. Staff 3 reported she did not document such things anywhere and "once the resident discharges from the facility, they are not a resident any more, and that's not my problem." Staff 3 reported she did not have a system or process other than attending the "Wednesday Meeting" for discharge planning. Staff 3 confirmed she was aware Resident 10 required an increase of home care giver hours and Witness 2 reported she would not check on the resident until 2/22/21. Staff 3 said Witness 2 stated Resident 10 had oxygen at home, so she did not order oxygen equipment. Staff 3 stated she did not know Resident 10 had no phone.
On 3/9/21 at 3:40 PM, Staff 2 reported the process for residents to discharge was to have the weekly UR meeting and any equipment, home health or home services which were needed were to be ordered by the Social Services Director. Staff 2 confirmed the facility staff talked about Resident 10's discharge but she was not aware of any notes taken in the UR meeting and none to her knowledge in the resident's health record.
On 3/9/21 at 4:12 PM, Staff 2 provided documents the facility provided to Resident 10 at the time of discharge which included a check list sheet, order summary and discharge summary.
On 3/10/21 at 1:09 PM, Staff 9 (RCM) reported she did not talk to Resident 10 about Hospice or Palliative care. Staff 9 believed she mentioned possible increased care to Resident 10 but had not use the words hospice and did not documented the conversation. Staff 9 stated she was on vacation the week prior to Resident 10's discharge. Staff 9 acknowledged Resident 10 varied in her/his abilities with ADLs and mental health. Staff 9 reported it was Staff 3's responsibility to ensure DME and home health services were in place for the resident's discharge.
In an interview on 3/10/21 at 1:24 PM, Staff 1 (Administrator) reported the IDT (Inter-disciplinary Team) met weekly and communicated about residents pending discharge and would expect any concerns of resident safety were brought to the meeting. Staff 1 confirmed it was Staff 3's responsibility to order recommend medical equipment, home health and home services. He added he would expect services ordered prior to residents leaving the facility.
On 3/10/21 at 4:00 PM, Staff 3 stated she had no additional discharge information on Resident 10. When asked to provide any piece of paper for Resident 10, Staff 3 provided a discharge check list sheet, which the charge nurse gave the resident at time of discharge and a blank social services assessment. The check list sheet revealed a 2/19/21 date for DME of a wheelchair and bed side commode. Staff 3 could not tell the surveyors if this date was the date the DME was ordered or the date it was required for the 2/19/21 discharge. Staff 3 stated Witness 2 told her the resident had oxygen at home but did not know the details whether it was an oxygen concentrator or tanks. Staff 3 confirmed no oxygen supplies were ordered as it was not on the check list sheet to be ordered. Staff 3 stated Resident 10 did not participate in the social services assessment and that was why it was blank. Staff 3 reported, after discharge, the bedside commode was denied by insurance and would not be delivered. Staff 3 reported the wheelchair was to be delivered to the resident's home but Staff 3 did not know when, as the resident had discharged and was not a resident any longer.
The surveyors contacted and received information on 3/10/21 at 11:48 AM from Witness 7 (DME vendor) and Witness 8 (DME vendor) which included the faxed page sent by Staff 3 for the request of Resident 10's DME. The fax was dated 2/19/21 for the 2/19/21 discharge. The equipment was directed to be delivered to Resident 10's home. The insurance denial for the bedside commode was attached. The wheelchair was scheduled to be delivered 2/23/21, which was 4 days after discharge. The DME equipment, wheelchair, and bed side commode were not delivered to Resident 10.
The surveyor contacted the Home Health agency which Staff 3 reported she requested home health services for Resident 10. On 3/11/21 at 1:18 PM, Witness 9 (home health vendor) provided Resident 10's records which confirmed no referral was made for the resident's care for the 2/19/21 discharge.
A 2/22/21 at 1:35 PM, Hospital ED (emergency department) triage note by Witness 10 (RN) revealed Resident 10 was covered in stool, combative and had pills adhered to her/his skin. At 6:43 PM, Witness 11 (Medical Doctor) documented Resident 10 was reported more confused than normal, EMS reported fast heart rate and she/he was covered in stool, positive for confusion, disoriented, impaired memory, and had cancer associated pain. Witness 11 noted Resident 10 was previously seen by Palliative care on 1/21/21 for assistance for pain management. Due to poor performance status Resident 10 was not a candidate for chemotherapy and was a candidate for hospice. Note on 2/23/21 by Witness 12 (OT) assessed Resident 10 as deficits with ADLs, safety during ADLs, activity tolerance, cognition, bed mobility, transfers, ambulation, balance, and strength. Resident 10 demonstrated impaired functional cognition with difficulty following one step commands consistently, impaired safety awareness and insight. Note on 2/23/21 by Witness 13 (PT) revealed Resident 10 displayed minimal ability to follow commands, moved legs somewhat on her/his own but only able to wiggle toes and slightly move legs when cued. Final hospital notes by Witness 14 (Doctor of Osteopathic Medicine) revealed the chem panel (basic metabolic panel) showed signs of dehydration, and the resident continued to lack capacity to make major decisions about her/his care. After transitioning to comfort measures on 2/28/21, Resident 10 expired on 3/1/21.
On 3/11/21 at 11:30 AM, Staff 1 and Staff 2 were informed of the IJ (immediate jeopardy) situation related to the facility's failure to develop interventions to meet Resident 10's discharge needs and ensure a smooth and safe transition from the facility to the post-discharge setting. The IJ template was provided and an immediate IJ removal plan was requested.
On 3/11/21 at 2:36 PM, the facility submitted a removal plan which was accepted and approved by the survey team.
The IJ Removal Plan indicated the facility would implement the following actions:
- Implementation of the discharge tracking tool which included: when home health and medical equipment were ordered with name of company and contact information, and if a home caregiver needed with name and contact information.
- Any discharge determined not a safe discharge and resident directed, would be reported to adult protective services.
- Inservice LN (licensed nurse), RCM and SSD on the following: LN to notify RCM if concerned of resident discharge: SSD/RCM to arrange any resident home health to start day of discharge; SSD/RCM to ensure family/caregiver support in place prior to discharge and meets resident's needs; SSD/RCM/LN medical equipment delivered to the facility, when possible, or to the resident's home in a timely manner; SSD/RCM to use the discharge tracking tool; SSD will notify Adult Protective Services if resident chooses to discharge unsafely with in 24 hours of discharge; All information related to discharge planning will be documented in the EHR (electronic health record).
- All new admissions will be added to the discharge tracking tool.
- SSD or designee will report any changes and discuss options in meetings.
- Administrator or DNS will audit the tracking tool to ensure proper notifications and orders were made for a safe discharge.
- Audit findings will be brought to the monthly Quality Assurance meeting for 3 months or until committee deems not necessary.
On 3/11/21 at 2:43 PM, Staff 1 acknowledged the facility "dropped the ball" for Resident 10 and would ensure corrections were made for all future discharges.
On 3/12/21 at 11:52 AM, surveyors verified all elements of the IJ removal plan were in process and completed to ensure the discharge needs of each resident are identified and resulted in the development of a discharge plan to meet the individuals resident's needs.
It is the policy of this facility to discharge patients in the safest manner possible with all home health needs, DME and caregiver support if indicated in place.1. Unable to do corrective action for patient # 10 as she has been discharged from facility. For all other patients who have the potential to be affected by the alleged deficit practice: Staff were in-serviced on 3/11/21 regarding the discharge planning process including that licensed staff will be a part of making sure it will be a safe discharge and that any concerns should be brought to the attention of the RCM, SSD or DNS for resolution. Corrective action taken for patients that may be at risk for an unsafe discharge were that all current patients in house who were scheduled to be discharged within the next 7 days were reviewed using the discharge tracking tool/EHR documentation to ensure that home health and any needed DME were ordered with the name of the company in the EHR. We also assessed that their physical functioning and medical stability were in line with the proposed discharge location and level of support. Any caregiver needs were also documented with the name of the caregiver in the EHR. For any patients that were determined to not be a safe discharge but patient or family was directing discharge APS was notified. 2. Measures/Systemic changes put in place to ensure the alleged deficit practice will not re-occur are: a. Licensed staff are to bring any concerns about unsafe discharge to the attention of RCM, SSD and/or DNS/Administrator or designee for review of appropriateness of discharge plan. Staff will also be in-serviced on an annual basis on abuse reporting.b. RCM and/or DNS will review physical functioning, medical stability and current orders prior to discharge to make sure all medical needs can be met at their discharge location.c. Social services or designated staff member will make sure that Home Health (if indicated) is to be arranged to start on day of discharge or next day whenever possible. If home health cannot start within 3 days of discharge Administrator, DNS, RCM, SSD or designee will make sure that patient is discharging to a safe situation with caregiver or family support if needed. Name of support person will be documented in EHR. d. Social Services/RCM or designated staff member will ensure caregiver and/or family support is in place prior to discharge, if needed and meets the patient needs. e. Social Service or designated staff member will ensure DME will be delivered to the facility whenever possible or to their home or other discharge location in a timely manner. Facility may provide loaner DME if needed to bridge the gap on delivery of DME.f. Upcoming discharges will be reviewed at the daily stand up meeting 5 days a week for updates to the plan of care. g. Social Services or designated staff will notify Adult Protective Services if patient chooses to discharge unsafely within 24 hours of discharge.h. Social Services or designee will stay in contact with patient and/or family regarding upcoming discharges to review any needed changes to be made or discuss other options for discharge. This will occur with the 72 hour huddle, any care conferences and within 72 hours prior to discharge. This will be documented in the EHR.I. All information related to discharge needs will be documented in the EHR with date, name of company, person at the company that was taking info and/or fax confirmation and date services or equipment are expected to begin or arrive.3. Administrator/DNS or designee will audit the discharge planning process including home health follow up with start dates, DME with delivery dates, family/caregiver assist if applicable and any concerns or teaching/training required for safe discharge weekly x 3 months to ensure proper notifications/orders have been made for a safe discharge. Audit findings will be brought to QA monthly meeting for review for 3 months or until QA committee deems not necessary.
Based on interview and record review it was determined the facility failed to ensure medically related social services were provided related to discharge for 1 of 3 sampled residents (#10) reviewed for discharge. This resulted in Resident 10's health complications, pain, hospital readmission and death with the unsafe discharge. Findings include:
The facility's "Transfer or Discharge, Preparing a Resident for" policy, revised 2016, directed a post-discharge plan would be developed for each resident prior to her/his transfer or discharge. Staff were to obtain orders for discharge and recommended discharge services and equipment.
Resident 10 was admitted to the facility on 1/29/21 for skilled nursing care and therapy after a hospitalization related to falls. Prior to the hospitalization, the resident lived at home alone, with no friends or family involved in her/his care. Resident 10's diagnoses included lung cancer, metastasis (cancer spread) to the bone, and two cranial dural lesions (brain tumor) which were recent diagnoses. Other diagnoses included insulin dependent diabetes, hypertension, chronic kidney disease, obesity, history of falls, and anxiety.
Resident 10's care plan initiated on 2/2/21 and continued until 2/19/21, time of discharge, revealed an anticipated discharge plan was to be determined. Interventions included to make arrangements with required community resources to support independence post-discharge and home health to be ordered prior to discharge. Resident 10 had self-care performance deficit and limited mobility related to weakness. She/he required assistance for bathing, eating, mobility, toilet use, and transfers. Identified on 1/30/21, Resident 10 had bowel and bladder incontinence related to impaired mobility and staff were to check routinely, encourage resident to use bedside commode instead of the floor, briefs were to be worn by the resident and staff were to assist to change. Resident had oxygen therapy related to lung cancer and staff were to change resident position every two hours to facilitate lung secretion movement and drainage. Oxygen was set at 0-4 liters per minute. Additionally, the care plan included the resident was at risk of falls related to incontinence and fall history.
Review of the 2/3/21 progress note by Staff 3 (Social Services Director) revealed Resident 10 lived in a single level home with four to five steps to enter the home with no rail. Resident 10 previously had a care giver for five hours per week, crutches, oxygen, and life alert (call for help with home/cell phone).
A 2/12/21 at 6:36 PM, therapy note by Staff 22 (OT) indicated Resident 10 was given an ACL (Allen Cognitive Level) and scored 4.2, which indicated the resident required 24-hour supervision to remove dangerous objects outside of visual field and solve any problems which arose from minor changes in the environment. The SLUMS (St. Louis University Mental Status) score of 17 of 30 indicated dementia.
The 2/13/21 Fall Risk Assessment indicated Resident 10 fell one to two times in the last month. Resident 10 scored a 19, which indicated a high risk of falls.
Record review of the 2/17/21 discharge visit progress notes by Staff 6 (Physician Assistant) revealed Resident 10's insight and judgement was poor and she/he had experienced anxiety. Resident 10 required a wheelchair upon discharge from the facility and her/his mobility was limited due to weakness. Resident 10 had difficulty ambulating distances even within her/his home and would have benefit from a bedside commode. The bedside commode would reduce her/his risk of falls, thereby reduced the risk of rehospitalization. Home health and MSW (Master's in Social Work) was ordered. Date signed 2/18/21 at 11:14 AM.
A 2/18/21 progress note by Staff 3 revealed she talked with Resident 10's previous home care worker (Witness 2) about the resident's discharge, on 2/19/21.
A 2/18/21 progress note by Staff 3 indicated she called Resident 10's case manager about the upcoming discharge, on 2/19/21, and requested an assessment for the resident to get more home care giver hours.
The 2/18/21 at 4:10 PM, therapy progress notes by Staff 21 (Occupational Therapy Assistant) indicated the completion of the discharge summary revealed Resident 10 had poor insight and recommended increased care giver hours at home. Resident 10 was unaware she/he was being discharged the next day and was very emotional. Resident 10 requested to speak to the social services staff.
There was no evidence indicating a follow up visit by social services was completed from Resident 10's request.
The 2/19/21 Discharge MDS indicated the resident required extensive assistance (one to two person) with bed mobility, transfers, dressing, locomotion off unit and toileting. Section Q. Participation in Assessment and Goal Setting, indicated Resident 10 had active discharge planning to return to the community and no referral needed.
Resident 10's 2/19/21 discharge paperwork indicated the resident needed PT, OT, MSW, home health aide, a wheelchair and a bed side commode for her/his home care. The wheelchair was to be delivered to her/his home. No additional equipment or services were ordered.
In an interview on 3/5/21 at 9:51 AM, Witness 1 (Hospital staff) was involved in Resident 10's care for the 2/22/21 hospital admission. The physician documented the resident had no intake by mouth (food or water) since the facility discharge. The resident was alert and oriented to self and to some locations but not situation, she/he could not answer history questions. At the time of admission, the resident was verbal but had significant word finding problems. On 2/24/21 she/he went downhill and stopped talking. On 2/25/21 it was determined nothing could be done to help the resident and she/he was transferred to comfort care and died on 3/1/21. Witness 1 contacted the Home Health agency from a prior hospitalization to see if they were assigned for the resident's care post discharge (2/19/21 start), the home health agency reported not being contacted for the resident's resumption of care.
In an interview on 3/8/21 at 12:49 PM, Witness 2 reported Staff 3 called her on 2/18/21, for Resident 10's discharge on 2/19/21 and she told Staff 3 she would not be able to go to the resident's home until 2/22/21, three days after discharge. Witness 2 reported Staff 3 stated Resident 10 would still be discharged on 2/19/21. Witness 2 stated Staff 3 was aware she was a home care worker for 5 hours a week, two times per week a little over two hours each time, prior to Resident 10's stay in facility. Witness 2 reported Resident 10 had no working phone as her/his cell phone bill had not been paid while she/he was in the facility. The resident was transferred home from the facility in a cab or wheelchair transport van. Witness 2 found Resident 10 in her/his home on 2/22/21, 3 days after discharge. Witness 2 reported when she opened the door to Resident 10's home, the resident's crutches were inside on floor, blocking the door, the resident was on the floor near the door, nude, covered in feces and urine, confused, unable to rise from the floor, as she/he held a sheet of popped out pills which were also covered in feces. Witness 2 reported the resident was found mostly unresponsive, she/he was really confused and disoriented with expressive aphasia (loss of ability to speak or understand). Prior to the discharge home on 2/19/21, Witness 2 cleaned the home and stocked it with food. When Witness 2 arrived on 2/22/21, no food had been touched, there were broken items that looked like the resident knocked them over, and there were trails of urine and feces. It appeared the resident crawled around on the floor. There were five cats and a dog, there was animal waste as well. Witness 2 called 911 and it took almost an hour to get her/him loaded into the transport. Resident 10 was admitted to the hospital, where she/he died on 3/1/21.
In an interview on 3/8/21 at 3:45 PM, Witness 3 (Case Manager) reported she received the first contact for Resident 10's discharge on 2/18/21 by a voicemail. Witness 3 stated Staff 3 reported the resident needed increased home care worker hours and no additional information was shared. Witness 3 was unaware Resident 10 did not have a working cell phone and attempted to call the resident on 2/19/21. Witness 3 reported, to her knowledge, Resident 10 did not have oxygen at home prior to the facility stay, used crutches, and a cane for mobility assistance and had no wheelchair. Witness 3 reported, although Resident 10 was strong willed she/he would have accepted more services, with the right approach, to allow her/him to stay at home, such as Hospice services.
In an interview on 3/9/21 at 1:34 PM, Staff 5 (LPN) reported Resident 10 would not sign the discharge papers and stated "she/he did not come here voluntarily and was not leaving here voluntarily." Staff 5 reported he was told by Staff 2 (DNS) to mark the papers as the resident refused to sign.
In an interview on 3/9/21 at 3:00 PM, Staff 3 was asked where it was documented for home health and medical equipment referrals made on behalf of Resident 10 for post-discharge care. Staff 3 reported she did not document such things anywhere and "once the resident discharges from the facility, they are not a resident any more, and that's not my problem." Staff 3 reported she did not have a system or process other than attending the "Wednesday Meeting" for discharge planning. Staff 3 confirmed she was aware Resident 10 required an increase of home care giver hours and Witness 2 reported she would not check on the resident until 2/22/21. Staff 3 said Witness 2 stated Resident 10 had oxygen at home, so she did not order oxygen equipment. Staff 3 stated she did not know Resident 10 had no phone.
On 3/9/21 at 3:40 PM, Staff 2 (DNS) reported the process for residents to discharge was to have the weekly UR (utility review) meeting and any equipment, home health or home services which were needed were to be ordered by the Social Services Director.
In an interview on 3/10/21 at 1:24 PM, Staff 1 (Administrator) reported the IDT (Inter-disciplinary Team) met weekly and communicated about residents pending discharge. Staff 1 confirmed it was the responsibly of Staff 3 to order the recommend medical equipment, home health and home services.
On 3/10/21 at 4:00 PM, Staff 3 stated she had no additional discharge information on Resident 10. When asked to provide any piece of paper for Resident 10, Staff 3 provided a discharge check list sheet, which the charge nurse gave the resident at time of discharge and a blank social services assessment. The check list sheet revealed a 2/19/21 date for DME of a wheelchair and bed side commode. Staff 3 could not tell the surveyors if this date was the date the DME was ordered or the date it was required for the 2/19/21 discharge. Staff 3 stated Witness 2 told her the resident had oxygen at home but did not know the details whether it was an oxygen concentrator or tanks. Staff 3 confirmed no oxygen supplies were ordered as it was not on the check list sheet to be ordered. Staff 3 stated Resident 10 did not participate in the social services assessment and that was why it was blank. Staff 3 reported, after discharge, the bedside commode was denied by insurance and would not be delivered. Staff 3 reported the wheelchair was to be delivered to the resident's home but Staff 3 did not know when, as the resident had discharged and was not a resident any longer. Staff 3 reported she never had called Adult Protective Services to report or ask for a wellness safety check for a resident with safety concerns post discharge.
The surveyors contacted and received information on 3/10/21 at 11:48 AM from Witness 7 (DME vendor) and Witness 8 (DME vendor) which included the faxed page sent by Staff 3 for the request of Resident 10's DME. The fax was dated 2/19/21 for the 2/19/21 discharge. The equipment was directed to be delivered to Resident 10's home. The insurance denial for the bedside commode was attached. The wheelchair was scheduled to be delivered 2/23/21, which was 4 days after discharge. The DME equipment, wheelchair, and bed side commode were not delivered to Resident 10.
The surveyor contacted the Home Health agency which Staff 3 reported she requested home health services for Resident 10. On 3/11/21 at 1:18 PM, Witness 9 (home health vendor) provided Resident 10's records which confirmed no referral was made for the resident's care for the 2/19/21 discharge.
On 3/11/21 at 11:16 AM, Staff 1 acknowledged he expected home health services, DME and sufficient home care giver assistance to be in place prior to Resident 10's discharge. Staff 1 acknowledged the facility failed Resident 10 with post-discharge care, which included the medical equipment ordered timely, home health services, caregiver needs and to ensure a safe discharge.
On 3/12/21 at 8:43 AM, review of Resident 10's Hospital Records for the 2/22/21 admission, revealed Resident 10 was admitted to the Emergency Department on 2/22/21, three days after the facility discharge, with Emergency Medical Technicians reporting Resident 10 was found on the floor of her/his home, covered in stool, with a high heart rate, nude and unable to rise from the floor. Resident 10 had pills adhered to her/his body. Resident 10 had underlying conditions, was in pain, dehydrated and anemic. The medical records confirmed Resident 10 died in the hospital on 3/1/21.
Refer to F660
It is the policy of this facility to provide medically related social services for each resident including transition of care services.1. Unable to do corrective action for patient # 10 as she has been discharged from facility. For all other patients who have the potential to be affected by the alleged deficit practice: Licensed staff, CNA's and SSDincluding social service personnel were in-serviced on 3/11/21 regarding the discharge planning process including that licensed staff will be a part of making sure it will be a safe discharge and that any concerns should be brought to attention of the RCM, SSD or DNS for resolution. Corrective action taken for patients that may be at risk for an unsafe discharge were that all current patients in house who were scheduled to be discharged within the next 7 days were reviewed using the discharge tracking tool documentation/EHR to ensure that home health and any needed DME were ordered with the name of company in the EHR and that physical functioning and medical stability were in line with the proposed discharge location and support. Any caregiver needs were also documented with the name of the caregiver and date of start of care. For any patients that were determined not to be a safe discharge but patient or family were directing the discharge APS was notified. 2. Measures/Systemic changes put in place to ensure the alleged deficit practice will not re-occur are:a. Licensed staff are to bring any concerns about unsafe discharge to the attention of RCM, SSD and/or DNS or designee for review of appropriateness of discharge plan. b. 5 days a week in daily clinical stand-up meeting upcoming discharges will be reviewed by nursing, SSD and therapy to make sure that everything will be in place for a safe discharge including DME, caregiver support and that the patient is medically stable for discharge. c. Social services or designated staff member will make sure that Home Health (if indicated) care is arranged in time to start on day of discharge or next day whenever possible. If home health cannot start in a timely manner Administrator, DNS, RCM and SSD or designee will make sure that patient is discharging to a safe situation with caregiver or family support if needed.d. Social Services/RCM or designated staff member will ensure caregiver and/or family support is in place, if needed, prior to discharge and meets the patient needs. e. Social Service or designated staff member will ensure DME will be delivered to facility whenever possible or to their home or discharge location in a timely manner. Facility may provide loaner DME if needed to bridge the gap on delivery of DME. f. Social Services or designee will stay in contact with patient and/or family regarding upcoming discharges to review any needed changes or discuss other options for discharge. This will occur with the 72 hour huddle, any care conferences and within 72 hours prior to discharge and be documented in the EHR. g. All information related to discharge needs will be documented in the EHR with date, name of company, person at the company taking information and/or fax confirmation and date services or equipment are expected to begin or arrive. 3. Administrator/DNS or designee will audit using the discharge planning tracking audit tool weekly x 3 months to ensure proper notifications/orders have been made for a safe discharge. Audit findings will be brought to QA monthly for review for 3 months or until committee deems not necessary.
The findings of the complaint (Intake #s 28750 and 28772) health survey conducted 3/4/21 through 3/11/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 3/11/21.
The sample was comprised of three closed records. The facility had a census of 79 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
DNS: Director of Nursing Services
F: Fahrenheit
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PRN: as needed
PT: Physical Therapist
qd: every day or daily
qid: four times a day
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UTI: urinary tract infection
The findings of the complaint #28750 and complaint #28772 health revisit survey conducted 04/13/21 through 04/14/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 Divisions 85 through 89.
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OAR 411-085-0360 Freedom from Abuse, Neglect, and Exploitation: Abuse
Refer to F609
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OAR 411-086-0060 Comprehensive Resident Centered Care Plans: Comprehensive Assessment and Care Plan
Refer to F660
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OAR 411-086-0240 Behavioral Health Services: Social Services
Refer to F745
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