cms_AZ: 47
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 47 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2018-06-28 | 622 | D | 1 | 0 | KWBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of hospital documentation, staff interviews and review of facility policies and procedures, the facility failed to ensure there was documentation in one resident's (#2) clinical record regarding the basis for the transfer. The sample size was three. Findings include: Resident #2 was admitted to the facility on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. Nursing Note dated (MONTH) 15, (YEAR) documented Arrived from (name of hospital) at 3:15 p.m .Alert and oriented x 3 but slow to speak appears exhausted .Oxygen two liters - not on home oxygen . Review of a Social Services Note dated (MONTH) 18, (YEAR) at 2:03 p.m. documented .requesting that patient be transferred to (another skilled nursing facility) to continue her skilled related to family's dissatisfaction with her care. Writer obtained telephone order for discharge . Review of a Physician Telephone Order dated (MONTH) 18, (YEAR) at 6:18 p.m. documented Send to ER (emergency room ). There was no documentation on the telephone order as to the reason for the transfer and the order was not signed by the resident's primary physician at the facility. Review of the clinical record revealed no documentation regarding the basis for the transfer to the hospital. Review of hospital documentation dated (MONTH) 18, (YEAR) at 10:30 p.m. documented .per her primary care physician .who saw the patient today, patient was somnolent and hypoventilating this afternoon and hypoxic (83% on room air) . An interview was conducted with the medical records clerk, staff #76 on (MONTH) 27, (YEAR) at 11:38 a.m. The medical records clerk stated that the resident did not get transferred to the other skilled nursing facility because of insurance purposes but that she thought the resident's family took the resident to the hospital. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 27, (YEAR) at 2:00 p.m. The DON stated that she did not think the resident had a change of condition but that she did not have anything to back that up because the agency nurse did not document why the resident was discharged . An interview was conducted with the resident's primary physician on (MONTH) 27, (YEAR) at 4:00 p.m. The physician stated that he was the resident's primary physician while she resided at the facility but did not give an order to send the resident to the hospital. An interview was conducted with the DON, staff #64 on (MONTH) 27, (YEAR) at 4:05 p.m. The DON stated that the resident also had a concierge physician who must have gave the order to transfer the resident to the hospital as the telephone order did not indicate which physician gave the order and it was not signed by a physician. The DON further stated that the licensed nurse did not document the reason for discharge to the hospital. Another interview was conducted with the DON, staff #64 on (MONTH) 28, (YEAR) at 9:10 a.m. The DON stated that the nurse who got the order to transfer the resident to the hospital was an agency nurse. The DON stated that she noticed there was no documentation in the clinical record so she called the agency to ask the agency nurse to document as to why the resident was sent to the hospital. The DON stated that the agency nurse stated that she could not remember. An interview was conducted with an RN (registered nurse), staff #92 on (MONTH) 28, (YEAR) at 12:28 p.m. The RN stated that if she had to transfer a resident to the hospital that she would write a basic summary of what was going on with the resident, who was notified such as the physician and family, and document that in the resident's clinical record. An interview was conducted with a LPN (licensed practical nurse), staff #93 on (MONTH) 28, (YEAR) at 12:35 p.m. The LPN stated that if she transferred a resident to the hospital that she would document the reason as to why the resident was being transferred, who was notified, who gave the order and any other pertinent information. The LPN further stated that she would document that in the resident's clinical record. Review of the facility's policy Emergency Transfer or Discharge documented .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: .Prepare a transfer form to send with the resident . | 2020-09-01 |