cms_DE: 49
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
49 | WILLOWBROOKE COURT AT COUNTRY HOUSE | 85003 | 4830 KENNETT PIKE | WILMINGTON | DE | 19807 | 2019-07-15 | 661 | D | 0 | 1 | N66611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, it was determined that for one (R47) out of one Admission, Transfer, Discharge sampled resident, the facility failed to develop R47's discharge summary that included a recapitulation of R47's stay, a final summary of the resident's status and post-discharge plan of care, including discharge instructions. Findings include: Review of R47's clinical record revealed: 3/13/19 - R47 was admitted to the facility for skilled nursing and rehabilitation. 4/16/19 - A physician's orders [REDACTED]. Review of R47's clinical record lacked evidence of a complete discharge summary that included: - a recapitulation of R47's stay at the facility that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results; and - a post-discharge plan of care that was developed with the participation of the resident, including any arrangements that have been made for the resident's follow-up care and any post-discharge medical and non-medical services. 7/9/19 at 11:27 AM - During a combined interview, findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E17 (SW) and E4 (ADON). The facility failed to develop a discharge summary that included a recapitulation of R47's stay, a final summary of the resident's status and post-discharge plan of care, including discharge instructions. | 2020-09-01 |