cms_ID: 91
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 91 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-08-09 | 660 | D | 1 | 0 | 1TM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received an adequate and/or updated discharge plan, timely referrals to home health services, and/or involve residents in the discharge planning process. This was true for 3 of 4 residents (#1, #3 and #4) reviewed for discharge planning. This failure created the potential for harm if residents' various discharge needs were not met. Findings include: The facility's Discharge Planning Process policy, dated (MONTH) (YEAR), documented: *Provide and document sufficient preparation to ensure a safe and orderly discharge. *Identify changes that require modification of the discharge plan.The discharge plan must be updated, as needed, to reflect these changes. *Involve the IDT, residents and resident's representative in developing the discharge plan. *Document the evaluation of the resident's discharge needs. 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including malignant neoplasm of the esophagus [MEDICAL CONDITION] (breathing tube), gastrostomy (feeding tube), and muscle weakness. Resident #3 was discharged from the facility on 5/29/18. Resident #3's discharge area of the care plan, dated 4/10/18, directed staff to: * Establish a pre-discharge plan with the resident. * Evaluate the resident's progress and revise the discharge plan. * Make arrangements with required community resources to support independence post-discharge. * Did not have a preferred home health provider. The discharge area of the care plan did not document Resident #3's needs regarding his [MEDICAL CONDITION] and PEG tube. Resident #3's Weekly Skilled Review meeting, dated 5/24/18, documented several staff attended without the resident present. The notes documented Resident #3's progress towards discharge, including his PEG (feeding tube) tube and [MEDICAL CONDITION] management status. Resident #3's Family Meeting and Social Service notes, dated 5/25/18, documented he and a family member were present. The notes documented Resident #3 wanted to discharge from the facility and agreed to be discharge on 5/29/18, after he was able to independently manage his [MEDICAL CONDITION] and PEG tube. Resident #3's Social Service notes, dated 5/29/18, documented, Resident approached discharge planner multiple times throughout the day to discuss discharge .Discharge orders were obtained and reviewed with resident .referral was sent to (Local Home Health Agency). Discharge planner stated it could take a few days for services to begin but resident could expedite process by contacting the home health agency and setting up an appointment that worked for both the home health and resident. A facility's Fax status page, dated 5/30/18 at 8:57 AM, documented Resident #3's medical information was sent to the HH[NAME] On 8/9/18 at 11:05 AM, the Social Worker said Resident #3's discharge portion of the care plan did not include updates discussed in the Weekly Skilled Review meeting or in the Family Meeting, did not document the resident's [MEDICAL CONDITION] and PEG tube needs at discharge, and did not document which HHA the resident had chosen. The Social Worker said she had made a verbal referral to the HHA and did not know why the resident's medical information was sent to the HHA the day after he was discharged . The Social Worker said she had contacted the HHA on 6/1/18 and had been informed that Resident #3 had been seen for the first time by the HHA that day. Resident #3's first visist from the HHA was completed 3 days after his discharge from the facility on 5/29/18. 2. The [DIAGNOSES REDACTED].#1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Discharge Plan dated 5/23/18, located in the electronic medical record and attached to the care plan documented: Resident #1 anticipates returning to (name) ALF (Assisted Living Facility) in (town) The discharge plan interventions included: * Encourage to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. * Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan. * Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitation, risks, benefits and need for maximum independence. * Make arrangements with required community resources to support independence post-discharge. (Resident #1) prefers (name) Home Health. * Provide a list of any upcoming appointments post discharge to (Resident #1) and (name) assisted living facility. On 6/4/18 at 2:00 PM, the Discharge Coordinator documented a family meeting was held that included the resident, resident's son, Discharge Coordinator, business office manager, therapy and nursing. The meeting addressed Resident #1's need for oxygen, walker, wheelchair, and power scooter. After the family meeting, Resident #1's 5/23/18 Discharge Plan was not updated to reflect his need for oxygen, walker, wheelchair, and power scooter after discharge. Resident #1's medical record, electronic and paper versions, was reviewed. Resident #1's medical record did not include documentation of an additional meeting, after 6/4/18 with him or his family about his discharge and discharge needs. On 8/9/18 at 11:50 AM, the Discharge Coordinator confirmed Resident #1's discharge plan was not updated with his current discharge information. 3. The [DIAGNOSES REDACTED].#4 was admitted to the facility 5/4/18 with [DIAGNOSES REDACTED]. The documentation further identified Resident #4 was discharged on [DATE]. Resident #4's Discharge Plan, dated 5/9/18, located in the electronic medical record and attached to the residents' care plan documented: (Resident #4) lives alone in a 2-level home with 4 - 5 steps to enter. There are 11 steps to the basement. The discharge plan interventions included: * Encourage to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. * Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan. * Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitation, risks, benefits and need for maximum independence. * Make arrangements with required community resources to support independence post-discharge. (Resident #4) prefers (name) Home Health. * Provide a list of any upcoming appointments post discharge. On 6/15/18 at 1:00 PM, the Discharge Coordinator documented a family meeting was held that included Resident #4, her brother, Discharge Coordinator, social service, therapy and nursing staff. The meeting addressed Resident #4's need for nutrition assistance, such as Meals-on-Wheels after discharge. After the family meeting Resident #4's 5/9/18 Discharge Plan was not updated to reflect her need for nutritional assistance post-discharge. Resident #4's medical record, electronic and paper versions, was reviewed and did not reflect an additional meeting with her or her family about her discharge. On 8/9/18 at 11:50 AM, the Discharge Coordinator confirmed Resident #4's Discharge Plan was not updated with current discharge information. | 2020-09-01 |