cms_ID: 92
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 92 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-08-09 | 661 | 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' records contained a complete discharge summary. This was true for 2 of 2 residents (#3 and #4) reviewed who were discharge from the facility. This failure created the potential for harm and inappropriate care due to incomplete documentation related to residents' discharge. Findings include: The facility's Discharge Summary policy, dated (MONTH) (YEAR), documented a recapitulation of residents stay included diagnoses, course of illness/treatment or therapy, pertinent lab, radiology, and consultation results. The policy did not address the need to include other care areas listed on the resident's most recent comprehensive assessment. 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 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 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] Resident #3's Discharge Summary, dated 5/29/18, documented he was admitted to the facility with a [MEDICAL CONDITION] and a feeding tube. The summary of stay included Resident #1 was assisted with therapies related to strengthening, gait/balance and speech, pain management, medication management and assistance with his activity of daily living. The summary did not document Resident #3 was discharged with the services of an HHA and his management status regarding his [MEDICAL CONDITION] and PEG tube. On 8/9/18 at 11:05 AM, the Social Worker and the Discharge Coordinator said nursing completed the discharge summaries and were not aware of what was required on the discharge summary. The Social Worker said the summary did not include documentation Resident #1 went home with services from an HH[NAME] On 8/9/18 at 12:10 PM, the DON said Resident #3's discharge summary did not include documentation he was discharged with HHA services and the DON was not aware of what was required on the discharge summary. 2. The [DIAGNOSES REDACTED].#4 was admitted to the facility 5/4/18 with [DIAGNOSES REDACTED]. The documentation further identified Resident #4 was discharged [DATE]. Resident #4 had a paper medical record in addition to an electronic medical record. Resident #4's Discharge Summary, which was handwritten by a Licensed Nurse on 6/21/18 documented: Pt (patient) admitted to GTC (Gateway Transitional Care) for left knee after surgery care. Pt received assistance (with) ADLs (activity of daily living), medication management, Labs (bloodwork) and Vitals (vital signs), PT/OT/SP (Physical, Occupational, Speech Therapy) for strength training balance and gait training, cognition training. No additional discharge summary information was found in the medical record. The Discharge Summary did not include the following required information: * Identification and demographic information * Customary routine * Cognitive patterns * Communication * Vision * Mood and Behavior patterns * Psychosocial well-being * Physical functioning and structural problems * Continence * Disease [DIAGNOSES REDACTED]. * Dental and nutritional status * Skin condition * Activity pursuit * Medications * Special treatments and procedures * Most recent discharge care plan * Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS. * Documentation of participation in assessment. This refers to documentation of who participated in the assessment process. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care/direct access staff members on all shifts. On 8/9/18 at 11:05 AM, the Discharge Coordinator was interviewed about the contents of the Discharge Summary. The Discharge Coordinator stated she was not aware of the federal discharge summary requirements. | 2020-09-01 |