| 88 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2019-08-22 |
623 |
D |
1 |
1 |
P5VQ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the resident or resident's representative, in writing, of the reason for a transfer for 4 (#s 22, 100, 135, and 238) of 38 sampled and supplemental residents. Findings include: 1. During an interview on 8/21/19 at 8:55 a.m., staff member F stated that resident #100 had sustained a fall with a [MEDICAL CONDITION] which required hospitalization in (MONTH) of 2019. During an interview on 8/22/19 at 10:10 a.m., staff member D stated when a resident has been transferred, she has not given the resident or resident's representative any written documentation related to the reason for the residents's transfer. During an interview on 8/22/19 at 10:15 a.m., staff member C stated when a resident has been transferred, she has not given the resident or the resident's representative any documentation related to the reason for the resident's transfer. During an interview on 8/22/19 at 10:25 a.m., staff member F stated she has done the communication notice, which informs the facility of the change for a resident. She stated the written notices to the resident, or the resident's representative, were done by the staff in Medical Records and Admissions. During an interview on 8/22/19 at 10:30 a.m., staff member [NAME] stated she had not done any written notification to the resident, or the resident's representative, when a resident had been transferred. Review of resident #100's medical record showed she was hospitalized from [DATE] through 6/3/19 for a [MEDICAL CONDITION]. The medical record failed to show a written transfer notification was provided in writing, identifying the reason for the transfer, and given to resident #100 or her representative. The transfer notification documentation was requested for resident #100 on 8/21/19 at 3:10 p.m. No documentation was received prior to the end of the survey. 2. During an interview on 8/21/19 at 3:14 p.m., staff member B stated the facility does not notify the resident or resident's representative of a transfer to the hospital, in writing. Review of resident #22's Iview Notification, dated 7/24/19, showed, Nurse left voicemail for (name) to return call-called and spoke with (name) and given ok to send to ED (emergency department). (sic) A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for the written transfer notification documentationfor resident #22 was not received from the facility. 3. During an interview on 8/22/19 at 9:18 a.m., staff member M stated she did not know what they currently do for transfer notifications for residents or resident's representatives. During an interview on 8/22/19 at 10:03 a.m., staff member A stated the facility had not been doing the transfer notifications right and had skipped the regulation all together. Review of resident #135's Progress note, dated 7/12/19, showed, Son (Name) notified of decline of condition and to be sent to the hospital. A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for the written transfer notification for resident #135 documentation was not received from the facility. 4. During an interview on 8/22/19 at 9:28 a.m., staff member L stated upon transfer to the hospital the facility calls the resident's representative and documents it in the electronic record. Review of resident #238's Care Management Progress Note, dated 7/2/19, showed resident #238 was hosptalized on [DATE]. A request on 8/22/19 at 9:08 a.m., for the written transfer notification documentation for resident #238 was not received from the facility. Review of facility's Transfer and Discharge Policy, dated (MONTH) 2008, showed the following: - When (Facility) transfers or discharges a resident under any circumstances above, the resident's clinical record will include the documentation by the resident's physician as to why transfer or discharge is necessary according to (a),(b), and (e) above. Documentation regarding transfer or discharge for any reason will be done by the nurses in the resident's clinical record. - The resident and/or the legal representative will be notified of the transfer or discharge thirty (30) days before the transfer or discharge is to take place except if health or safety is endangered due to medical needs. - The written notice will include the reason for transfer or discharge, the effective transfer or discharge, the location being transferred or discharged to, and the right to appeal the transfer or discharge . |
2020-09-01 |