| 22 |
GREENBRIAR HEALTHCARE |
305005 |
55 HARRIS ROAD |
NASHUA |
NH |
3062 |
2018-10-16 |
660 |
D |
1 |
0 |
QTPI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and facility policy and procedure it was determined that the facility failed to implement the discharge planning process to ensure that the needs of 1 resident were met at the time of discharge back to the home setting in a survey sample of 12 discharged residents. (Resident identifier is #1.) Findings include: Review on 10/16/18 of the facility policy and procedure titled Discharge Summary and Plan dated 11/2017 revealed the following: POLICY When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Guidelines a) When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ,,,, etc.), a discharge summary and post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. b) The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. Current diagnosis; b. Medical history .; c. Course of illness, treatment and/or therapy since entering the facility; d. Current laboratory, radiology, consultation, and [DIAGNOSES REDACTED].>e. Physical and mental functional status; f. Ability to perform activities of daily living .; g. Sensory and physical impairments (neurological, or muscular deficits, for example, a decrease in vision and hearing, paralysis, and bladder incontinence); h. Nutritional status and requirements; . i. Special treatments or procedures . j. Mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indications of resident behavior and mood); k. Discharge potential (the expectation of discharging the resident from the facility within the next three months); l. Dental condition . m. Activities potential . n. Rehabilitation potential . o. Cognitive status . p. Medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration and recognition of significant side effects that would be most likely to occur in the resident). c.) As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. d.) Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. e.) The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include; . f.) The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. g.) The resiident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan; h.) Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. i.) If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. j.) Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals and treatment preferences. Data used in helping the resident select an appropriate facility includes the receiving facility's . k.) The resident or representative . should provide the facility with notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed. l.) A member of the IDT (interdisciplinary team) will review the final post-discharge plan with the resident and family before the discharge is to take place. m.) A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records . k. An evaluation of the resident's discharge needs. l. The post-discharge plan; and m. The discharge summary. Resident #1. Review on 10/16/18 of Resident #1's electronic medical record and the soft paper record revealed that Resident #1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review on 10/16/18 of the Nurse Notes for Resident #1 revealed the following; - 2/19/18 TC (telephone call) to (name and telephone number) re (regarding) Status of getting (Resident#1) home. ML (message left) waiting for (Sentence not completed.) - 4/26/18 S.S. (social service) spoke with (Resident #1) about .over all plan as far as discharging home. S.W. (social worker) has been following up with .in the county where (Resident #1) lives to find assistance for . (Resident #1) when (Resident #1) has an actual discharge date . - 5/10/18 .S.S. working on d/c (discharge) plan for (Resident #1) to get home with equipment and services - 8/28/18 @ 13:58 S.W. spoke with (Resident #1) prior to .discharge tomorrow in the S.S. office. (Resident #1) had this writer buy (Resident #1) a sit to stand lift and have it delivered to (Resident #1's) home. During this time this writer stated that (Resident #1) will need to stay a few more days longer do (sic) to it taking 5-10 days for this lift to even be delivered. There was (sic) witnesses in the office when (Resident #1) stated that is was able (sic) to scoot slide out of . power chair and would like to go home knowing that (Resident #1) will not receive the sit to stand lift on discharge. (Supplier) will be providing the rest of his DME (durable medical equipment) tomorrow. Services were set up through (visiting nursing) and (ambulance) was booked for 2pm pickup to home. S.S. will follow up as needed. - 8/28/18 Resident (#1) had a pulmonologist appointment and new medications were prescribed. (Physician) notified and ordered for the resident (#1) to be given prescripts tomorrow on discharge to home. - 8/29/18 Resident left (discharged ) for home at 1500. Review on 10/16/18 of the physician note for Resident #1 dated 8/17/2018 revealed the following: Pt (patient) is wheelchair dependent, (Resident #1) can use a manual w/c for short distances, due to carpal tunnel syndrome bilateral wrists, (Resident #1) is currently able to use an electric w/c. Needs a stand assist to transfer. Pt is cont (continent) of B&B (bladder & bowel), needs assist to transfer to commode. 1. The patient requires a wide/heavy duty commode chair due to (Resident #1's) weight is over 300lbs (pounds) and pt is confined to a single room. 2. (Resident#1) will require a manual wheelchair for inside .home use as (Resident #1) is a paraplegic and nonambulatory . 3. Pt. requires a hospital, semi electric hospital bed, due to pt. [MEDICAL CONDITION], hx (history) GERD, and persumptive dx (diagnosis) of [MEDICAL CONDITION] with chronic cough. Pt needs .head elevated when .in bed to be more than 30 degrees .requires frequent positioning. 4. Pt needs a Patient Lift, (stand assist) to transfer between .bed, wheel chair and commode. Pt cannot transfer independently due to [MEDICAL CONDITION] without a lift pt would be bed bound. 5. Pt requires a support surface, a mattress overlay due to [MEDICAL CONDITION] and inability to independently reposition Record review on 10/16/18 revealed the Physician Attestation of Face to Face Encounter for Home Health Referral dated 8/23/18 for PT (physical therapy), OT (occupational therapy) therapeutic exercise ROM (range of motion), safety endurance. RN (Registered Nurse) assess & med (medication) management, HHA (home health aide) ass (assist) + ADLs (activities of daily living), SW (social worker) liaison to community resources. Review on 10/16/18 revealed a fax to a home health agency dated 8/29/18 the day of discharge from the facility for PT, OT, HHA, SW services for Resident #1. Review on 10/16/18 of Resident's #1 electronic medical record revealed the following; - 8/30/18 . This writer (social worker) had a home care agency in place as well for them to go out and see (Resident #1) 48 hours after d/c (discharge). This writer received a voicemail from the agency that stated they could not take (Resident #1) on case load due to not having the staff to go to (Resident #1's town). The agency left this writer another agency to call that could better service. This writer called (home health agency) and faxed all .paper work to them for RN and HHA in the home Interview on 10/16/18 at approximately 11:30 a.m. with Staff C (Social Worker) revealed after review of the electronic and paper record for Resident #1that there is no documented evidence that the social worker followed up with discharge plans on 2/19, 4/26, 5/10 and 8/28/18, that there was no documented evidence of a discharge plan with goals and needs to ensure a safe transition from the facility, no documentation prior to discharge that the referral home health agency accepted Resident #1 for the services ordered in the home, no documentation that Resident #1 was given the prescriptions for new medications ordered at the time of discharge and no documentation of a copy of the evaluation of Resident #1's discharge needs, post-discharge plan and discharge summary. Interview on 10/16/18 at approximately 3:00 p.m.with Staff A (Registered Nurse) and Staff B (Registered Nurse) confirmed the findings listed above for Resident #1. The facility failed to fully implement the discharge planning process prior to discharge and Resident #1 was discharged to Resident #1's home with no ordered home health services and adaptive equipment in place to meet Resident #1's needs in the home setting. |
2020-09-01 |