cms_OR: 23
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 660 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a resident was discharged with adequate supervision for transfers after the resident was discharged for home for 1 of 3 sampled residents (#4) reviewed for facility discharge. This placed residents at risk for falls. Findings include: Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's admission CAAs dated 5/5/18 indicated the resident broke her/his foot and was non-weight bearing. The resident was at moderate risk for falls related to cognitive issues, pain and balance issues. The Care Plan initiated on 4/28/18 indicated the resident was at risk for falls related to developmental delay, generalized weakness and the use of pain medications. The resident was also identified to be at risk for ADL decline. Interventions included the staff were to assist the resident with toileting and the resident was to be assisted with one staff and the use of a walker. The care plan was not revised to indicate the resident was independent to walk. The care plan indicated the anticipated discharge plan was for the resident to be discharged to the community. The plan was for staff to communicate with the resident's family/support to determine if the resident was safe to be discharged to home or to an assisted living facility. The 6/21/18 Progress Notes by Witness 6 (Former Social Service Director) indicated the resident's Medicare benefits were to end for skilled services on 6/26/18 and the resident did not want to appeal the decision. The plan was to discharge the resident on 6/27/18. The notes also indicated the resident reported mobility restrictions and impaired ability to perform all mobility related ADLs and wheelchair was to be used. The resident demonstrated the physical and mental abilities to operate a wheelchair in the home setting safely through practice with therapy and nursing staff. The resident was to be discharged to her/his home with home health services. The note only addressed the resident's ability to safely use the wheelchair for mobility but did not address if the resident would be safe to transfer independently. The Physical Therapy Discharge Summary by Staff 7 (Physical Therapist) dated 6/27/18 Discharge Status and Recommendations indicated the resident was to be discharged home with assist from others. The resident was to have stand by assistance for functional transfers and to walk. The resident's functional outcome indicated the resident required close supervision for the majority of task for safety but no physical contact was required. On 10/24/18 at 1:20 pm Staff 7 indicated when Resident 4 discharged from the facility the resident required cueing for safe mobility. It was recommended by therapy for the resident to have stand by assistance for transfers. Staff 7 indicated she would not have recommended the resident be discharged home alone. On 10/24/18 at 11:00 am Staff 6 (Therapy Director) indicated the resident was developmentally delayed, was cooperative with care but did not always follow weight bearing precautions and needed verbal reminders to perform tasks. The Progress Note dated 6/27/18 indicated the resident discharged from the facility at approximately 2:00 pm and was transported to her/his home via cab. On 10/23/18 at 1:55 pm Witness 7 (Resident 4's Friend) indicated Resident 4 was transported to her/his home on 6/27/18. Witness 7 indicated she arrived to the resident's home approximately 3 to 4 hours after the resident arrived. The resident was in her/his wheelchair with the leg rests on. The resident was not able to remove the leg rests in order to transfer. Witness 4 indicated she informed the facility she was able to assist the resident but would not be able to stay with the resident. On 10/24/18 at 12:45 pm Staff 4 (RNCM) indicated the resident's discharge was set by insurance non-coverage. Staff 4 reviewed the resident's PT discharge recommendations and acknowledged the resident was to have stand by assistance for transfers and the resident was sent home alone. Staff 4 indicated the resident wanted to go home and did not want to go to an assisted living facility. On 10/29/18 Witness 6 (Former Social Services Director) indicated she could not state if she saw the 6/26/18 PT recommendations for Resident 4 to have stand by assistance for transfers. Resident 4 Medicare benefits ended and the resident did not want to pay to stay at the facility. Witness 6 indicated if the therapist recommended stand by assistance for transfers the resident would need to have someone with her/him at home. If the resident did not have someone to stay with the resident and still wanted to be discharged the nurse and or social service person would need to document the resident's wish to go home and the potential risks. On 10/24/18 at 1:50 pm a request was made to Staff 1 (DNS) to provide documentation the staff addressed the PT recommendations for there resident to have stand by assistance for transfers after discharge. No additional information was received. | 2020-09-01 |