cms_WV: 9911
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9911 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-08-05 | 284 | D | 0 | 1 | 2XEX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted by the facility to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to develop a post-discharge plan of care that accurately and completely identified and communicated to the resident's family and receiving facility the care and services the resident would require in order to ensure a safe and orderly discharge. The discharge transition plan developed by the nursing facility for Resident #57 failed to communicate significant information about the resident's medical history (including a recent history of alcohol dependence) and current health status, failed to identify the need for home health services and occupational therapy as ordered by the physician, and failed to accurately communicate the need for such things as diet modifications and special equipment. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, "...Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. ..." Also on page 2 was stated, "Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time." (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: "5. Activity is ambulation with assist and a walker." A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under "A/P" ("assessment" and "plan"): "5. Alcohol dependence: Abstain from future use ...." - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading "Summary of Care" was noted: "Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility." Under the heading "Discharge Recommendations" was noted: "Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair)." Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading "Summary of Care" was noted: "Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment." Under the heading "Discharge Recommendations" was noted: "Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker)." Review of the speech therapy progress notes, for 07/20/10, revealed under the heading "Current Status": "Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners". Under the heading "Encounter Summary" was noted: "... SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. ..." Review of the resident's telephone orders found an order dated 07/27/10 for: "Home Health w/ (with) PT & OT." Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was "rough". According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. -- b) During an interview with the nursing facility's administrator (Employee #53) on 08/04/10 at 12:03 p.m., she stated that discharge planning was primarily the responsibility of the facility's social worker. She confirmed that no reason for the transfer / discharge of Resident #57 was documented, that no written notice prior to transfer was documented, and that no arrangements were made for appropriate transportation, follow-up physician appointment, and ordered adaptive equipment. She agreed there was no evidence to reflect appropriate medical history had been communicated to the receiving facility. She stated the social worker was hired about six (6) months ago, had no previous long term care experience, and, although she had received orientation, she was in need of education on long term care requirements and services. -- c) A review of facility policy and procedures for discharge and transfer, conducted on 08/05/10 at 8:00 a.m., found the following: - Under the section "Policy" is stated: "Customers and/or legal representatives will be provided proper notice in accordance with state and federal regulations should a transfer or discharge be initiated by a Genesis ElderCare Center." - Under the section "Process" is stated as #1: "The social services department is responsible for coordinating transfers and discharges." -- d) A review of facility policy and procedures for discharge planning, conducted on 08/05/10 at 8:20 a.m., found under the section "Policy": "Upon admission, all customers will be asked about their discharge goals and assessed for discharge potential. For customers anticipating a short stay, discharge/transition planning will begin upon admission and be completed as part of the Interdisciplinary Care Plan process." Under the section "Purpose" is stated: "To ensure the most appropriate discharge/transition plan for all customers" and, "To provide comprehensive discharge information for all customers, family members, and post-discharge care providers." -- e) On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Among these materials were found "Rehab UM Meeting" notes and a discharge transition plan. - Review of the facility's "Rehab UM Meeting" notes for Resident #57 on 07/21/10 revealed, "... D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified [MEDICATION NAME] swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids)." - Review of the facility's "Rehab UM Meeting" notes for Resident #57 on 07/27/10 revealed, "... D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance." Handwritten in the block containing Resident #57's name was: "DC tom (discharge tomorrow) pm". Review of the resident's discharge transition plan, dated 07/29/10, revealed the following: - "You can get around (at discharge): With a little help. Devices used: wheelchair" (There was no mention of a front-wheeled or roller walker.) - "Get up/down from a seated position (at discharge): W/ at great deal of help" (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) - "Your dietary recommendations are: Regular Diet" (There was no mention pureed foods or thickened liquids.) - On page 3, under the heading of "Your physician follow-ups", nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) - On page 5 of this document, under the heading "Your health services provider follow-ups" were checked "Physical Therapy", "Home Medical Equipment / Supplies", and "Pharmacy Provider". None of the services under "Home Care Services" was checked, nor was "Occupational Therapy" checked under "Therapy Services", as had been ordered by the physician on 07/27/10. Under "Home Medical Equipment / Supplies", someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. . | 2015-08-01 |