| 65 |
VALLE VISTA MANOR |
275021 |
402 SUMMIT AVE |
LEWISTOWN |
MT |
59457 |
2017-10-12 |
201 |
D |
1 |
1 |
BU9C11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident was assisted with an appropriate discharge plan, when the resident wanted to immediately leave the facility, to ensure the resident's ongoing needs were met, but the facility had determined that long term care was necessary, for 1 (#1) of 10 sampled residents. Findings include: During an interview on [DATE] at 6:00 p.m., staff member C stated that resident #1 was discharged from the facility on [DATE]. Staff member C stated that resident #1 was discharged because the facility could not meet his needs per staff member B. Staff member C stated that resident #1 did not have an initial discharge plan, as he was considered to be a long term resident, and could not return to live in the community. Staff member C stated that after the resident left the facility, and had been taken to the hospital, the hospital had not notified the facility directly when resident #1 was discharged from the hospital. Review of the resident's Discharge Return Anticipated MDS, with an ARD date of [DATE], showed in Section Q, under Discharge Plan, A was coded as a 1 which is for a yes meaning active discharge planning was already occurring for the resident to return to the community. The MDS contradicted what staff member C had stated relating to long term care placement. Review of resident #1's Resident Incident Report, dated [DATE] at 9:18 p.m., showed resident #1 became increasingly verbally angry with facility staff, and he stated he wanted to leave in his vehicle. When resident #1 would not calm down, staff member P phoned staff member B and was informed of the situation. Staff member B advised staff member P to contact law enforcement, due to the resident's behavior. Resident #1 was escorted from the facility by law enforcement, although a discharge plan had not been initiated for the resident, prior to the resident leaving the facility. Further review of the incident report for resident #1 showed: -NF4 had not been notified by the facility of the incident that occurred on [DATE]. -NF3 reported concerns about resident #1 to NF4 on [DATE], after the resident was no longer at the facility. -The report showed that the facility had contacted the hospital and informed the hospital staff they would not accept the resident back at the nursing home. -The resident was not allowed back on the facility's premises, therefore, the facility would not accept the resident as return resident. When resident #1 was discharged from the hospital on [DATE], he did not have shoes, and did not have a location to live. -NF3 had came to the facility, and obtained the resident's shoes, and he then found the resident shelter. -The report reflected that the resident did not have placement assistance from the hospital or any discharge follow up care in place by the facility. The resident had been released into the community without any support. During an interview on [DATE] at 9:45 a.m., staff member B stated that the facility had discharged resident #1 right away. Staff member B also stated the facility staff had heard resident #1 had gone to the hospital, but the facility staff had not been notified of this. Staff member B stated that she thought the resident did come back to the facility later (with NF3) but would not come inside to get his personal items. During an interview on [DATE] at 2:30 p.m., NF4 stated that she was a case manager for resident #1 for a long time when he resided in the community. NF4 said that resident #1 was not known to be an aggressive person and it was out of character for him to be a drinker. NF4 wondered why the resident had not been checked for an infection, prior to his discharge, referring that this may have been the cause of the resident's behavior change. During an interview on [DATE] at 4:45 p.m., staff member P stated that resident #1 would not calm down and wanted to leave. Staff member P attempted to talk to resident #1 on [DATE], but the resident did not make sense. Staff member P told the resident he could leave but it would be AMA (against medical advice). The medical record did not show attempts of the facility to set up community services for ongoing care. During an interview on [DATE] at 9:05 p.m., staff member Q stated the resident thought the staff were stealing from him. He began to bring his clothes up and stack them by the handicap door to load them into his van. Staff member Q stated the resident said I will kill anyone who tries to stop me. The resident did not target anyone specifically, he just thought staff were going to detain him. He was able to read his rights from the Resident Right's board and the staff all agreed he had a right to leave. The facility had not addressed the resident's change, or concerns with his not making sense to ensure the change was not potentially a contributing factor in the resident's drive to leave to leave the facility, in an attempt to ensure safety. Review of resident #1's nurses' Progress Note dated [DATE] at 2:21 a.m., staff member P had wrote that staff member B was phoned a second time, updated on the situation, and staff member P was advised to call the physician. The physician on call was reached and staff member P had explained the situation occurring with the resident, as it occurred. Staff member B was notified a third time, updated on the situation, and staff member P was instructed to document the events. Review of another nurses' Progress Noted dated [DATE] at 8:48 a.m. showed resident #1 was unwilling to consent to an assessment. At 8:30 a.m. that same date, a peace officer was given resident #1's medication administration sheet and medications. No welfare check by the facility was initiated. Review of resident #1's Care Plan, with last review date of [DATE], showed under the Focus area: Behavior - The resident had exhibited rage which is evidenced by yelling and shaking fists when he became overwhelmed and does not comprehend complex questions. The intervention was to offer reassurance and attempt to redirect me when I am exhibiting indicators of psychosocial distress and notify nurse. Also, under the Focus area: Discharge Planning - showed the resident elected to stay at the facility for long term placement as his needs could not be met in the community. The last revision date was [DATE], and this was documented by staff member C. Information was requested for the incident that occurred on [DATE], and discharge information relating to the resident, which had not yet been provided. The following information was not received prior to the end of the survey: - A discharge order from the physician - A discharge summary - A discharge plan, or a follow up discharge plan. During an interview on [DATE] at 2:50 p.m., NF1 stated she was not notified of the resident's discharge from the facility, which took place on [DATE]. During an interview on [DATE] at 11:20 a.m., staff member C stated that if the resident had remained in the hospital on [DATE], she would have followed up with the resident to assist with a discharge plan. Since the incident happened over the weekend, and it happened so quickly, the situation did not allow time for her to complete this. The investigation showed the resident had expired after a motor vehicle accident on the early morning of [DATE]. |
2020-09-01 |