| 5896 |
SIDNEY CARE AND REHABILITATION CENTER, LLC |
285113 |
1435 TOLEDO STREET |
SIDNEY |
NE |
69162 |
2016-08-31 |
284 |
J |
1 |
0 |
F2SC11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C2 Based on observations, interviews, and record reviews; the facility failed to develop a post-discharge plan for one sampled resident (Resident 4) including: 1) involvement of the physician; 2) determination of safety capabilities and consultation with therapy to meet physician recommended discharge requirements; and 3) pre-assess the safety of the discharge environment and acceptance of discharge by the resident's family. The facility additionally failed by aiding the resident to transport and remain in a setting incapable of meeting the resident's safety needs. The failure resulted in Immediate Jeopardy of the resident's safety and led to a resident fall and fracture culminating in hospitalization . Facility census was 27. Findings are: Record review of Resident 4's Admission Record printed on 8/30/16 revealed the resident was initially admitted to the facility on [DATE]. Among medical [DIAGNOSES REDACTED]. Record review of Resident 4's Quarterly review assessment MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 8/22/16 revealed the following: - The resident's Functional Status for Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position was recorded as Extensive assistance- resident involved in activity, staff provide weight-bearing support at a minimum of three times during a seven day period. The Support provided for the activity was One person physical assist. - The resident's Functional Status for walking in and out of room was recorded as Activity did not occur. - The resident's Functional Status for Locomotion off unit- how resident moves to and returns from off-unit locations (e.g. areas set aside for dining, activities, or treatments) . how resident moves to and from distant areas on the floor. If in wheelchair, self sufficiency once in chair. The item recorded the resident received Extensive Assistance for the activity with the assistance of one staff. - Active Medical [DIAGNOSES REDACTED]. - The resident experienced pain over the last five days Frequently and rated the worst pain at 8 on a pain scale of 0-10 with 0=no pain and 10= very severe pain. - The resident experienced one fall since the prior assessment. - The resident's weight was recorded as 398 pounds. - The resident had not received any Occupational therapy since 1/6/16 and had not received any Physical Therapy since 7/26/16. Record review of Resident 4's care conference on 6/2/16 revealed the resident was invited to the conference and had not attended. The Discharge Plans for the resident at the conference were recorded as Long term. Record review of Resident 4's Care Plan initiated on 5/24/16 revealed the resident's discharge plan was recorded as I would like to make plans to discharge to a skilled nursing facility closer to my home. Further review of the care plan revealed a focus problem with Physical functioning deficit related to: Mobility Impairment, self care impairment, r/t (related to) [MEDICAL CONDITION] and recent BKA (Below Knee Amputation). The problem was initiated 5/24/16 and identified Transfer assistance of 2 staff with gait belt, extensive assist regarding interventions for the problem. Record review of a Report of Consultation with the resident's physician on 7/14/16 revealed the purpose of the visit was: 60 day- wants d/c (discharge) orders. The physician documented under Recommendations that the resident (MONTH) d/c home if can transfer to shower chair or toilet. Record review of the facility's Progress Notes for (MONTH) (YEAR) revealed the following entries: - 8/17/16 recorded at 3:10 p.m.- At 1150 (11:50 a.m.) Resident is found on floor by CNA (Nurse Aide). Resident states was transferring self from bed to w/c (wheelchair) using slide board. Resident also reports that slide board slips and causes to fall . Resident is helped up off floor via Maxi-lift and an assist of 4 onto bed . - 8/22/16 recorded at 5:04 p.m.- . (resident) stated wanted to go home . Resident has discharge to home orders per (name of physician) with the stipulation of being able to transfer self from w/c to toilet and back independently. Resident is able to perform transfer without difficulty. Resident has begun to gather belongings to leave for (name of town) tomorrow morning . Staff notified of discharge and will escort resident to home. - 8/23/16 recorded at 9:46 a.m.- Resident left facility via (facility) transportation for d/c, to be d/c to home with (family member), sent medication and medication list with resident. Resident left with w/c which will be brought back by staff, left with belongings . resident refused vital signs to be taken at this time, no questions or concerns. - 8/24/16 recorded at 6:50 p.m.- Resident went to motel instead of home. Concerned about how (resident) would get food/water and cook. Reported having family/friends/money for these things. Resident now in hospital. Discussed with DON (Director of Nursing) today. Interview with the SSD (Social Service Director) on 8/30/16 at 1:35 p.m. and Staff-B (facility van driver) on 8/31/16 at 9:35 a.m. revealed Resident 4 requested a discharge to the home of a family member and requested facility transportation to the home. The residence was in a town over two hours away. The facility provided van for transport and the SSD and Staff-B assisted the resident during the transport. They stopped at a medical supply vendor on the way and picked up a new wheelchair for the resident. The SSD stated when arriving at the town, the resident stated the family member would be sleeping and requested staff help the resident check into the motel where the resident would wait until the family member got off night shift work and would take the resident to the home. The SSD stated they assisted the resident with check in as the resident was unable to get inside the lobby due to the resident's size of wheelchair and inability to walk. Both staff then assisted the resident to the motel room. Staff-B stated the resident's wheelchair was too big for the resident to get through the door of the motel room and both the SSD and Staff-B stated the resident was unable to use a prosthetic leg to stand and transfer and requested use of a slide board which the facility brought along. Staff-B stated the resident used the slide board and staff placed one wheelchair inside the room in the doorway and the resident wheeled the other one outside the doorway and transferred into the wheelchair in the motel room with the aid of the sliding board. The resident requested they leave the slide board and the staff complied. The SSD stated they asked the resident if there were any other needs and resident stated no and the SSD and Staff-B left the resident and returned to the facility. Interview with the motel owner on 8/29/16 at 12:51 p.m. revealed the owner was in the office when Resident 4 arrived at the motel on 8/24/16 after lunch. The owner stated the facility staff came in and requested check in for the resident as the resident was wheelchair bound and oversized and unable to get into the office. The owner told the staff the motel was not equipped for handicapped individuals and the facility staff proceeded with the check in anyway. The owner stated later in the night the owner received a call from Resident 4 who stated having fallen and experiencing pain and felt this was not going to work. The owner stated Resident 4 requested transfer to a nursing home. The owner instructed the resident to contact family. Telephone interview with Resident 4's family member (identified by facility as the family member to which the resident requested discharge to) on 8/29/16 at 11:45 a.m. The family member stated not having any knowledge of the resident's intent to discharge to the family member's home and heard nothing of what happened until being notified by Resident 4 by phone while at work on the night shift on 8/24/16. Resident 4 called the family member at work and reported having been dropped off at the motel by the facility staff. Resident 4 stated having fallen and that the resident's back was hurting. The family member then planned to go to the motel at end of shift and assist. The family member stated when arriving, Resident 4 was in pain and unable to be moved without help and an ambulance was called. The family member stated it took six responders to assist the resident into the ambulance for transport to the hospital. Further interview with the family member revealed the family member was unable to provide care for Resident 4 due to the resident's size and amputated leg. The family member stated the home was not equipped for handicapped accessibility and stated if the resident were to fall, there would be no way to get the resident off the floor without extensive assistance of several persons. Observation of Resident 4's motel room conducted with the motel owner on 8/29/16 at noon revealed one entry/exit door into the room. The room was not handicapped accessible regarding the doorway size entering the room. The entry door measured 32 inches and the bathroom door entry measured 28 inches. Both of these were confirmed by the owner. There were no grab bars or assistive devices inside the room or bathroom. The telephone to the room was located across from the bed behind the television. The only water source in the room was in the bathroom. Interview with an EMT (Emergency Medical Technician) on 8/29/16 at 11:44 a.m. revealed the EMT responded to the call at the motel involving Resident 4 on 8/24/16. The EMT stated having arrived sometime between 5 a.m. and 5:30 a.m. on 8/24/16 . The resident was lying on the bed and was stoic and complaining of significant back pain. The resident stated having fallen sometime during the night. The EMT stated due to the resident's size and amputation, six personnel were required along with the use of the slide board to get the resident onto the transfer cot where the resident was transported to the hospital. Record review of Resident 4's hospital documents revealed the following: -Patient Registration Form from the hospital revealed the resident was admitted to the hospital on [DATE] at 10:10 a.m. -History and Physical Report on 8/24/16 revealed documentation the resident was released from the nursing home yesterday and fell last night at the (name of motel) hurting (the resident's) back. They waited until this morning, then called the ambulance, hurts in the high lumbar spine. (Resident 4) has had back pain before, but this was different and that it was more severe . (Resident 4) is a very poor historian. Seems to be slow mentally . The physical report assessed that the resident had an amputation on the right side below the knee. The Assessment recorded: New L1 (area of the lumbar spine) compression fracture intractable pain. - Radiology Report dated 8/24/16: Findings recorded: There appears to be loss of height at the L1 level consistent with a mild compression fracture. The fracture was not apparent on the previous study . - Hematology report on 8/24/16 revealed the resident's [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disorders) toxicology report discovered a reading of 32.6 ug/ml (micrograms of medication per milliliter of blood) and recorded the result as H (Higher than normal with normal range for the medication between 10 and 20 ug/ml). Observation of Resident 4 in the hospital on [DATE] at 12:15 p.m. revealed the resident was in a hospital bed and had an amputated right leg below the knee. Interview with Resident 4 on 8/29/16 at 12:15 p.m. verified the resident requested discharge to a family member's home on 8/22/16 and the facility discharged the resident and assisted with the transfer on 8/23/16. The resident verified directing staff to transport the resident to a motel instead of the family member's home and that the staff honored the request and assisted the resident checking in to the motel and then into the motel room. The resident stated after being left, the resident was uncertain if this would work out and requested the motel owner to get the resident to a nursing home. The resident was told to contact family member by the motel owner. Resident 4 stated having fallen and was in a lot of pain. After the family member arrived, the resident was taken to the hospital by ambulance. The resident confirmed the family member was not consulted regarding the discharge by Resident 4 or the facility prior to the discharge. Interview with facility NA (Nurse Aide)-C on 8/30/16 at 11:15 a.m. revealed NA-C worked with Resident 4 in assisting with the resident's daily needs. NA-C stated transferring the resident was problematic due to the resident's size and amputated leg. NA-C stated the resident had not used the prosthetic leg and refused transfers with a mechanical lift. NA-C was aware staff had been injured during transfer of the resident resulting in a Physical Therapy review. After the review, the resident began transferring from the w/c to the bed with the use of a slide board but for safety reasons, staff still needed to be present during these transfers to ensure a safe transfer. Resident did not always comply with this or use the call light. Interview with the facility PT (Physical Therapist) on 8/30/16 at 11:30 a.m. revealed the PT had worked with Resident 4 when admitted following a [MEDICAL CONDITION]. The resident was discharged from therapy in (MONTH) of (YEAR) due to lack of progress and refusal to continue. The resident was again seen 7/26/16 for a wheelchair evaluation. The PT recalled the resident being seen due to size and transfer problems, staff were getting injured with transfers. A transfer board was initiated and resident was transferring with this when discharged . The PT verified therapy was not consulted after 7/26/16 to assess the resident's transfer ability and safety to return to a home setting. The PT stated the evaluation would determine if the resident could safely transfer between surfaces, evaluate the home setting to determine if doorways could accommodate size and wheelchair size, evaluate if steps were there, evaluate how the resident would get in and out of bed and mobilize from room to room. Other consideration would be how the resident would get in and out of the home. Record review of Resident 4's therapy documentation revealed the following: -PT Therapist Progress & Discharge summary signed on 1/6/16 revealed the resident was discharged as a Long term resident due to a plateau in progress and lack of motivation to participate and assist with transfers. Pt (patient or Resident 4) is unable to ambulate and cannot stand for greater than 10 seconds due to a fear of falling/walking . PT has encouraged and educated the pt to participate and assist more with transfer in order for the pt to return to prior living environment . - OT (Occupational Therapy)- Therapist Progress & Discharge Summary signed on 1/7/16 revealed documentation the resident was morbidly obese individual with a BKA who has been struggling to make progress over past several weeks. Pt is now at 372 pounds with a goal of 350 pounds in order to be a candidate for a prosthesis . - Physical Therapy Plan of Care (Evaluation Only) dated 7/26/16- revealed therapy was referred to assess and acquire a wheelchair and evaluation of posture and positioning. The therapist documented resident was on therapy case in past year following a Right BKA and was discharged due to unwillingness to continue or participate. The resident returned for the evaluation expressing desire to return home and will require a w/c for mobility. The resident was discharged to the Skilled Nursing Facility with plans to return home, however was unable to fully indicate home environment and location. Record review of facility policies regarding transfers and discharges revealed the following: an updated policy of - Transfers and Discharges number SS-705. The Purpose of the policy read: Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and family in accordance with federal and state specific regulations. - Discharge/Transfer of the Resident procedure number CLIN1300-320 dated 1/26/15 revealed the procedure purpose was To provide safe departure from the facility and to provide sufficient information for after care of the resident. The Procedure included: Explain discharge procedure and reason to resident and give copy of Transfer & Discharge notice as required. Include resident representatives. Further instructions in the policy included: The attending physician is required to write a discharge order . When calling the attending physician for a discharge order, inquire whether or not the resident's medication is to be sent with the resident . include instructions for post discharge care and explain to the resident and/or representative . Interview with the facility DON (Director of Nursing) on 8/31/16 at 1:30 p.m. verified Resident 4 had multiple co-morbidities regarding the resident's medical status. Among these were Diabetes with Diabetic [MEDICAL CONDITION] and pain, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Chronic embolism/[MEDICAL CONDITION] history, and amputation of the right leg below the knee. The DON verified the resident had fallen five days prior to discharge using a transfer board independently, but was deemed by facility as independent to return to a home setting. The DON could not recall who specifically cleared the resident as safe for discharge and self transfers but said the administrative team discussed this. The DON confirmed the resident requested to go to a family member's home and the facility assisted with the transport without contacting the family member or determining if the family member's home could accommodate the special safety needs for the resident. The DON confirmed the physician nor the therapy department were consulted prior to the resident's discharge, regarding the discharge to determine if the resident had met the discharge safe transfer recommendation or if the resident was medically stable for discharge. The DON verified there was no documentation supporting whether the facility discussed diabetic needs, safety with [MEDICAL CONDITION] medications and monitoring labs, or any discussions regarding other medical needs with the resident or family. The DON verified the resident had a [MEDICAL CONDITION] disorder history and received daily doses of [MEDICATION NAME] for the [DIAGNOSES REDACTED]. The DON confirmed the family member was not consulted to assure the facility that the discharge to the family member's home would be safe and the resident's needs would be met. The DON confirmed the facility aided in the transport of the resident to a motel room which was not handicapped accessible without access to water or bathroom facilities and doorways capable of allowing the resident to exit the room in an emergency. Prior to the survey team exit on 8/31/16, the facility's Quality Assurance team convened and developed a plan of action to prevent re-occurrence of the violation and implement immediate changes regarding resident discharges. The plan included identifying all residents with active discharge plans and validating the environment being sent for discharge was safe before implementing the discharge. The plan provided education of facility transportation aides and the Social Service Director immediately and education to all staff on duty regarding discharge policy implementation. In addition the facility plan included assurance the physician or other interdisciplinary team members including therapy were notified of planned discharges and involved in consultation prior to the discharges. Due to these measures, the Immediate Jeopardy was abated and scope and severity lowered to a G. |
2019-08-01 |