| 3 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2020-01-16 |
661 |
E |
1 |
0 |
WQZY11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop detailed Discharge Summaries (to include overviews of resident stays at the facility and a final summary of resident statuses at the time of discharge) for 3 (R #'s 1, 2 and 3) of 3 (R #'s 1, 2 and 3) residents reviewed for discharging home. This deficient practice has the potential to prevent residents from receiving adequate care from home health agencies and primary care physicians due to being uninformed, which could result in resident goals and needs not being met as well as readmittance to a nursing facility. The findings are: Findings for R #1: [NAME] Record review of R #1's admission record revealed that R #1 was admitted to the facility on [DATE]. B. Record review of R #1's progress notes revealed that R #1 was discharged home on[DATE]. C. Record review of the facility's Discharge Summary and Plan policy revised (MONTH) (YEAR) stipulates: 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, intermediate care facility for individuals with intellectual disabilities, etc.) a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. 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 (including any history of mental disorders and intellectual disabilities); c. Course of illness, treatment and/or therapy since entering the facility; d. Current laboratory, radiology, consultation, and diagnostic test results; e. Physical and mental functional status; f. Ability to perform activities of daily living including: (1) bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems; (2) the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; and (3) the ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility. 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: (1) weight and height; (2) nutritional intake; and (3) eating habits, preferences and dietary restrictions. i. Special treatments or procedures (treatments and procedures that are not part of basic services provided); j. Mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators 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 (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of dentures or other dental appliances); m. Activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); n. Rehabilitation potential (the ability to improve independence in functional status through restorative care programs); o. Cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and 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). 3. 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. On 01/14/20 at 10:50 am, during an interview, the Director of Nursing reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #1; however all discharges are discussed during the Daily Stand-Up Meeting and the resident names are documented under the Discharges Yesterday or Planned Discharges This Week sections of the Daily Stand-Up Meeting form. E. On 01/14/20 at 12:30 pm, the Social Services Director reported that the Dr./Medical Director tries to complete a Discharge Summary on all residents that discharge, but he does not always get the opportunity to do so. The SSD reported that she recently started providing the Physicians' Assistant (PA) with a list of upcoming discharges. The SSD reported that the list is titled Notification of Discharges and is provided to the PA on weekly basis. The SSD reported that they are working on tightening up (improving) their process (for discharging residents). The SSD reported that they do not have a Discharge Summary on file for R #1. F. On 01/14/20 at 1:14 pm, during a telephonic interview, R #1's wife reported we were very unhappy with the service, we received at (name of the nursing facility) for my husband. She reported we decided to bring him (R #1) home, because it didn't seem like he was getting a lot of help at (name of the nursing facility) and he appeared to be getting weaker. R #1's wife reported that he left the faciity on [DATE] and by the time they made the short drive home, R #1 was weak and so out of it mentally. She reported that when they arrived home, she had to ask her neighbor to help her get R #1 out of the car. R #1's wife reported he (R #1) spent the rest of the day in his lounge chair knocked out and when the neighbor came over to check on us, he called 911 right away. He (R #1) was hospitalized for [REDACTED]. R #1's wife reported that she does not recall receiving any discharge paperwork from the facility. [NAME] On 01/14/20 at 3:17 pm, during a telephonic interview, the office of R #1's primary care physician reported that they did not receive a Discharge Summary for R #1 from the facility upon discharge on 08/09/19. H. On 01/15/20 at 11:07 am, during an interview, the SSD reported that the following documents were provided to the home health agency for R #1 upon discharge: Dr's Discharge Orders, Admission Record, Order Summary Report, Dr's Progress Note for date of service 07/12/19, Physical Therapy Progress Reports for 07/19/19 - 07/25/19 & 07/26/19 - 08/01/19, Physical Therapy Treatment Encounter Notes for 07/22/19 - 07/24/19 & 07/30/19 - 08/01/19, Occupational Therapy Progress Reports for 07/19/19 - 07/25/19, & 07/26/19 - 08/01/19, Occupational Therapy Treatment Encounter Notes 07/19/19 - 07/25/19 & 07/26/19 - 07/31/19, Speech Therapy Progress Report for 07/23/19 - 07/29/19 and Speech Therapy Treatment Encounter Notes 07/23/19 - 07/26/19. I. On 01/15/20 at 11:17 am, during an interview, the SSD reported the only thing we provide to residents upon discharge is a Transfer/Discharge Report, but we did not provide one to (first name of R #1) upon discharge. [NAME] On 01/15/19 at 5:04 pm, during a telephonic interview, the office of the home healthcare agency reported that R #1 never started services with their agency and therefore they did not receive any discharge paperwork from the facility for R #1. Findings for R #2: K. Record review of R #2's admission record revealed that R #2 was admitted to the facility on [DATE]. L. Record review of R #2's progress notes revealed that R #2 was discharged home on[DATE]. M. Record review revealed no detailed Discharge Summary on file for R #2. N. On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #2. O. On 01/14/20 at 12:30 pm, during an interview, the SSD reported that they do not have a Discharge Summary on file for R #2. P. On 01/15/20 at 11:07 am, during an interview, the SSD reported that the following documents were provided to the home health agency for R #2 upon discharge: Dr's Discharge Orders, Admission Record, Dr's Progress Note for date of service 08/30/19, Physical Therapy Progress Report for 09/06/19 - 09/12/19, Physical Therapy Treatment Encounter Notes 09/07/19 - 09/12/19, Occupational Therapy Progress Report for 09/06/19 - 09/11/19 Occupational Therapy Treatment Encounter Notes 09/06/19 - 09/11/19 and Order Summary Report. Q. On 01/15/20 at 11:17 am, during an interview, the SSD reported that a Transfer/Discharge Report was provided to R #2 upon discharge. The Transfer/Discharge Report contained the following information: Resident Name, admitted , Resident No., Sex, Birthdate, Age, Marital Status, Religion, Primary Language, Medicare Beneficiary ID, Social Security #, Secondary Insurance ID, Medicare Advantage #, allergies [REDACTED]. The SSD reported there is nothing else provided to the residents upon discharge. R. On 01/15/20 at 3:48 pm, during a telephonic interview, the office of the home health agency reported that the facility did not provide an Order Summary Report or Discharge Summary for R #2 upon discharge. Findings for R #3: S. Record review of R #3's admission record revealed that R #3 was admitted to the facility on [DATE]. T. Record review of R #3's progress notes revealed that R #3 was discharged home on[DATE]. U. Record review revealed no detailed Discharge Summary on file for R #3. V. On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #3. W. On 01/14/20 at 12:30 pm, during an interview, the SSD reported that they do not have a Discharge Summary on file for R #3. X. On 01/14/20 at 3:36 pm, during a telephonic interview, the Receptionist at R #3's primary care physicians office reported that they did not receive a Discharge Summary for R #3 upon discharge. Y. On 01/15/20 at 11:07 am, during an interview, the SSD reported that the following documents were provided to the home health agency for R #3 upon discharge: Dr's Discharge Orders, Admission Record, Dr's Progress Notes for date of services 09/24/19 & 09/09/19, Physical Therapy Progress Reports for 09/12/19 - 09/18/19 & 09/23/19 - 09/29/19, Physical Therapy Treatment Encounter Notes 09/12/19 - 09/17/19 & 09/23/19 - 09/27/19, Occupational Therapy OT Evaluation & Plan of Treatment certification period 10/01/19 - 11/29/19 and Order Summary Report. Z. On 01/15/20 at 11:17 am, during an interview, the SSD reported that a Transfer/Discharge Report was provided to R #3 upon discharge. The Transfer/Discharge Report contained the following information: Resident Name, admitted , Resident No., Sex, Birthdate, Age, Marital Status, Religion, Primary Language, Medicare #, Medicaid #, Social Security #, Secondary Insurance ID, allergies [REDACTED]. The SSD reported there is nothing else provided to the residents upon discharge. A[NAME] On 01/15/20 at 3:48 pm, during a telephonic interview, the office of the home health agency reported that the facility did not provide an Order Summary Report or Discharge Summary for R #3 upon discharge. |
2020-09-01 |