| 76 |
LAS VEGAS POST ACUTE & REHABILITATION |
295006 |
2832 S. MARYLAND PARKWAY |
LAS VEGAS |
NV |
89109 |
2017-05-04 |
250 |
D |
1 |
1 |
XLYQ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and document review, the facility failed to provide necessary Social Services to 1 of 15 sampled residents for a Public Guardian (Resident #5); failed to provide appropriate discharge planning for 1 of 15 residents (Resident #15); and failed to ensure a referral was completed per a physician's orders [REDACTED].#16). Findings include: Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Record of Admission documented the resident had no next of kin and the resident was the responsible party. A Neuropsychological consultation dated 12/20/16, documented the resident's performance on the Mini-Mental State Exam (MMSE), a measure of basic cognitive functioning, was in the moderately impaired range. The resident was diagnosed with [REDACTED]. The Minimum Data Set (MDS)Annual Resident Assessment and Care Screening dated 12/26/16 documented the resident scored 1 on the Brief Interview for Mental Status (BIMS) Summary Score. On 5/3/17 at 2:00 PM, the Director of Social Services explained a BIMS score of 1 meant the resident was alert and oriented times 1 and had poor short and long term memory. An evaluation by the Director of Social Services dated 12/26/16, documented the resident's cognition was severely impaired as evidenced by a BIMS score of 1. A Psychiatric consultation dated 1/2/17 documented the resident's memory appeared significantly impaired. The resident was alert and oriented times 1 to person, but not to place, time or situation. The resident was diagnosed with [REDACTED]. The resident's clinical record lacked documented evidence of a Public Guardianship referral. A consent for admission and treatment form revealed two facility staff members signed as witnesses for the resident on 12/19/16. The resident's signed the consent form on 12/28/16. On 5/4/17 at 11:30 AM, the Director of Nursing (DON) confirmed the resident was cognitively impaired on admission. The DON confirmed the consent to admit and treat should not have been signed by the resident. The DON explained the facility's process was to obtain a physician's orders [REDACTED]. On 5/3/17 at 2:00 PM, the Director of Social Services reported the resident had no family at the time of admission. The Director indicated the resident should have had a referral for a public guardian. On 5/3/17 at 3:20 PM, the Director of Social Services confirmed an application for the resident's public guardianship was not completed at the time of the resident's admission. Review of facility policy entitled Resident Rights-Incompetency (undated) documented after thorough assessment of a resident's incompetency, Social Services would apply for Guardianship. Resident #15 Resident #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to a group home. The policy, Discharge Summary and Plan, dated 11/2014, documented when the facility anticipates a resident's discharge to a private residence, another nursing care facility. -The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. -The post discharge plan would be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family. -A copy of the post discharge plan and summary would be filed in the resident's clinical record. The resident's clinical record lacked documented evidence of a completed discharge summary and a copy of the post discharge plan and summary. The Interdisciplinary Discharge Summary form, dated 9/27/17 had an area on the form to document the following: -The treatment provided. -The progress and the reason for discharge/discharge diagnoses. -Assistive devices the resident required -The drug therapy required. All of these areas were left blank or not completed. A nurses note dated 9/27/16 documented the resident was discharged to a group home, discharge instructions were given and verbalized understanding. On 5/4/17 at 9:40 AM, the Director of Nursing (DON) explained any discharge planning and discharge summary documentation should be in the resident's closed clinical record. On 5/4/17 at 10:45 AM, the Social Worker explained the discharge summary documents would be in a binder in the office. All discharge planning should be documented in the resident's clinical record. The Social worker could not locate the completed documentation of the resident's discharge including: -A recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. -The post discharge plan developed by the care planning/interdisciplinary team with the assistance of the resident and family, including the resident's preferences, how care should be coordinated if continuing treatment involves multiple caregivers, identify specific needs after discharge (ex. personal care, sterile dressings and physical therapy etc) and how the resident needs to prepare for the discharge. On 5/4/17 at 12:30 PM, the Medical Records Assistant could not locate the completed discharge documentation for the resident. Resident #16 Resident #16 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. The current facility was not meeting the resident's needs. The resident's clinical record lacked documented evidence a referral was made to a facility located in California or documented evidence a referral was made to a long term care facility in accordance with the physician orders On 5/4/17 at 1:45 PM, the Social Worker explained she did not see the physician order [REDACTED]. Complaint # and Complaint # |
2020-09-01 |