| 83 |
CENTRO MEDICO WILMA N VAZQUEZ SNF |
405025 |
ROAD 2 KM 39 5 BO ALGARROBO |
VEGA BAJA |
PR |
693 |
2018-08-20 |
640 |
E |
0 |
1 |
1LG411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the required Minimum Data Set (MDS), Discharge assessment was encoded and transmitted for 12 of 12 residents reviewed, 11 unsampled and one sampled, (Resident (R)1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R84 when they left the care of the facility. Findings include: 1. Review of R1's EMR Summary revealed she had been admitted post left knee replacement on 12/08/17. According to her Discharge Notes she was discharged home with family present on 12/18/17. The MDS tab of R1's EMR listed an Entry Tracking assessment, dated 12/11/17, and an Admission MDS assessment, completed 12/12/17. The Admission MDS assessment indicated R1 expected to be discharged back to the community and discharge planning had been started (Section Q). There was no Discharge Assessment available in the EMR. 2. Review of R5's EMR Summary revealed she had been admitted post right knee replacement on 02/23/18. According to her Discharge Notes she was discharged home with family present on 03/02/18. The MDS tab of R5's EMR listed an Entry Tracking assessment, dated 02/23/18, and an Admission MDS assessment, completed 02/28/18. The Admission MDS assessment indicated R5 expected to be discharged back to the community and discharge planning had been started (Section Q). There was no Discharge Assessment available in the EMR. 3. Review of R11's EMR Summary revealed she had been admitted post left knee replacement on 04/06/18. According to her Discharge Notes she was discharged home with family present on 04/15/18. The MDS tab of R11's EMR listed no Entry Tracking assessment. An Admission MDS assessment was completed 04/10/18. The Admission MDS assessment indicated R11 expected to be discharged back to the community and discharge planning had been started (Section Q). She had a Non-PPS assessment dated [DATE] that was coded under A0310., section F) as Discharge assessment-return not anticipated. However Review of the ASPEN MDS Resident Viewer information revealed the resident was not listed for a Discharge MDS Assessment was submitted to the required national database. 4. Review of R3's EMR Summary revealed she had been admitted post right knee replacement on 03/22/18. According to her Discharge Notes she was discharged home with family present on 03/31/18. The MDS tab of R3's EMR listed an Entry Tracking assessment dated [DATE], and an Admission MDS assessment, completed 03/26/18. The Admission MDS assessment indicated R3 expected to be discharged back to the community and discharge planning had been started (Section Q). There was no Discharge Assessment available in the EMR. 5. Review of R8's EMR Summary revealed she had been admitted post right knee replacement on 03/15/18. According to her Discharge Notes she was discharged home with family present on 03/25/18. The MDS tab of R8's EMR listed an Entry Tracking assessment dated [DATE], and an Admission MDS assessment, completed 03/19/18. The Admission MDS assessment indicated R8 expected to be discharged back to the community and discharge planning had been started (Section Q). There was no Discharge Assessment available in the EMR. Review of the ASPEN MDS Resident Viewer information revealed none of the above residents had Discharge MDS Assessments submitted to the required national database. Interview on 08/20/18 at 12:20 PM with the MDS Coordinator revealed the facility was only able to show the MDS data submitted to the national database from (MONTH) (YEAR) to (MONTH) (YEAR). She could show where Discharge-return not anticipated MDS data had been done in the facility computer system, however she was unable to show where any MDS data had been submitted for the above residents. The MDS Coordinator was unable to explain why there were no Discharge Assessments submitted for those residents to the national database. 6. According to the facility electronic medical record (EMR) Profile, the facility admitted R2 on 02/19/18 and was discharged home on[DATE]. The MDS tab of the EMR listed a 5-Day MDS admission assessment, dated 02/25/18. The 5-Day admission assessment indicated R2 was expected to be discharged back to the community and discharge planning had been started (Section Q of the MDS). An 03/01/18 Progress Note indicated, Resident was discharged home with daughter. Review of R2's EMR revealed no evidence of a Discharge MDS assessment was completed or submitted. 7. According to the facility EMR Profile, the facility admitted R3 on 02/21/18 and was discharged home on[DATE]. The MDS tab of the EMR listed a 5-Day MDS admission assessment, dated 02/25/18. The 5-Day admission assessment indicated R3 was expected to be discharged back to the community and discharge planning had been started (Section Q). An 03/03/18 Progress Note indicated, Resident was discharged home with daughter. Review of R3's EMR revealed no evidence of a Discharge MDS assessment was completed or submitted. 8. According to the facility EMR Profile, the facility admitted R4 on 02/23/18 and was discharged home on[DATE]. The MDS tab of the EMR listed a 5-Day admission assessment, dated 02/27/18. The 5-Day admission assessment indicated R4 was expected to be discharged back to the community and discharge planning had been started (Section Q of the MDS). An 03/05/18 Progress Note indicated the, Resident was discharged home with spouse. Review of R4's EMR revealed no evidence of a Discharge MDS assessment was completed or submitted. 9. According to the facility EMR Profile, the facility admitted R6 on 03/06/18 and was transferred back to the hospital on [DATE]. The MDS tab of the EMR listed a 5-Day MDS admission assessment, dated 03/12/18, and a Non-PPS (Prospective Payment Systems) MDS assessment, completed 03/16/18. The 5-Day admission assessment indicated R6 was expected to be discharged back to the community and discharge planning had been started (Section Q of the MDS). An 03/16/18 Progress Note indicated, Resident was transferred back to hospital via ambulance. Review of R6's EMR revealed no evidence of a Discharge MDS assessment was completed or submitted. 10. According to the facility EMR Profile, the facility admitted R7 on 03/11/18 and was discharged home on[DATE]. The MDS tab of the electronic medical record listed a Non-PPS assessment, dated 03/19/18. that indicated R7 was discharged back to the community and discharge planning had been started (Section Q of the MDS). An 03/19/18 Progress Note indicated, Resident was discharged home with son. Review of R7's EMR revealed no evidence of a Discharge MDS assessment was completed or submitted. 11. According to the facility EMR Profile, the facility admitted R10 on 03/29/18 and was discharged home on[DATE]. The MDS tab of the EMR listed a 5-Day MDS admission assessment, dated 04/02/18, and a Non-PPS MDS assessment, completed 04/08/18. The 5-Day admission assessment indicated R10 was expected to be discharged back to the community and discharge planning had been started (Section Q of the MDS). An 04/08/18 Progress Note indicated, Resident was discharged home with son. Review of R10's electronic medical record revealed no evidence of a Discharge MDS assessment was completed or submitted. 12. Review of R84's EMR) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her MDS in the EMR revealed she had only had a 5-day assessment dated [DATE], a 14-day assessment dated [DATE], a 30-day assessment dated [DATE] and 90-day assessments dated 06/06/17, 09/06/17, and 12/06/17. She had no MDS assessment dated after 12/06/17. The assessments in the EHR were marked as complete in the facility's computer system however there was no indication they had been sent and were not present in the CMS system (in the surveyor's computer). On 08/20/18 at 12:40 PM the MDS Coordinator stated the MDS assessments in the computer system had never been transmitted to CMS and no MDS assessments were completed after 12/06/17 because the resident was not a Medicare resident. |
2020-09-01 |