cms_TN: 3396
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3396 | NASHVILLE CENTER FOR REHABILITATION AND HEALING LL | 445512 | 832 WEDGEWOOD AVENUE | NASHVILLE | TN | 37203 | 2018-12-20 | 661 | D | 1 | 0 | E5NC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to ensure 3 of 11 residents reviewed (#10, #18, and #20) were provided a post discharge plan of care. Additionally, the facility failed to develop a discharge summary for Resident #18. See F622 (Discharge) and F660 (Discharge Planning), for additional information regarding Resident #10. The findings include: Review of facility policy, Discharge Planning, undated, .Development of Discharge Plan .Social Services/designee will coordinate the obtaining of the required information from the Care Plan Team members to include .Current functional status and needs (from each discipline) .Progress notes and any subsequent revisions to the Discharge Plan to be recorded by all disciplines .Social services/designee and the care plan team will make an evaluation of alternate levels of care available, outside support systems available, and factors impacting on the continuous, uninterrupted needs of the resident . The policy did not address the importance of the involvement of the resident and/or their representative in the development of a post discharge plan of care. Medical record review of the Admission Record, revealed Resident #10 was admitted to the facility on [DATE] with dianoses of Altered Mental Status, Metabolic [MEDICAL CONDITION] (abnormal levels of electrolytes, water, and vitamins that possibly affect brain function), muscle weakness, and difficulty walking. Review of the 14 day Admission (MDS) data set [DATE] revealed a Brief Interview for Mental Status score 3 of 15 indicating she was severely cognitively impaired. A comprehensive review of the medical records revealed there was no documented evidence Resident #10, or her representative was provided a post discharge plan of care that was developed with the resident and/or her representative. Interview with the Administrator, Director of Social Services, Rehabilitation Director #109 and the Physical Therapist #112) revealed Director of Social Services stated there was a baseline care plan for Resident #10 and he/she would need to check with nursing if there was a post discharge plan of care for this resident. No further documents reflecting a discharge plan were ever provided to the SSA prior to exit from the facility. Medical record review of the Admission Record revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a social Servicces evaluation completed on 10/9/18 noted Resident #18's Brief Interview for Mental Status score was 6 out of 15 which indicated he was severely cognitively impaired. Interview with the interim Director of Nursing (DON) #11 on 12/20/18 at 4:02 PM confirmed there was no discharge summary completed by nursing for Resident #18, no documentation from the medical provider to address the stay of the resident and no post discharge plan of care for the resident. Interview with the interim DON #11 on 12/20/18 at 4:23 PM, revealed she stated an agency nurse was the person who opened the discharge summary and did not complete it for Resident #18. She confirmed there was no discharge summary, or a post discharge plan of care developed for this resident. Resident #20 was admitted on [DATE] with [DIAGNOSES REDACTED]. She was discharged on [DATE]. Medical record review of a care plan, last revised on 8/24/18, revealed Resident #20's placement in the facility was short term. The interventions included Assist with obtaining DME (durable medical equipment) and medical supplies prior to discharge. Educate resident and/or designated representatives about community resources. Facilitate discharge planning with all disciplines via CCP {Coordinated Care Plan) meeting. Identify resident support in community. Make appropriate referrals as needed i.e.(including) homecare. Provide resident and/or designated representatives with teachings as needed i.e. (including) medications, diet, wound care, adaptive equipment. Provide support and counseling re: (regarding) discharge concerns. Social Worker will meet resident and/or designated representatives to identify needs for discharge. Medical record review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #20's Brief Interview for Mental Status (BIMS) was 6 out of 15, indicating she had severe cognitive impairment. She required extensive assistance with bed mobility, transfers, dressing, eating, hygiene and toilet use. She required total assistance with bathing. Medical recod review of Resident #20's Discharge Summary, dated 9/19/18, revealed the resident was discharged home and [NAME] Discharge Instructions: 1. Discharge Instructions Provided. Medical record review of a Progress Note dated 9/19/18, revealed Resident #20 was discharged home with her daughter, no documentation the resident/family had been adequately prepared for discharge back to the community, and no documentation of referrals to home health services as recommended by physical therapy. Review of the Physical Therapy Discharge Summary, signed on 9/21/18, revealed the discharge recommendations included home health and assistive device for safe functional mobility and assistance with activities of daily living. Medical record review revealed there was no post-discharge plan of care or discharge instructions. There were no social work progress notes to indicate the social worker had met with the resident and/or family to identify needs for discharge. Interview with the Administrator on 12/20/18 at 5:40 PM, confirmed there was no post-discharge plan of care or discharge instructions given for Resident #20. Interview with Registered Nurse Manager #23 on 12/20/18 at 5:48 PM, revealed she was familiar with the resident and family. She stated she had provided discharge instructions and referrals to home care and confirmed she was unable to provide a copy of the post-discharge plan of care or discharge instructions. | 2020-09-01 |