cms_UT: 55
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 55 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 622 | D | 1 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving provider. Specifically, the resident's physician did not document the reason for discharge in the medical record. In addition, the receiving provider did not receive contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information to ensure a safe and effective transition of care. Resident identifiers: 124. Findings include: Resident 124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 124's medical record was reviewed on 5/21/19. an order for [REDACTED]. (Note: The temporary guardianship was to expire on 3/15/19.) A physician's orders [REDACTED]. A Social Service Note dated 2/24/19 at 12:04 AM, documented (Resident 124) is a [AGE] year old male with 'hx (history) alcohol and drug abuse' admitted [DATE] from (Hospital name) where he was taken 'after being found pulseless in asystole.' Hospital discharge notes indicate that (Resident 124) 'has been hospitalized since 12/21 with severe Korsakoff' and 'has very poor/no insight and is unable to care for himself long term.' Office of Public Guardianship appointed guardianship to act on resident's behalf. LCSW (Licensed Clinical Social Worker) met with (Resident 124) for welcome, information gathering, and review of resident rights and facility grievance policy. (Resident 124) was alert and oriented x (times) 3. His mood and affect seemed appropriate, short term memory and insight limited. He did not report (nor did he appear to be attending to) any internal stimuli. Current plan for discharge is unclear per resident's report. He indicates he 'has a job' and is ambivalent about 'staying in Utah or going back to California.' Social worker will address discharge planning during first IDT (interdisciplinary team) meeting. A Care Conference dated 2/28/19, documented . Resident states his ultimate goal is to d/c (discharge) to friend's home in Ogden. Guardian stated guardianship will expire d/t (due to ) not meeting criteria. A Social Service Note dated 3/5/19 at 3:16 PM, documented Spoke with (Deputy Guardian name) who needed M[NAME]A (Montreal Cognitive Assessment), BIMS (Brief Interview for Mental Status), and letter from DON (Director of Nursing) re: (regarding) capacity. Sent requested documentation and asked that (Deputy Guardian name) send a copy of court order if changes to guardianship order. A Social Service Note dated 3/12/19 at 11:31 AM, documented Spoke with guardian, (Deputy Guardian name). She said we are ok to discharge tomorrow 3/13/19. Called bishop who will try to be here for discharge in the morning at 10-11 am but will call to let us know if he can make it. A Discharge Summary note dated 3/13/19 at 11:09 AM, documented: Reason for DC (discharge) (Met Goals, Change of Condition, etc.): Patient met goals discharge date : 3/13/19 Discharge Time: 1100 (11:00 AM) Discharge Location: Ogden with Friend (name of friend) Transported by: (name of friend) (friend) Home Health/hospice agency (specify agency if applicable): N/a (not applicable) Order Summary sent & (and) signed with resident/responsible party: Yes Medications sent with resident/responsible party: All medications including narcotics signed by resident. Resident left with all personal belongings: Yes Resident verbalized understanding of discharge education: Yes Follow with PCP (primary care physician) scheduled? (if no, educate resident to schedule): Resident knows to schedule an appointment A physician's orders [REDACTED]. On 5/21/19 at 12:56 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 124 wanted to go home. RN 1 stated that resident 124 was in a lot of pain and had spoken to the Nurse Practitioner (NP) regarding his pain. RN 1 stated that when the NP suggested that resident 124 go to a pain clinic resident 124 refused. RN 1 stated that resident 124 would request to go to the emergency room but did not have a reason to go to the emergency room . RN 1 stated that she had heard from other staff that resident 124 did not qualify to be at the facility. RN 1 stated that she was the nurse that completed the discharge for resident 124 and she was under the impression that it was a last minute discharge. RN 1 stated that she did not get a physician's orders [REDACTED]. RN 1 further stated that she printed out resident 124's Order Summary Report so he was able to self administer his medications after discharge. On 5/21/19 at 1:39 PM, an interview was conducted with the LCSW. The LCSW stated that resident 124's plan since admission was to discharge home with the bishop. The LCSW stated that when a resident was admitted to the facility she would complete a discharge assessment and planning, discuss barriers, and anticipation of needs. The LCSW stated that resident 124 was not sure where he was going to go when discharged but she had been speaking with resident 124's bishop about discharge. The LCSW stated that resident 124 did not have a lot of options for discharge. The LCSW stated that when a resident has limited options she will complete applications for housing with the resident. The LCSW stated that she was not sure if resident 124 would have qualified for an Assisted Living Facility so she did not submit the New Choice Waiver application for resident 124. The LCSW stated that the Physician would always get involved with a resident discharge. The LCSW stated that she had a discharge packet that she would complete for the nursing staff that will include physician's orders [REDACTED]. The LCSW stated that she was not sure that the Physician completed an order for [REDACTED]. The LCSW stated that she was still trying to learn her job. On 5/21/19 at 3:04 PM, an interview was conducted with the Minimum Data Set (MDS) coordinator. The MDS coordinator stated that resident 124's cognition had a significant improvement from the day of hospital discharge until a few days after admission. The MDS coordinator stated that she thought resident 124 would qualify for long term care after reviewing the hospital records. The MDS coordinator stated that resident 124 was so impaired, she thought he would be long term. The MDS coordinator stated that a M[NAME]A was completed on resident 124 at the facility and resident 124 scored 26 out of 30 which was showing normal ranges. The MDS coordinator stated that resident 124's Korsakoff's was related to alcohol and he recovered quite fast. The MDS coordinator stated that on going dementia was anticipated with resident 124's condition. The MDS coordinator stated that resident 124 was very high level functioning, required very little therapy, and Speech said there was nothing they could do with him. The MDS coordinator stated that with resident 124's high level functioning he was not meeting Long Term Care criteria. The MDS coordinator stated that resident 124 did not want to be at the facility and he did not qualify to be at the facility. The MDS coordinator stated that there was not much the facility could do for resident 124 and he was homeless prior to his most recent hospital stay. The MDS coordinator stated that the staff were trying to figure out a safe plan for discharge. The MDS coordinator stated that a friend of resident 124's agreed he could come home with him. The MDS coordinator further stated that the weekend prior to discharge resident 124 tried to leave the facility and stated that he wanted to leave. The MDS coordinator stated that the staff on Monday set up the discharge for resident 124. The MDS coordinator further stated that unfortunately, there was no other discharge documentation that could be provided. The MDS coordinator stated that sometimes there were extra documents, but in this case there was not. On 5/22/19 at 11:13 AM, an interview was conducted with the DON. The DON stated that the LCSW would bring her a list of residents who will be discharging and the MDS coordinator will issue the resident Notice of Medicare Non-Coverage forms. The DON stated that the staff will usually notify the Physician, obtain discharge orders, and the Physician will agree if the discharge was safe from a medical standpoint. The DON stated that after the morning standup meetings the staff will review residents that were going to be discharged . The DON stated that every member of each discipline team would need to agree that the discharge was safe. The DON stated that resident 124 was not reviewed in the morning standup meeting because because it was implemented after resident 124 discharged from the facility. The DON stated that resident 124's cognition was much greater than what the hospital paperwork lead her to think. The DON stated that therapy gave the okay to discharge and she knew that resident 124 was okay medically. Additional documentation provided by the LCSW on 5/22/19, included email correspondence between the LCSW and OPG Deputy Guardian. On 3/12/19 at 9:33 AM, LCSW documented . Does this mean that we are okay to discharge (Resident 124) (even if court order is not finalized)? . On 3/12/19 at 10:33 AM, Deputy Guardian documented . You can discharge tomorrow. That's when the guardianship expires. (Note: an order for [REDACTED]. The temporary guardianship was to expire on 3/15/19.) | 2020-09-01 |