| 57 |
MT OLYMPUS REHABILITATION CENTER |
465006 |
2200 EAST 3300 SOUTH |
SALT LAKE CITY |
UT |
84109 |
2019-05-23 |
661 |
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 that anticipates discharge did not have a discharge summary that included a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent laboratory, radiology, and consultation results. Specifically, a resident did not have a complete discharge summary that included a post discharge plan 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. 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 Transfer/Discharge Report dated 3/13/19, documented the following information: a. Resident Information: Resident Name, Unit, Room/Bed, admitted , Resident number, Sex, Birthdate, Age, Marital Status, Religion, Primary Language, Medicaid number, and Social Security number. b. Other Information: allergies [REDACTED]. c. Primary Contact: Name and Relationship. d. Primary Physician: Physician e. Diagnoses: [REDACTED]. f. Last Vital Signs: Blood pressure dated 2/24/19, Pulse dated 2/28/19, Temperature dated 2/18/19, and Respirations dated 2/28/19. (Note: The Transfer/Discharge Report did not include a recapitulation of resident 124's stay at the facility, a final summary of the resident's status, and discharge plan of care. A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another.) 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 Licensed Clinical Social Worker (LCSW). The LCSW stated that she had a discharge packet that she would complete for the nursing staff that would 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 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. The MDS coordinator stated that resident 124 did not have a complete discharge summary and a physician's orders [REDACTED]. On 5/22/19 at 11:13 AM, an interview was conducted with the Director of Nursing (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 the 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 it was implemented after resident 124 discharged from the facility. |
2020-09-01 |