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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4016 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 520 | F | 1 | 0 | WA6612 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observations, record reviews and staff interviews, the facility's Quality Assurance process failed to identify compliance issues and develop and implement appropriate plans of action to correct those deficient practices once they had been identified. The revisit survey found the facility had failed to identify and correct deficient practices identified and cited during the annual survey of 03/00/17. The facility's Quality Assurance process had failed to identify those issues with respect to which quality assessment and assurance activities were necessary, and the facility's Quality Assurance process subsequently failed to develop and implement appropriate plans of action to correct those quality deficiencies once they had been identified and cited. Seven (7) of twenty-five (25) deficient practices cited during the annual survey of 03/01/17 were found to remain out of compliance during the revisit survey. This had the potential to affect all residents. Facility census: 55. Findings include: a) The facility failed to operationalize its policies and procedures for training new employees regarding abuse/neglect. Eleven (11) nursing staff members on Unit 3, and the Housekeeping, Dietary, and Maintenance Departments were not included in abuse reporting and sexual abuse training. 1. Abuse Reporting/Sexual Abuse Training On 06/12/17 at 11:07 a.m., after a review of the P[NAME] which stated, Staff have been reeducated on policies and procedures of abuse reporting and notification of changes on 3/2/17 through an outside consulting firm and/or Social Service worker, with all staff having completed reeducation by 4/26/17. Any staff on leave of absence will have reeducation by the Social Worker/designee prior to performing any work duties. A continuing review of the P[NAME] revealed eleven (11) nursing staff members (Employees #110, #109, #105, #101, #100, #95, #68, #64, #63, #103, and #121) who work on the Third Floor (an acute care floor) did not attend the in-service regarding abuse reporting and sexual abuse. In addition, there was no evidence the Housekeeping/Dietary/Laundry/Maintenance Departments attended the in-services. In an interview with the Nursing Home Administrator (NHA) on 06/12/17 at 10:31 a.m., when asked if the Third Floor nursing staff were utilized at times to assist with staffing on the First and Second floors, the NHA responded Yes. When asked were the Third Floor staff and the support departments included in the abuse training, the NHA responded in very loud voice, Were we supposed to? On 06/12/17 at 2:01 p.m., when asked about the participation of the Housekeeping Department in the Abuse Reporting/Sexual Abuse in-service, the Housekeeping Manager stated she was not sure and would investigate to see if the department had attended the in-services. On this same date at 2:25 p.m., the Housekeeping Manager provided a written statement which stated, No abuse inservicing was done for my department. b) All rooms cited in the original survey for failure to maintain a sanitary, orderly, and comfortable interior were inspected accompanied by Administrator, #79 and maintenance personnel #39 on 6/8/17 at 10:00 a.m. Rooms #204 and #26 were not in compliance. room [ROOM NUMBER] had an unsecured covering under the sink in the resident room hanging partially open revealing dust and grime in the rectangular opening. room [ROOM NUMBER] had missing cove molding at the base of the wall between the entry door and the bathroom door. The observations were confirmed by maintenance personnel #39 during the tour. c) The facility failed to ensure psychiatric services were provided to residents with diagnosed mental/psychological disorders and failed to ensure those residents received the appropriate treatment/services to manage assessed problems and emergent behavioral occurrences. In addition the facility failed to ensure staff were provided with guidance regarding identification of triggering events, dealing with escalating behaviors, and interventions to deal with the behaviors of the residents individually. The facility failed to ensure psychiatric services were provided timely and of sufficient frequency to promote the highest practicable level of well-being of the residents. These issues were identified for three (3) of three (3) residents reviewed for psychiatric services. : 1. Resident #83 Review of the medical record on 06/05/17 at 2:18 p.m. revealed this resident was admitted from a neighboring community hospital psychiatric unit to this facility on 04/03/17. His [DIAGNOSES REDACTED]. Physical outbursts. Poor judgment and disinhibition), [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality resulting in hallucinations and delusions. This can also include violence and aggression toward oneself or others), anxiety disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Current medications included [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITIONS] disorder and depression) 50 mg by mouth (po) at bedtime, [MEDICATION NAME] (diuretic medication) 20 mg po twice a day and Klonopin (a benzodiazepine/sedative medication used to treat panic attacks, convulsions and [MEDICAL CONDITION]) 1 mg po twice a day. Resident #83 had been receiving the medication [MEDICATION NAME] on admission, but it had been discontinued on 05/25/17. Review of the psychiatric consults found Physician #115 had visited Resident #83 on 04/20/17. -- A follow-up visit on 05/18/17 under the title Subjective/Objective(typed as written): (Resident #83 name) was seen briefly for follow-up. He has thus far done well but reportedly is a little less tolerant of the disruptive behaviors exhibited by other residents, particularly in the evening when sundowning become a problem. He is of course unable to speak with any real insight about such events in retrospect due to his dense anterograde amnesia. Under the title Plan (typed as written): For now, no treatment changes are required. -- A visit dated 05/25/17 under the title Subjective/Objective(typed as written): Agitation and irritability are reported to have increased but by staff reports this remains largely confined to evening sundowning hours during which other residents tend to become loud, agitated and intrusive. While their behavior tends to agitate him, he is observed to be reasonably kind and supportive of older impaired co-residents . Under the title Plan (typed as written): No treatment changes. Employee #Z commented during a confidential interview that Resident #83, ' .is about to explode.' His behaviors are increasing and you can see the anger in his face. The psychiatrist nor behavioral services are doing anything for him, neither are they advising or recommending interventions for the staff to use to deal with his behaviors which he has had since admission. He (Resident #83) pulled the fire alarm today and when asked about it, he (Resident #83) stated you are not doing anything for me here. Employee #Z stated, It is really terrible when the resident who has mental illness can recognize that he is not getting the treatment he needs or deserves. He is younger than our other residents and a big man that could hurt either himself, other residents or staff. After review of consult reports by Physician #115, Physician #W agreed and verified during a confidential interview that the psychiatric consults under the title: Plan, .Do not constitute a plan because it does not contain recommendations to deal with the behaviors, nor does it provide guidance for the staff as far as what to watch for that may cause behaviors or what to do to if behaviors happen for the staff or attending physician, nor does it provide when or how often the resident will be seen and what the goal of the therapy will be, this should be included with all consult reports. Physician #W stated, I know these issues have been addressed with (Physician #115's name), but as far as addressing the residents as a whole for their psychiatric services they are not being met at this time, it is a work in progress. (Physician #129's name) is at this facility one day a week to see the residents and he is a very busy man. When asked if residents were receiving the services and treatment from behavioral services/psychiatrist that they needed or deserved, Physician #W just looked away and did not reply. On 06/13/17 at 10:45 a.m., Resident #83 sat outside in the courtyard of Nursing Care Facility (NCF) 1 with Employee #75. The Nursing Home Administrator (NHA) went outside and Employee #75 returned to the unit. Also at that time, a Police officer was at the nurses' station speaking with nurses. Visitors were observed using the courtyard as an entrance to the unit in full view of the situation. Immediately after this observation Employee #V reported Resident #83 was having a psychotic break with paranoia, threatening to blow himself and the facility up, and if he had a gun to shoot himself. Resident #83's attending Physician ordered for the police to be called due to the threatening behavior. When asked whether behavioral service or his psychiatrist were involved, Employee #V stated, Are you kidding? It is not the psychiatrist's day to visit the facility and the nurse phoned Behavioral Services and had to leave a message, but they never called back and they won't because there is no help from Behavioral Services even in an emergency. This has happened in the past, not with this resident, but other residents and we are on our own with no help. The sad thing is that any direction that you go out of town there are psych hospitals and facilities that could care for him and provide services and treatment if he (Resident #83) can't get what he needs here, but none have ever been contacted. At 11:35 a.m., Employee #Z commented the resident had a psychotic break and his attending physician instructed the nurse to call the police due to the threatening behavior and to get him out of here to a psychiatric facility designed to take care of this type of behavior and protect the other residents and staff. The employee commented, This has been ongoing since 9:45 a.m. with no resolution. The psychiatrist will not be here until this evening because it is not his day to visit the facility. The Police and Magistrate would do nothing because the facility has in-house psychiatric services so the Police left. Behavioral Services was called and had to leave a message that we had an emergency situation, but they have never responded in the past and they are no help to us even though it is said we have in-house psych services. We cannot get him (Resident #83) inside to try to get him to the emergency department (ED) .we are afraid he will really snap. At 11:40 a.m., a nurse was overheard telephoning the attending physician and notifying him of the continued situation. The nurse received orders for [MEDICATION NAME] (an antipsychotic medication) 5 mg IM (intramuscularly) now, obtain laboratory tests if possible and then transfer to the ED (emergency department) to attempt emergency transport to another facility to provide psychiatric services. At 12:06 p.m. Resident #83 was escorted inside the facility to his room in his wheelchair by the NHA, according to Employee #112 without receiving the medication [MEDICATION NAME] due to being cooperative at this time. An observation of Resident #83 at 1:05 p.m. found him sitting in a wheelchair in his room with his roommate present and no staff monitoring in or outside of his room. During an interview with the NHA on 06/13/17 at 1:47 p.m., when asked whether there was a contract between the facility and behavioral health services, she reported, There is no contract between behavioral health services and the nursing care facility. They are the same entity and provide services whenever needed. It is the same as the hospital providing laboratory or x-ray services or emergency room services, same building same family. Continued medical record review on 06/13/17 at 2:10 p.m. revealed the resident's care plan contained on the date 05/20/17 the resident (typed as written), outside next to ER (emergency room ) dept. (department) for just a few minutes before staff found him next to guardrail. ER dept. called nurse. On the same date (typed as written), Found on elevator by 3rd floor staff stated he was looking for his wife Also on the same date (typed as written), the resident made statements such as, If I had a gun I would shoot myself--staff to be aware and monitor-provide emotional support-redirect . On 05/31/17 it was documented the resident had agitation. Interventions include, staff to monitor if his hallucination/paranoia impose a danger to himself or other residents/intervene/redirect/provide safety . Assess if resident's behavioral/mood symptoms present a danger to the resident and/or others. Intervene as needed. Notify MD (Medical Doctor) as needed . Resident to have appointments with (name of Physician #115) as needed/scheduled Review of the nursing progress notes dated 06/13/17 at 9:45 a.m. found (typed as written): Resident self propelled into courtyard and continued to gate. CNA's (nurse aide) along with nurse went to courtyard to attempt to have resident come inside. Resident told staff to open the gate that he was leaving. (Name of resident) then swung at both male CNA and cursed at them to leave. Nurse gave ok to the CNA's to back away and began talking to him. Resident was rambling about using cologne (which was in his hands) to burn everyone. When asked to come inside due to high temperatures (name of resident) replied that he wanted it to be 150 million degrees so that he would blow up. He then pulled his pressure alarm apart and threw the box across the yard At 9:50 a.m. (typed as written), .(name of attending physician) came down and spoke with him (Resident #83) and he then threatened him (attending physician) .(name of attending physician) gave order to call police to take to hospital . At 10:08 a.m. (typed as written): Police stated that they are unable to subdue this resident. Sheriff's dept. (department) has that responsibility only after papers have been filed with a magistrate to obtain a mental hygiene At 10:15 a.m. (typed as written): (name of attending physician) present states that resident needs to be sent to psych for eval. (evaluation) and that he is not to return here r/t (related to) unable to meet his needs At 10:16 a.m. (typed as written): Call placed to behavioral medicine for (name), psychologist to come and speak with resident. No answer at her office. A voicemail message was left. At 10:19 a.m. (typed as written): .Labs to be sent to (name of hospital in neighboring town) for clearance to be admitted to psych floor. At 12:05 p.m. (typed as written): Attempted to contact Behavioral med. (medicine) regarding resident acute [MEDICAL CONDITION] to request (name of Psychiatrist #115) services. Behavioral med. returned call (name of psychiatrist) not at this facility until 06/15/17 During a confidential interview, Employee #Z reported, Resident #83 went to the ER and was there between 1547 (3:37 p.m.) to 1930 (7:30 p.m.). His labs (laboratory tests) were ok and he was cleared to send to another facility but no facility would accept him. (Name of Medical Director and head of ER) was involved and even calling facilities. He was medicated in the ER and has been 1:1 since he came back to us. Some medications changes were done and he was seen by the psychologist in the ER, which is the first time they (Behavioral Health Services) saw him since this all began yesterday morning. Review of the copies of ER visit notes provided by Employee #107 on 06/14/17 at 9:10 a.m. revealed Resident #83 was seen in the ER at 1629 (4:29 p.m.). The ER Physician's note stated (typed as written): c/o (complaint of) psychotic behavior and is danger to self and others the rest of the documentation was illegible. A document titled Initial Psychiatric Evaluati.2 dated 06/14/17 and electronically signed by Psychologist #131 at 07:15. Under the heading 'Note' (typed as written), Request for consult via (name of ER physician). Patient evaluated. Unoriented. Exhibiting paranoia, delusional thinking. Patient potential risk to both self and others. During a confidential interview on 06/08/17 at 9:23 a.m., Employee #Y explained the procedure for obtaining services from Behavioral Health services. . phone the attending Physician, get an order then tell the Director of Nursing (DON) because she schedules all the appointments. Usually (name of Psychiatrist #115) sees them within a week most of the time is longer, because he (Psychiatrist #115) is only here one day a week. The reasonable expectation is for a resident to be seen within a week, which has gotten better since the survey because before we waited months before anything was done. I can tell you there is no consult report in the chart for the psych visit which is what happens so we never know if he has seen them or not. Which is no big deal because that report doesn't tell us anything anyway other than what we already know that they are having behaviors which is why we call in the first place. The staff here is on their own as to how to deal with any and all behaviors. Most of us are at a disadvantage dealing with most behaviors because we have never worked a psych unit and don't know what to do in an emergency. Behavioral health here is a joke because they don't do anything for the residents and all they and (Psychiatrist #115) say is how busy he is and that he can't be expected to take care of every resident. The sad thing is that any direction that you go out of town there are psych hospitals and facilities that could care for him and provide services and treatment if he (Resident #83) can't get what he needs here, but none have ever been contacted. No outside psych services have ever been contacted and we are only thirty to sixty minutes away from three of them, that could at least come in and do something. Resident #83 was admitted to the facility with known psychiatric and mental illness with behaviors requiring psychiatric care and services. A concise and scheduled psychiatric plan was not made known to the staff providing care and services to the resident related to preventative measures or detailed interventions for exhibited behaviors/moods and/or to deescalate an emergent situation to protect the resident for self-harm and the potential for harm or injury to other residents. During an observed and documented psychotic break no psychiatric services were available for the escalating event for the resident involved and protection for other residents who could have been involved. The staff were able to provide limited care to the resident with no intervention from expert psychiatric services/Behavioral health located within the facility either during or immediately following this crisis. At the conclusion of the survey Resident #83 remained in the facility with 1:1 observation without provided guidance or interventions from psychiatric services regarding any behaviors or mood changes. No other outside psych consults were made if services and/or treatment at the facility were or could not be made available for this resident with behaviors. 2. Resident #29 On the initial tour on 06/05/17 at 10:10 a.m., Resident #29 stated to this Surveyor and Surveyor # , Hello beautiful women or I should say (2) two hot mamas. This was overheard by the Director of Nursing (DON) in the hallway who laughed and stated, I see you have been greeted by (name of Resident #29). Review of the medical record on 06/07/17 at 10:17 a.m. revealed Resident #29 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Her current medications included: -- [MEDICATION NAME] (anti-depressant) 40 mg (milligrams) po (by mouth) at HS (bedtime), -- [MEDICATION NAME] (for the treatment of [REDACTED]. -- [MEDICATION NAME] XR (for treatment of [REDACTED]. -- [MEDICATION NAME] 0.25 mg po BID prn (as needed) for anxiety. The medication [MEDICATION NAME] originally was prescribed as 30 mg po at bedtime to decrease libido (sexual desires) on 04/20/17. The medication was increased to 40 mg po on 05/18/17 and then decreased to 20 mg po daily on 06/10/17. Resident #29's behaviors included attempted elopement, nervousness, crying, confusion, and inappropriate conversation. Review of the nursing progress notes revealed (typed as written): -- 04/27/17 - She was seen by (name of Psychiatrist #115) 03/21/17 due to inappropriate comments about sex, etc., to visitors/staff and then was placed on [MEDICATION NAME] (her [MEDICATION NAME] was d/c) to help decrease libido. (Name of Psychiatrist #115) thought it may decrease libido but probably not reduce her flirtatious behavior. -- 05/19/17 - The Maintenance Director reported, .she smacked me on the butt earlier and then she tried to kiss me. Just wanted to report to you. Resident in hallway no abnormal behavior noted. This was the day after [MEDICATION NAME] was increased to 40 mg -- 05/23/17 - a progress note described a behavior monitoring at 0230 (2:30 a.m.) included, .the resident was found by a CNA (certified nurse aide) standing beside her roommate's bed and yelling -- the roommate stated I just can't handle it anymore. I could just kill her -- she turned and went back to bed. Called (name of Behavioral Health Services) for approval for psych consult regarding residents behaviors referral will be made for (name of Psychiatrist #115). -- 05/28/17 at 1716 (5:16 p.m.) .Resident in dining room at this time. Other resident's family in to visit. Resident (Resident #29) being inappropriate towards family members. Resident redirected. -- 06/01/17 at 1249 (12:49 p.m.) (name of attending Physician) gave order to have (name of Psychiatrist #127). At 1252 (12:52 p.m.) Called (Behavioral Health Services) and spoke with (name of person). Made aware that (name of Resident #29) needed to be seen. (Name of person) stated that she is already on his follow up list and resident should be seen this afternoon. Review of the consult reports found only a consult report by Psychiatrist #115 dated 03/21/17. During a confidential interview on 06/08/17 at 9:23 a.m., Employee #Y explained the procedure for obtaining services from Behavioral Health services. Phone the attending Physician, get an order then tell the Director of Nursing (DON) because she schedules all the appointments. Usually (name of Psychiatrist #115) sees them within a week most of the time is longer, because he (Psychiatrist #115) is only here one day a week. The reasonable expectation is for a resident to be seen within a week, which has gotten better since the survey because before we waited months before anything was done. I can tell you there is no consult report in the chart for the psych visit which is what happens so we never know if he has seen them or not. Which is no big deal because that report doesn't tell us anything anyway other than what we already know that they are having behaviors which is why we call in the first place. The staff here is on their own as to how to deal with any and all behaviors. Most of us are at a disadvantage dealing with most behaviors because we have never worked a psych unit and don't know what to do in an emergency. Plus, (name of Resident #29) is always making inappropriate sexual comments and gestures toward family members of other residents which includes children sometimes, other residents and anyone new that comes on the unit. We were told that is the way she is just deal with it as best you can and apologize to the family members. What kind of psychiatrist does that without giving us some type of guidance or directives to deal with the behaviors. Behavioral health here is a joke because they don't do anything for the residents and all they and (Psychiatrist #115) say is how busy he is and that he can't be expected to take care of every resident. The sad thing is that any direction that you go out of town there are psych hospitals and facilities that could care for her and provide services and treatment if she can't get what he needs here, but none have ever been contacted. No outside psych services have ever been contacted and we are only thirty to sixty minutes away from three of them, that could at least come in and do something. The DON reported on 06/12/17 at 12:18 p.m. after inquiry if a psychiatrist consult was performed after an order obtained on 06/01/17, Yes, I have a consult report waiting to have clarification on his recommendations which are not clear. She further stated, Yes there is a communication problem with the psych department here. The medical director has been notified of the issue with (name of Psychiatrist #115) and we were told that (name of Psychiatrist #115) has been spoken to by the medical director but there are no changes. Yes, it is very frustrating because the consults don't get on the chart because I have to wait to clarify his recommendations which in this case involve medications that he prescribed but the recommendations are incorrect involving the present medications that she is receiving. This is because he only comes to our units one day a week no matter what is going on here. The psych department and Behavioral Health services is not a good mix for our residents. It is my expectation that if a resident has increased behaviors they should be seen immediately but that is impossible with a psych doctor coming only once a week because he has residents throughout the facility and in outpatient. We could utilize (name of Psychologist #131), but that is not always possible either because sometimes she is not a good mix for our residents and again sees patients throughout the facility and informs us that the outpatients are more important. So, in other words we have a Behavioral health department in our facility that is not meeting the needs of our residents because it is not able to be utilized ninety-nine percent (99%) of the time. Sometimes he (name of Psychiatrist #115) sees residents on a scheduled time but we never know when that is because nothing is ever in the consult report about future visits or how often they are going to be seen. I have waited almost 2 weeks to get this clarified because he cannot be contacted and the resident is no longer on the medication [MEDICATION NAME], it was changed by him (Psychiatrist #115) to [MEDICATION NAME] and I don't know if he wants the [MEDICATION NAME] given with the [MEDICATION NAME] A copy of the psych consult by Psychiatrist #115 was immediately provided after the interview. A review of the consult report revealed Resident #29 was visited by Psychiatrist #115 on 06/01/17. Under the title Subjective/Objective (typed as written): .However, she insisted on hugging me when I entered and spoke of shoving a boob into you. Whatever the question or comment on my part, she nearly always turned the discussion to sexual content, although she did not directly propose sexual contact beyond the above statement. Under the title Plan (typed as written): Behavioral/environmental interventions have generally not been found effective in frotteurism (a sexual disorder in which a person derives sexual gratification by rubbing against a non-consenting person or object for sexual pleasure) and related sexually unacceptable behaviors in dementia patients of either gender. Suggest reduction of [MEDICATION NAME] ([MEDICATION NAME] can be used for depression and [MEDICAL CONDITION]) to 20 mg qd (every day) and initiation of [MEDICATION NAME] (sometimes used to treat patients with treatment-resistant mood and anxiety disorders) 300 mg po tid (three times a day). Will follow. During a follow-up interview and after review of the consult report on 06/12/17 at 12:30 p.m., the DON stated, No that is not a plan for the staff to follow and doesn't give any plan for the staff to follow and the medications are incorrect. We have had problems in the past with these consults and not having plans listed that could be followed by the staff and the medical director has spoken with him. Inquired if the behavioral health ca not adequately take care of the residents needs why another consult from another psych department has not been consulted, she replied, Because they keep telling us we have a psych department here and no outside psych department has ever been contacted unless we just send them to another facility. Yes, I am sure that there are numerous outside consults that could be done. Employee #X reported during a confidential interview after reviewing the consult from Psychiatrist #115, That is not a plan for a resident and even has the wrong current medications on it. No, her psych needs and behavior needs are not being met by the facility or by the psych/Behavior Health department. I know that if an employee's son comes here, he has to be escorted out of the facility because she (Resident #29) will gravitate toward him and either touch him inappropriately or make numerous sexual inappropriate comments. This happens to visitors, staff and other residents and the staff try to keep her away from the male residents and redirect her. At the time of exit for this survey no evidence for clarification of the consult report dated 06/01/17 for the medications was presented. The facility failed to ensure Resident #29 received adequate psych/behavioral health services and/or treatments to minimize or treatment her ongoing verbal and/or physical inappropriate sexual behaviors toward visitors, staff and other residents even though Psychiatrist #115 stated in his consult that .interventions have generally not been found effective . no other recourse other than pharmacological interventions are being pursued. A clear concise plan for psych services/treatment was not outlined or recommended for this resident including scheduled visits. The ability to contact the Psychiatrist for medication clarification was delayed due to the facility's inability to contact the Psychiatrist and/or Psychiatrist availability in the facility. The needs of Resident #29 were not found to be met by the facility Behavioral Health/psych services to either minimize or control her behaviors consistently putting visitors, residents and staff at risk for her targeted behaviors. Also, putting Resident #29 at risk for being isolated from group and individual socialization due to her inappropriate behaviors by interventions of redirection, remove from male residents and remove from the situation. There was no evidence that outside psych services were contacted for services and/or treatment to assist with providing psych services and consultation to this resident for management of her behaviors. 3. Resident #34 Review of the resident's medical record on 06/06/17 at 11:09 a.m., revealed Resident #34 was admitted to the facility in 2011 with a [DIAGNOSES REDACTED]. The 'History of present illness' stated, pt (patient) has a long Hx (history) of psychiatric disease and lacks (illegible) independent living, pt is here for placement The minimum data set (MDS) assessment with an assessment reference date (ARD of 05/11/17 n | 2020-03-01 |