| 50 |
GUARDIAN ELDER CARE AT WHEELING |
515002 |
20 HOMESTEAD AVENUE |
WHEELING |
WV |
26003 |
2018-05-03 |
657 |
D |
0 |
1 |
X20F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include the resident in the care planning process. Specifically, the facility failed to keep one resident (#108) reviewed for Discharge informed of his progress towards discharge. This failed practice had the potential to affect a limited number of residents. Resident identifier: #108. Facility census: 142. Findings included: a) Facility policy The care planning policy, revised 09/2013, was reviewed on 5/3/18 at 9:15 AM. The policy indicated in pertinent part: .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Every effort will be made to schedule care plan meeting at the best time of the day for the resident and family .' b) Resident #108 Resident #108 admitted to the facility on [DATE] and discharged to the community on 4/30/18. According to admission physician's orders [REDACTED]. Review of the 3/22/18 Minimum Data Set (MDS) assessment on 5/2/18 at 11:35 AM. According to the MDS, the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. The MDS assessed he required extensive assistance with all activities of daily living (ADLs). In an interview on 4/30/18 at 1:13 PM, the resident stated he was scheduled to be discharged around 3:00 PM that day. He complained that there was a lack of communication between the facility and himself. He stated he received therapy under his insurance and that staff never discussed his progress with him or discussed when discharge may occur. He said, all of a sudden they came and spoke with him and said they were discharging him in a couple days. He said he appealed the discharge and won, but he did not want to stay at the facility due to the lack of communication. He said they had a meeting with him when he first arrived back in March, but no other meetings since then. He said the staff had an internal meeting every week to discuss residents, but no one ever came and spoke to him about what was talked about in that meeting regarding his care or progress. The resident's record was reviewed on 5/2/18 at 1:15 PM. The discharge care plan, initiated on 3/15/18, identified the resident expressed his wish to discharge home with family. Interventions included reviewing progress towards discharge during scheduled meetings. Review of progress notes revealed no documented conversations with the resident regarding his progress or plans towards discharge. There was no evidence of care conferences that took place during his stay. A Social Services note, dated 3/15/18, revealed the Social Service staff met with the resident, completed the admission packet with him and spoke with his family member by phone. They discussed options in case the resident would be unable to return home. The plan was for the resident to return home with family. Social Services made them aware of their services and assistance. Social Services documented the internal Medicare meeting that occurred each week. The Medicare meeting note dated 4/25/18 revealed the resident's last covered day would be 5/4/18 with long term care being recommended. There was no documentation after the meeting indicating the resident was informed of the upcoming end of therapy. On 4/27/18, Staff #70 documented in the record that she issued the notice of Medicare non coverage to the resident. The notice was discussed with the resident's family member via phone. She discussed the appeal process with both of them. There was no explanation for the 2 day delay between when the facility determined the resident's therapy would end and when the resident was notified. On 4/30/18, Social Services documented the resident was discharging from the facility and which services would be provided at home. A note from the nurse practitioner on 4/30/18 documented in pertinent part, .At this time patient feels he is being thrown out. Discussed situation and insurance and he would continue therapy at home . The Physical Therapy and Occupational Therapy daily progress notes were reviewed on 5/3/18 at 11:20 AM. Review of the notes revealed there was no documentation from therapy discussing the resident's progress with the resident or progress towards discharge. On 4/27/18, the same date the resident was notified his therapy was ending, Physical Therapy documented, Therapist met with patient and spouse and discussed patients D/C (discharge) planning. Educated patient on his progress with therapy to this point and discussed patients future progress and plans. In an interview on 5/2/18 at 1:27 PM, Social Services #51 explained one of the two Social Service staff met with residents within 48 hours of admission. They provided the resident with a packet of information, discussed their history and goals, and the discharge planning process. She said they had an open door policy so if any one wanted to speak to them, they were able to. Social services helped arrange for home services and placements. She said she met with residents regularly to complete MDS assessments. She said the facility had internal Medicare meetings every Wednesday morning. She tried to meet with the residents after that meeting, but mostly met with those that had upcoming discharge date s or that were going to need increased services. She said she always tried to document in the record whenever she had a conversation with a resident or family member. She remembered speaking with Resident #108's family member more than the resident. She stated the family member called every couple weeks to find out what the resident was going to need when he returned home. She further explained when she met with a resident upon admission she told them that they could have a care conference any time they wanted to. She said the short-term residents did not have a set care conference schedule and that the resident, family, or therapy were the ones to typically initiate the scheduling of a care conference. She said the facility did not complete an admission care conference. In an interview on 5/2/18 at 5:33 PM Case Manager #70 said she was the case manager for the residents that had managed care. She helped with discharge planning along with social services. She remembered having a conversation with the resident when she issued his notice of Medicare non-coverage. She explained that he was being discharged by his insurance. She said it was hard to let the resident know when they may be discharged because insurance could cut them off at any time. The interim therapy director was interviewed on 5/3/18 at 10:34 AM. She said therapy discussed progress on a daily basis with residents during their sessions. Those conversations would be documented in their progress notes. She said therapy did not attend care conferences unless they were the ones to request the care conference. Normally a care conference was suggested when the discharge was questionable, which would be if the resident needed placement instead of returning home. She stated she worked directly with Resident #108 and remembered having conversations with the resident about his progress. She remembered speaking with the resident's family member a couple of times as well. She said she was not sure why no care conference was held, but the resident got mad at therapy because they were discharging him. In an interview on 5/3/18 at 11:40 AM, the interim therapy director reviewed the weekly progress notes. She confirmed there was no documentation to indicate the resident was spoken to about his progress towards discharge. She was certain that conversations occurred but could not find any evidence of the conversations. In an interview on 5/3/18 at 12:35 PM the Administrator said the facility met internally every week to discuss short term stay residents. Social Services communicates with the residents and gets the discharge information from the resident, such as their prior level of function and home setting upon admission. Therapy speaks to residents from the beginning as well about discharge planning and how the process worked. She said care conferences should be completed prior to the resident being discharged and therapy would be at that meeting. |
2020-09-01 |