Health inspection·September 29, 2021

Regulation: F660 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility’s discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and— (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident’s or caregiver’s/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident’s goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident’s comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident’s goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident’s needs, and include in the clinical record, the evaluation of the resident’s discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident’s representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident’s discharge or transfer. On 10/27/2020 at 9:30 A.M., an unannounced visit was conducted at the facility to investigate a complaint alleging Resident 1 was discharged without any resources or referrals. The facility failed to provide a safe discharge for Resident 1, when the facility did not communicate with, or properly prepare Resident 1's caregiver for the discharge needs of Resident 1. As a result, Resident 1 was discharged home and did not receive the assistance needed to perform his activities of daily living (routine activities people do, such as feeding, bathing, dressing, and grooming). Resident 1 was found in pain and was taken to the hospital where he was diagnosed with weakness and tachycardia (fast heart rate) related to dehydration (a harmful reduction in the amount of water in the body). A review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on 4/28/2020 with diagnoses which included hemiplegia (weakness on one side of the body) affecting the left side of his body, type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), generalized muscle weakness, and abnormalities of gait (manner of walking) and mobility according to the facility's face sheet, dated 10/27/2020. Resident 1's ace sheet also indicated Resident 1 was his own responsible party. During a review of the clinical record for Resident 1, the Minimum Data Set (MDS -assessment tool), dated 5/4/2020, indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - a screening to identify a person's mental status) score of 15 (cognitively intact). Per the same MDS, Resident 1 needed extensive assistance with two-person physical assist for bed mobility and toileting. During a review of the clinical record for Resident 1, the Activities of Daily Living (ADL) sheet, dated 7/14/2020-7/27/2020 (a week before discharge) indicated, on 7/24/20, 7/25/20 and 7/26/20, Resident 1 was not transferred out from the bed. The record also indicated on 7/27/20 (day of discharge), Resident 1 required extensive assistance & two-person physical assist with transfer. During a review of the clinical record for Resident 1, the Discharge Summary and Post Discharge Plan of Care", dated 7/27/2020 (day of discharge from facility) indicated, Resident 1 was non- ambulatory (unable to walk) and required extensive assistance (someone to provide weight bearing support for the resident) when preforming activities of daily living (care such as feeding, bathing, dressing and grooming). The document indicated Resident 1 was discharged on 7/27/2020 and was transported home by family. The document also indicated home health would follow up with Resident 1. During a telephone interview on 10/26/2020 at 3:55 P.M., Resident 1's Friend 1 (FR 1) stated Friend 2 (FR 2) picked-up Resident 1 by the facility curbside the day the resident was discharged from the facility on 7/27/2020 and brought the resident home to his apartment. FR 1 stated FR 2 asked him (FR 1) to come to the apartment to help transfer Resident 1 to the couch because FR 2 could not transfer the resident alone. FR 1 stated he found Resident 1 the next day in the same position on the couch and he had not moved for over 24 hours. During a telephone interview on 11/5/2020 at 1:25 P.M., Resident 1's Friend 1 (FR 1). FR 1 stated when he went to Resident 1's apartment the day after the resident was discharged from the facility, Resident 1 was in a lot of pain, and was physically unable to get up to get himself anything to drink or use the toilet. FR 1 stated Resident 1 had not moved for over 24 hours and could not reach his cell phone to call for assistance. During a telephone interview on 11/16/20 at 3:40 P.M., Resident 1 stated the facility told him on admission that they could help him walk again after he completed the physical therapy at the facility. Resident 1 stated the facility did not do what they promised because he still could not ambulate when the facility discharged him to his apartment. Resident 1 stated he was independent before he was admitted to the facility. Resident 1 stated he cooked for himself and managed all his self-care needs. Resident 1 stated he never told the facility that his daughter was his full-time caregiver because his daughter was a single parent and took care of her mother fulltime. During a telephone interview on 12/11/2020 at 1:15 P.M., Resident 1's family member (FM 1) stated she was her father's part time care giver prior to him being admitted to the facility. FM 1 stated her role as her father's caregiver before he went to the facility was to shop for his groceries, bring him to doctors' appointments and other needs he could not do for himself around the apartment. FM 1 stated before her father was admitted to the facility, he took care of his bathroom needs, used a cane, transferred himself to his wheelchair and cooked for himself. FM 1 stated her father was unable to ambulate or move himself back into his wheelchair from the couch when her brother and FR 1 found Resident 1 in his apartment the day after his discharge from the facility. FM 1 stated she went over to Resident 1's apartment to help transfer the resident. FM 1 stated she attempted to help Resident 1 to bathroom from the couch but could not because Resident 1 required more assistance than she anticipated. FM 1 stated her father was too weak. FM 1 stated she was able to help Resident 1 without difficulty by herself prior to his admission to the facility. FM 1 stated they called an ambulance for her father because he was weak, in a lot of pain and unable to do anything for himself. FM 1 stated no one called her from the facility or homecare agency to discuss Resident 1's discharge needs before or after Resident 1's discharge from the facility on 7/27/2020. During a review of the clinical record for Resident 1, the acute care hospital record titled "ED to Hosp-Discharge" dated 7/29/2020 indicated, Resident 1's chief complaint on admission to the emergency department via ambulance was weakness and pain. The record indicated Resident 1 was tachycardic (fast heart rate) on arrival due to mild dehydration (reduction of the amount of fluid in the body). The record indicated that Resident 1 could not return home because he was not safe to take care of himself and did not have a caregiver at home full time. The record indicated Resident 1 was admitted to the hospital until placement could be arranged for Resident 1 to be transferred to a skilled facility where he could obtain the level of care, he required post discharge. During a record review of the home health agency document titled, "Communication Log" indicated the following: -"07/27: Patient referral was received over the weekend from (name of facility), patient will discharge home today from facility. Received telephone call from (name of facility and social worker name) who let me know patient primary contact. Called patient daughter as requested by facility with no answer received, unable to leave voicemail. Called secondary number who belongs to patient who stated he has a wound on his tailbone and nurses at the facility did not put a patch to cover for the reason he was rushing to leave the facility. Appointment is scheduled for tomorrow in the morning, patient will require in home MSW for IHSS." -"07/28: Patient did not answer clinicians phone calls, per RN patient phone line was marked busy all day. Patient was called to reschedule with no answer received, left voicemail." -"07/29: Patient was called with no answer received, left voicemail. Called patient daughter with no answer received, unable to leave voicemail." -"07/30: Called patient and daughter to reschedule soc with no answer received, unable to leave voicemail." -"07/31: Received telephone call from business owner (name of business owner) last night stating patient was taken to hospital because he was not seen ...." During an interview and concurrent document review on 11/5/2020 at 1:25 PM, the facility's Case Manager/Social Service (CM/SS) stated she did not typically call a resident's caregiver to coordinate discharge needs if the resident was alert. The CM/SS stated if she felt a resident was not alert or had cognitive issues, she would call the resident's caregiver to discuss the resident's discharge needs. The CM/SS stated, when asked how she decided when to call or not to call a resident's caregiver to coordinate discharge needs, "I go by my gut feeling". The CM/SS stated she did all the discharge arrangements herself and the facility's IDT did not complete the task. The CM/SS was asked if she would follow up with a caregiver if the resident needed extensive care and the CM/SS stated, "Some occasions I check and some I don't." The CM/SS stated, "I probably should call on everyone." The CM/SS stated she should have followed up on everyone to make sure the caregivers were ready and knew the status of the residents' discharge needs. The CM/SS stated she spoke to Resident 1's daughter/caregiver one time when she came to visit the resident at the facility and the daughter confirmed that she was the caregiver for Resident 1. The CM/SS stated she did not attempt to call Resident 1's daughter/caregiver to coordinate the resident's discharge or discuss the discharge needs of Resident 1. The CM/SS stated she should have called Resident 1's daughter/caregiver and that it was a "bad judgment on my part". The CM/SS stated she should have checked to see if Resident 1's caregiver could handle his care since Resident 1 was "very different from his baseline". The CM/SS reviewed the facility's policy titled "Discharge Planning Process", dated 11/2016, and stated, "I did not follow d and e". The facility's policy indicated, "d. Involve the interdisciplinary team (IDT) in the ongoing process of developing the discharge plan. The IDT shall include; the resident's attending physician, a registered nurse and nurse's aide with responsibility for the resident, a staff member from food and nutrition services, the resident and the resident's representative (to the extent possible). e. Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.". In violation of the above cited standards, the facility failed to provide a safe discharge for Resident 1, when the facility did not communicate with or properly prepare Resident 1's caregiver for the discharge needs of Resident 1. As a result, Resident 1 was discharged home and did not receive the assistance needed to perform his activities of daily living (routine activities people do, such as feeding, bathing, dressing, and grooming). Resident 1 was found in pain and was taken to the hospital where he was diagnosed with weakness and tachycardia (fast heart rate) related to dehydration (a harmful reduction in the amount of water in the body). This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.