Health inspection·February 14, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility policy the facility failed to ensure Resident #103 received an orderly discharge from the facility. This affected one resident (Resident #103) out of three residents reviewed for discharge. Residents Affected - Few Findings include: Review of Resident #103's medical record revealed an admission date of 09/23/21 and diagnoses included quadriplegia, C5 through C7 incomplete, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of Resident #103's care plan revised 11/02/22 included Resident #103 had an ADL (Activity of Daily Living) self-care performance deficit related to limited mobility due to quadriplegia, scoliosis and other diagnoses. Interventions included Resident #103 was dependent on staff for dressing, Resident #103 preferred to wear shoes and to make sure shoes were comfortable and not slippery. Review of Resident #103's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #103 was cognitively intact. Resident #103 was dependent on staff for toileting, bathing, lower body dressing, personal hygiene and putting on and taking off footwear and transfers. Resident #103 used a motorized wheelchair. Review of Resident #103's physician orders dated 01/24/24 revealed discharge Resident #103 home with OT (Occupational Therapy) and STNA (State Tested Nursing Assistant) for ADL's. Review of Resident #103's progress notes dated 02/07/24 at 12:02 P.M. revealed Resident #103 was discharged from the facility at 10:15 A.M. Resident #103 was in a wheelchair and transportation was provided. Resident #103's belongings were taken separately. Review of Resident #103's progress notes dated 02/07/24 at 12:55 P.M. included Resident #103 was discharged to her new apartment. Resident #103's aunt was called to pick up the rest of Resident #103's belongings which were located on the first floor in front of the nurses station. Interview on 02/14/24 at 9:11 A.M. of Family Member (FM) #300 revealed Resident Service Director (RSD) #301 was out sick on 02/07/24 and apologized because she was not able to assist with Resident #103's discharge. FM #300 stated she did not know if RSD #301 called anyone to help Resident #103 get packed up before she was discharged from the facility, and someone did not do everything they were supposed to do to make sure the discharge went smoothly. FM #300 stated they forgot to get her up and help Resident #103 get washed up, dressed and ready for her discharge. FM #300 indicated it was Page 1 of 3 365879 365879 02/14/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few totally unacceptable the way the discharge went and Resident #103 did everything she could to keep from crying. FM #300 stated Resident #103 only had the use of one hand and had to use that hand to maneuver her wheelchair. Resident #103's medications were put in a bag and the discharge papers were placed in her lap and both were given to her and she was trying to hold onto the papers and medications and maneuver her wheelchair and felt like she was going to cry. FM #300 stated she had to go to the facility after Resident #103 was discharged to pick up her belongings, and Resident #103's wheelchair charger was not in the bags of belongings she picked up from the facility. FM #300 had to call the facility multiple times to have staff track down the charger and she had to make another trip to the facility to pick the charger up. Interview on 02/14/24 at 9:23 A.M. of Resident #103 revealed her transportation was set for 10:00 A.M. but she was told 11:30 A.M. Resident #103 stated they rushed to get me up, did not wash her, put her clothes on and she was not wearing shoes. Resident #103 indicated the nurse put her pills in a little plastic bag, gave the pills to Social Worker (SW) #302, and SW #302 gave the pills to her and the nurse did not talk to her or verbally give Resident #103 any discharge instructions. Resident #103 stated the staff came in her room at 9:47 A.M., woke her up, rushed to get her dressed, transferred her to the wheelchair and threw everything in her lap. Resident #103 stated the only instructions she was given was from SW #302 regarding the program which was helping her transition from the facility to her new home. Resident #103 stated it was planned for her to leave on 02/07/24, she asked various staff and aides for three days to have someone pack her belongings, it did not happen, and she felt like she was rushed out and pushed out and felt like crying. RSD #301 told her the aides would help her but it did not happen. Resident #103 indicated when FM #300 picked her belongings up and brought them to her the plastic bags holding the belongings had tears in them and her things were poking out of the holes. Resident #103 indicated her wheelchair charger did not come home with her and FM #300 had to make a special trip to pick it up from the facility. Interview on 02/14/24 at 10:39 A.M. of SW #302 revealed discharge planning started when residents were admitted to the facility and her responsibilities included anything for the discharge to be successful. SW #302 stated she did not arrange transportation and that was Resident Transportation Scheduler's (RTS) #303's job. SW #302 stated the IDT (interdisciplinary team) made the decision when a resident was ready for discharge and the residents physician had to approve the discharge. SW #302 indicated the aides packed the resident's belongings, which was usually done prior to the resident leaving the facility, and sent the belongings with the resident when they left. SW #302 stated sometimes families assisted with the packing. SW #302 revealed RSD #301 was out sick on 02/07/24 and asked her to make sure Resident #103's discharge went smoothly. SW #302 stated Resident #103 had a little bit of a rocky discharge and when she arrived to the nursing unit Resident #103 resided on State Tested Nursing Assistant (STNA) #304 was dressing Resident #103 and her belongings were not packed. SW #302 stated she called ahead and told STNA #304 to pack Resident #103's belongings, but that did not happen, and the belongings should have been packed. Once Resident #103 was dressed and transferred to her wheelchair using a mechanical lift she came to the nurses station desk and asked about her jacket and cell phone and SW #302 found these items for her. SW #302 stated Resident #103 asked for her shoes to be put on, but the shoes could not be found and Resident #103 left the facility not wearing any shoes. SW #302 stated transportation arrived on time, would not wait if a resident was not ready, and Resident #103's discharge was completed at the nurses station. SW #302 stated Resident #103 left the facility without all her belongings because they were not packed up. After Resident #103's belongings were packed up, SW #302 took them the the first floor and put them behind the nurses station. SW #302 indicated she was did not know Resident #103's wheelchair charger was 365879 Page 2 of 3 365879 02/14/2024 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not packed with the rest of her things. SW #302 stated a discharge summary was completed and the nurses did their part, Resident #103's discharge summary was printed out and she went over all sections with her and asked if she had questions. SW #302 stated she placed Resident #103's paperwork in a folder and slid it to the side of her chair, and she could not remember what she had in her hands or if she was having trouble juggling things. SW #302 indicated she accompanied Resident #103 to the transportation vehicle and Resident #103 asked about her medications because she did not have them. SW #302 stated she went back to the nursing unit to get Resident #103's medications and Licensed Practical Nurse (LPN) #305 handed the medications to her and said she did not remember Resident #103 was leaving. Interview on 02/14/24 at 11:03 A.M. of STNA #304 revealed she was working day shift on 02/07/24 which was the day Resident #103 was discharged from the facility. STNA #304 stated she just got her out of bed when it was time for her to leave, and Resident #103's belongings were not packed and ready to go. STNA #304 stated she did not know what happened to the belongings that were not packed and did not go with Resident #103 when she left. STNA #304 stated multiple people talked to her about packing Resident #103's belongings, but she could not provide the names of those people. STNA #304 stated Resident #103's shoes could not be found and she left the facility wearing socks. Interview on 02/14/24 at 11:38 A.M. of the Director of Nursing (DON) and the Administrator revealed the DON was in the facility on 02/07/24 when Resident #103 was discharged . The DON stated she observed Resident #103 getting dressed and she did not have shoes on and left the facility wearing non skid socks. The DON stated Resident #103's shoes could not be found and were boxed up. The DON stated she reviewed Resident #103's medications with her before she left the facility. The DON confirmed Resident #103's belongings were taken to the first floor reception area and were picked up by FM #300 after Resident #103 left the facility. The DON was not aware Resident #103's wheelchair charger was not sent with her when she left. Interview on 02/14/24 at 1:19 P.M. of STNA #307 revealed she was assigned to take care of Resident #103 on 02/07/24 and knew she was being discharged . STNA #307 stated Resident #103 left really quick and she did not see her off because her discharge was so fast. STNA #307 indicated STNA #304 got her up for her because she was busy with another resident, and the only thing she did was pack Resident #103's belongings after she was discharged . Interview on 02/14/24 at 2:12 P.M. of RTS #303 revealed the facility had a new transportation company and the company did not give a time they were coming to transport Resident #103 out of the facility. RTS #303 indicated the transport company told her they would call on 02/07/24 and give the transportation time. RTS #300 revealed the transportation company called on 02/07/24 at 8:00 A.M. and said the pick up time was 10:00 A.M. Interview on 02/14/24 at 3:14 P.M. of RSD #301 revealed information was given to the staff that Resident #103's transportation time was 02/07/24 at 10:00 A.M. Review of the facility policy titled Discharge Planning Policy revised 05/2022 included the Social Service Department or designee was to assure that personal belongings were packed. The team would notify the charge nurse of pending discharge. This deficiency represents non-compliance investigated under Complaint Number OH00150923. 365879 Page 3 of 3