Health inspection·September 10, 2021

F745 §483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Tittle 22: § 72523 Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to ensure Resident 1 was safely discharged from the facility to reduce factors for a readmission to the general acute care hospital (GACH). The facility failed to discharge Resident 1 home without providing the following: 1. Necessary supplies such as medication and gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) formula feedings. Resident 1 required insulin (medication to control elevated blood sugar levels in the blood) and Nepro [a feeding formula that provides total nutrition for residents receiving dialysis (a process in which a machine helps filter your blood to rid your body of harmful wastes, extra salt, and water)] G-tube feeding. 2. Family education on administration of medication (insulin) and formula feeding (Nepro via G-tube). 3. Arrangement for visits with a Home Health (HH, health care or supportive care provided by a professional caregiver in the individual's home) agency. As a result, Resident 1 required emergency services and was hospitalized with a diagnosis of Diabetic Ketoacidosis [DKA, a serious complication where the body produces excess blood acids (ketones) caused by too much sugar in the blood], which could lead to death. Resident 1's blood sugar level was 1,105 milligram per deciliter (mg/dL) (normal blood sugar range between 70 and 99 mg/dL), which required Resident 1 to be put on an insulin drip (medication administered directly through the veins to lower blood sugar levels) and admitted to the GACH's Intensive Care Unit (ICU, a section in the hospital to care for patients who are critically ill) two days after the facility discharged Resident 1 home. On 6/16/21 at 1:30 p.m., an unannounced visit was conducted to the facility to investigate a complaint regarding a resident discharge without proper discharge planning. During a telephone interview, on 6/15/21 at 12:47 p.m., Resident 1's Representative 1 (Rep 1) stated the facility discharged Resident 1 on 6/9/21. Rep 1 stated the Social Services Director (SSD) told him the facility arranged Resident 1's HH services. Rep 1 stated the resident's feeding machine (machine used to deliver formula feeding at a specified rate) was delivered to the resident's home on 6/8/21 but the resident's feeding formula (Nepro) and insulin (a medication to help control blood sugar levels in the blood for people with diabetes) were not delivered. Rep 1 stated he had to return to the facility on 6/10/21 to pick up Resident 1's feeding formula and one vial of insulin. Rep 1 stated the company that delivered the feeding pump showed him how to set it up. Rep 1 stated the facility did not provide any education on how much insulin or G-tube feeding to give Resident 1 prior to discharge. Rep 1 stated the HH nurse never came to the resident's home after the resident was discharged. Rep 1 stated Resident 1 got sick again and, "Did not look right." Rep 1 stated the resident was restless and, "Not herself." Rep 1 stated that Resident 1 required admission to a GACH on 6/11/21 because the resident's blood sugar was high. Rep 1 stated that the SSD failed to make sure the resident had all the equipment and follow up visit with the HH agency was done. Rep 1 stated the SSD did not do her job in helping Rep 1 with the resident being discharge home. A record review of Resident 1's Admission Record indicated Resident 1, a 49 year old, admitted to the facility on 5/6/21, with diagnoses that included dysphagia (difficulty swallowing), gastrostomy status, Type 2 Diabetes Mellitus (DM, disease that causes too much sugar in the blood), and dependence on renal dialysis. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/13/21, indicated the resident had moderate impairment in cognitive skills. Resident 1 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 1's Order Summary Report for the month of June 2021, indicated orders for the following medications for administration routinely: 1. Aspirin (a medication that can also be used to reduce risk of heart attack) 81 milligrams (mg) via G-tube one time a day (Q day) for CVA (cerebrovascular accident, damage to the brain from interruption of blood supply) prophylaxis (preventative). 2. Docusate sodium (stool softener) 100 mg via G-tube Q day for bowel management, hold if loose stools. 3. Hydralazine [medication used to treat high blood pressure (BP)] 25 mg via G-tube three times a day (TID) for hypertension (HTN, high blood pressure). 4. Insulin NPH (intermediate acting insulin to help control elevated blood sugar levels) 10 units subcutaneously (SQ) two times a day (BID) for DM, hold if blood sugar less than 120, rotate sites. 5. Lipitor (mediation used to treat high cholesterol) 20 mg via G-tube at bedtime for hyperlipidemia (high cholesterol). 6. Metoprolol (medication used to treat high BP) 25 mg via G-tube BID for HTN, hold for systolic BP (SBP, pressure inside of the artery when the heart is contracting to pump blood) less than 110 or HR less than 60. 7. Miralax (medication to prevent constipation) 17 grams (gm) via G-tube Q day for bowel management, hold if loose stools, mix with 8 ounces of water. 8. Norvasc (medication used to treat high BP) 5 mg via G-tube Q day for HTN, hold if SBP less than 110. 9. Pepcid (medication to treat increased acid in stomach) 20 mg via G-tube Q day for gastroesophageal reflux disease (GERD, when stomach acid frequently flows back into the tube connecting the mouth and stomach). 10. Reglan (medication used to treat nausea) 10 mg via G-tube every eight (8) hours for GERD. A review of Resident 1's Multidisciplinary Progress Record, dated 5/28/21, indicated that the SSD would follow up with the HH agency to initiate discharge planning for the resident. A review of Resident 1's Multidisciplinary Progress Record, dated 6/6/21, indicated an anticipated discharge date of 6/9/21 for Resident 1 with HH services which included: physical therapy (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), occupational therapy (OT, use of self-care and work and play activities to promote and maintain health, prevent disability, increase independent function), and the facility nurse would provide discharge teachings at discharge. A review of Resident 1's physician order, dated 6/9/21, indicated that the facility discharge the resident home on 6/9/21 with HH to provide the following services: 1. PT, 2. OT, 3. Speech therapy (ST, training to help people with speech and language problem to speak more clearly), 4. RN for G-tube management, and DM/Insulin management, Nepro at 55 ml/hr. for 20 hr. or until dose limit was completed, and 5. G-tube supplies. During an interview, on 6/16/21 at 2:12 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the SSD arranged HH for the residents. LVN 1 stated on the day of discharge licensed nurses are supposed to go over the list of discharged medications, give instructions on taking their medications, then document in the computer that they provided teaching instructions upon discharge to the resident and/or family representative. During an interview, on 6/16/21 at 2:31 p.m., the Director of Nursing (DON) stated the SSD coordinated HH services for residents. The DON stated that the resident's family should not have to call the HH agency themselves to set anything up (such as appointment dates for home visits, medications, and/or supply deliveries). During an interview, on 6/17/21 at 3:30 p.m., the SSD stated she was responsible to meet with the resident's family to find out the resident's needs and arrange for HH services as ordered by the physician. The SSD stated she would fax the resident's documents to the HH agency, which included: the resident's face sheet (admission record), history and physical (H&P, provides concise information about a patient's history and exam findings at the time of admission), list of medications, rehabilitation (care that can help get back, keep, or improve abilities that are needed for daily life) notes, and discharge order. The SSD stated that the HH agency should have reached out to the resident's family prior to the resident's discharge. The SSD stated that she would follow up with the resident's family to make sure that the HH agency contacted them. The SSD stated she was not familiar with medications and that the nurses were responsible for providing teaching to the resident/family about the resident's medications. During an interview, on 7/1/21 at 12:20 p.m., the SSD stated that Resident 1's insurance company arranged the HH services and that she did not set up any appointments for the resident. The SSD stated she spoke with a representative from the residents' health insurance carrier to follow up with the HH service arrangements. The SSD stated the resident's health insurance carrier told her that, "Everything was arranged." The SSD stated she did not receive any paper confirming HH services was arranged by the residents’ health insurance carrier. The SSD stated that she did not know which HH agency or when the HH agency staff would visit Resident 1's home. A review of Resident 1's Nurse's Note, dated 6/9/21 at 2:36 p.m., indicated the resident was discharged home with Rep 1 in a stable condition via private car. The nurse's note did not have documentation indicating that the nurse provided teaching regarding medications (such as insulin) ordered or any supplies for G-tube (such as formula feeding) was sent home with the resident upon discharge. A review of Resident 1's Interdisciplinary Discharge Summary, dated 6/9/21, under the section titled, "Nursing Services," indicated that Resident 1 required blood sugar monitoring, insulin therapy, and to send medications with the resident. The summary did not include what medications Resident 1 was to continue at home. During a follow-up telephone interview with SSD, on 8/10/21 at 10 a.m., the SSD stated that Rep 1 called her (could not remember the day, stated maybe a day or two after discharge) and told her that the HH agency did not show up to the home for the scheduled visit. The SSD stated that Rep 1 returned to the facility to pick up medications for Resident 1. During a follow up telephone interview with Rep 1, on 8/10/21 at 10:50 a.m., Rep 1 stated that Resident 1 never received any insulin medication while at home after being discharged from facility (6/9/21). Rep 1 stated that he did not have a machine to check Resident 1's blood sugar level and did not receive any teachings about insulin or G-tube feeding during discharge. Rep 1 stated that he did not receive any paperwork or instructions on how much insulin to administer to the resident or the rate to administer the resident's G-tube feeding. Rep 1 stated upon discharge the SSD told him the HH agency would provide the teaching of medications and administration of insulin and G-tube feeding. During a telephone interview with Representative 2 (Rep 2), on 8/11/21 at 1:08 p.m., Rep 2 stated that Resident 1's family did not get the proper education needed to care for Resident 1. Rep 2 stated that the facility just wanted to get Resident 1 out of the facility and expected the HH agency to do everything. Rep 2 stated that HH staff never came and that the SSD did not follow up to make sure everything was arranged before the facility discharged Resident 1 home. Rep 2 felt, "This was an unsafe discharge." A review of Resident 1's GACH admission record, dated 6/11/21, indicated Resident 1 was diagnosed (clinical impression) with DKA, altered mental status, and chronic kidney disease (condition in which the body is unable to get rid of wastes). The record indicated Resident 1's blood sugar level was 1,105 mg/dl and placed on an insulin drip. Resident 1 required admission to the GACH's Intensive Care Unit (ICU-a section in the hospital to care for patients who are critically ill). A review of the facility's policy and procedure (P&P) titled, "Discharging the Resident," revised 12/2016, indicated to ensure the resident and/or responsible party received teaching and discharge instructions if the resident was discharged home. The P&P also indicated to assemble the equipment and supplies necessary to discharge the resident. The facility failed to ensure Resident 1 was safely discharged from the facility to reduce factors for a readmission to the general acute care hospital (GACH). The facility failed to discharge Resident 1 home without providing the following: 1. Neces