TUCSON, AZ- MOUNTAIN VIEW CARE CENTER

Based on clinical record review, staff interviews, and facility documentation and policies, the facility failed to implement effective discharge planning resulting in an unsafe discharge for one resident (#3). The deficient practice could result in unsafe resident discharges.

A pressure ulcer care plan, dated August 19, 2022, included that the resident had pressure ulcers including a stage 4 on the right buttocks, one on the left buttock, sacrum and a stage 2 on the right ischium. Interventions included to administer treatments as ordered and monitor for effectiveness.

A physician’s order dated August 31, 2022 included the resident’s anticipated discharge from the facility on September 2, 2022. The order included home health with skilled nursing for medication management. Also, the order included home safety evaluation and treatment and evaluation and treatment for other disciplines. The order also included Physical Therapy (PT) and Occupational Therapy (OT) evaluation and treatment.

A wound care note dated September 1, 2022 included that the resident was scheduled to discharge and home health for wound care was arranged and the resident was mildly confrontational about his wound care. The note included that the resident is going to a boarding house and does not appear to be happy about this. The note included that due to his circumstance of noncompliance and going to a boarding house, the provider suspects the resident’s wound will not be well managed and become infected again required additional antibiotics and/or hospitalization.

A physician’s order dated September 2, 2022 included anticipate discharge September 2, 2022. Evaluate and treat for indwelling catheter care. An additional discharge order included to evaluate and treat for wound care.

The clinical record revealed no evidence if the resident was offered the opportunity to stay in the facility or that the resident left Against Medical Advice (AMA).

Review of a text message exchange between the facility and a local home health care company, dated September 2, 2022, included that the home health company said they would not have availability until late the next week on Friday. This would mean that the resident would not be receiving home health services for his wounds until 7 days after the date of discharge.

A discharge summary and post-discharge plan of care dated September 2, 2022 included that the resident was being discharged to a local boarding home and that the resident had home health services for nursing and therapy through a local home health company.

An interview was conducted on October 4, 2022 at 8:44 AM with a representative from the local boarding house who said that the resident was not a resident at the boarding house and had never been a resident at the boarding house.

An interview was conducted on October 4, 2022 at 8:49 AM with a social services staff (staff #17), who said that the facility starts the discharge planning on admission, which includes where the resident previously lived, a therapy meeting to see if it is safe to return there, ordering supplies, and if she does not see that their placement is fit to return to, she communicates this to family to see about finding another option for placement upon discharge. She said that the staff worked with a placement agency and that agency had made arrangements for the resident to go the local boarding house. She said that the placement agency provided an address for the boarding house and that is where the resident was discharged to. She said that it turned out that this was not the correct address and he instead was sent to a home health company. She said that she was not sure what happened after that because the social services director handled it.

An interview was conducted on October 4, 2022 at 9:15 AM with the social services director (staff #40) who said that the resident was placed at the local boarding house. She said that she was provided the incorrect address by the placement agency. She said that the discharge paperwork included to call the facility if there was an issue but the transport did not. She said that the transport took the resident to the home health company who decided not to admit him after telling the facility they would and instructed him to go to the hospital. She said that she did not call the hospital but the home health company contacted her and told her he was in the hospital.

A second interview was conducted on October 4, 2022 at 12:57 PM with the social services supervisor (staff #40) who said that she found out the resident did not go to the right facility because the home health company did not notify her until September 7 at 1:56 PM. She said she called the clinical director over there who said the resident was not appropriate for home health and they had him go to the hospital. She said that often times the facility will call the receiving facility and give report on the resident but that when a resident discharges to a boarding home, they don’t do this because the home does not require a report especially since he was completely independent with ADLS. She said that they used a placement agency to place this resident and when they do that, the agency arranges everything and she did not even speak to the boarding house about the resident coming there. She said that the placement agency is responsible for setting it all up including confirming the address. She said the resident was provided with the option to remain in the facility but he did not want to pay because he had to pay for the boarding house. She said that home health was going to provide wound care and PT/OT. She said they provided him with the option to stay in the facility because home health wouldn’t be established for a while. She said that an average wait time for services is variable and that they are supposed to start home health services within 48 hours.

An interview was conducted on October 4, 2022 at 2:38 PM with a Licensed Practical Nurse (LPN/staff #87) who said that when residents transfer or discharge from the facility they give the receiving facility report and send documentation about the resident’s care. She said that she did not call report for this resident. She said that the nurse supervisor (staff #69) was helping her with the discharge and that she thought that the supervisor had called. She said that social services makes sure that the receiving facility gets all the information and they set up transportation.

An interview was conducted on October 4, 2022 at 3:19 PM with a LPN supervisor (staff #69) who said that she calls the receiving facility to give a report on the resident if the resident is going to the hospital or another facility. She said she usually calls report even when it’s a boarding home. She said that she did not remember the resident and she did not complete the discharge.

An interview was conducted on October 12, 2022 at 2:52 PM with a representative of the local home health company who said that when the facility asked for placement, they told the facility that they would not be able to provide home health services for 7-10 days from the time the resident was to be discharged . She said he ended up showing up to the company with a broken wheelchair that had no lock for the wheels and no cushion and he was wearing a gown with nothing on underneath it. She said they called the facility and he was redirected to a homeless shelter and told that he was not paying for his services at the facility. She said that she sent a nurse to do an emergency wellness check and he was found to have an infected wound and a high fever and that the nurse called 911. She said that she did not know what hospital he went to because he was not a patient of theirs so they were not informed. She said that the resident had three pressure ulcers on his bottom and no ability to care for himself. She said that her company does not provide care at their office.