Beach Gardens Rehab and Nursing Center
June 14, 2017 Complaint Survey

Standard Health Citations

FF10 483.40(d):PROVISION OF MEDICALLY RELATED SOCIAL SERVICE

REGULATION: (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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 14, 2017
Corrected date: August 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Complaint ID # 964), the facility did not provide medically related social services to ensure a safe discharge for one of three residents reviewed for discharge (Resident #1). Specifically, the resident was discharged to a shelter without providing required information about history, medical and functional status to the receiving agency and without providing education to the resident prior to discharge. The receiving agency did not accept Resident #1, transferred the resident back to the facility, and the facility did not accept the resident for readmission. The police were summoned by the facility and the resident was then escorted to a hospital emergency department for further determination of the resident's disposition. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented that Resident #1 was cognitively intact; required limited assist of 1 person with transfers and toileting and supervision with dressing, eating, personal hygiene, and locomotion on and off the unit. The Comprehensive Care Plan (CCP) for discharge potential dated 11/1/2016 documented the resident's discharge status was uncertain and that the resident was homeless. The Policy and Procedure for Discharge Planning dated 1/2016 lacked a documented procedure for discharging a resident to a shelter. The CCP for DM dated 11/1/2016 documented interventions to include blood sugar finger sticks four times a day and observe for diet compliance. The CCP for Vision dated 11/18/2016, documented the resident's vision was highly impaired; she was legally blind with a history of bleeding and fibrosis in the retina. Interventions included encouraging the resident to wear glasses; monitor for signs and symptoms of decreased vision such as bumping into things, failure to recognize familiar objects; identify objects for the resident if needed, as well as an ophthalmology consult and psychotherapy for the vision loss. The CCP for Care Plan meeting dated 11/23/2016, documented the resident attended the meeting, had the potential to be discharged , and was capable of self-administrating medications. There was no documented evidence the resident was educated or observed administering her own oral or injectable medication. The Physical Therapy Discharge Summary documented that the resident reached her highest practical level of achievement and was discharged from physical therapy on 12/7/2017. The Discharge Status Recommendations documented the resident needed supervision with transfers, close guard of 75 ft. with a rolling walker. The Physician order [REDACTED]. The Social Work Progress Notes (SPN), dated 1/24/2017 (no time noted), documented cigarette ashes were found in the first-floor women's bathroom by the housekeeper. Video surveillance documented the resident entering the bathroom. She was interviewed by the social worker and the recreational therapist and eventually admitted she was smoking because it was raining outside. The resident was reeducated on the smoking contract she signed and that she is putting others at risk and that if this behavior continued, it could result in discharging the resident. The resident verbalized she understood. The SPN dated 1/25/2017 (no time noted), documented the resident was found smoking in the yard at 10:45 AM and refused to comply with the smoking contract rules. A discharge notice was being given; the resident was yelling and cursing and went back outside to smoke at 11:20 AM. The Ombudsman was called and agreed to the discharge and the women's shelter was called and could accept the resident. The facility attorney and administrator were called and agreed. The resident refused to sign the discharge notice and agreed to leave the facility. Administration paid for a taxi to take the resident to the shelter and she was discharged at 3:50 PM and all parties were notified. The travel time from the facility in Far Rockaway to the shelter in the Bronx is approximately 1 hour and 10-15 minutes. The PO dated 1/25/2017 documented the resident was being discharged to the women's shelter. The Discharge Plan dated 1/25/2017 documented the resident could dress herself and needed supervision with ADL's, and could transfer and propel in the wheelchair independently and that she was going to be discharged to a shelter, is safe and all parties were notified. The Discharge Medication List dated 1/25/2017 documented the resident was on Glucophage (oral antidiabetic medication) 500mg twice a day, and on a sliding scale of Novolog Insulin injections 4 times a day. There was no documented evidence that the resident was educated or assessed for ability to demonstrate safe self-administration of medications. Resident #1's medical record lacked documentation evidence of who was contacted at the shelter or that the resident's care needs were discussed. There was no documented evidence that a shelter packet of resident information, including a shelter outreach referral form required by the shelter, was completed and provided to the receiving agency or the resident. The SPN dated 1/25/2017 documented the resident returned from the shelter via cab and the police were called and took the resident to the hospital emergency room at 9:45 PM. On 1/26/2017, the Social Worker (SW) at the hospital was looking to return the resident to the facility but the social worker told them they would assist the ER SW on placement if needed but the facility could not take the resident back into the facility. During an interview on 1/30/2017 at 12:35 PM with the Director of Social Services, (DSS), she stated the resident previously lived at an assisted living facility and did not have a specific discharge plan because she was currently homeless, and still needed physical therapy after her leg amputation. The DSS stated that the resident would not adhere to the smoking schedule or the safety regulations for smoking and when confronted, the resident would tell her she would not do it again. She stated the resident would not forfeit her cigarettes or lighter as outlined in the smoking contract and that there was nothing she could do except alert the nursing staff. The DSS stated the housekeeper alerted her about the resident smoking in the first-floor bathroom and that she saw the ashes on the sink. The DSS spoke to the resident who admitted she was smoking in the facility, so the DSS informed the resident that the next time she smoked she would be discharged ; the resident verbalized she understood and told her she would not do it again. The next day the resident was found smoking in the yard off hours and unsupervised by the DSS, so she told the resident she was going to be discharged because she was putting the entire facility at risk and that the resident was yelling and cursing and then went out and smoked another cigarette. The DSS stated she spoke to the Medical Doctor (MD) who approved the discharge to the shelter and that she spoke to SW #2, the Administrator, facility attorney, and Ombudsman who all agreed that the resident could be discharged . The DSS stated the process for discharging a patient to a women's shelter, from her experience, was that she had to send the resident with ID (identification), the discharge summary, and the medication list. The DSS stated she called the shelter first to see if they would take the resident and they could. She believed the resident was a safe discharge to the shelter because she was alert and oriented and was independent with care. She stated Physical Therapy cleared the resident for discharge because she was supervision of 1. She stated she stayed with the resident as her room was being packed and helped put the resident's belongings in the cab including a wheelchair. The DSS stated that, at around 7:30 PM, the resident came back to the facility telling the Registered Nurse Supervisor (RNS) that the shelter would not take her because she was missing paperwork, so the RNS called her. The DSS stated she told the RNS that SW #2 handed the paperwork to the resident when she left and that she could not accept the resident back because she was discharged , so the police were called, and they took the resident over to the emergency room . The ER SW tried to reach the DSS the next day to see if they could take the resident back, but she explained that they couldn't because she was a danger to the other residents and the facility because she would not comply with the smoking contract or give staff her lighter or cigarettes. The DSS stated she told the ER SW that she tried to get the resident into the assisted living facility where she previously lived, but they would not take the resident back. The DSS stated another facility was willing to assess her in the ER for placement, but the resident was gone by that time she got in touch with the ER SW; the resident's friend took her home. She stated there was not a discharge plan in place because the resident was still getting therapy and had no discharge plan in the beginning of January. During a subsequent interview on 1/31/ at 12:35 PM with the DSS, she stated before she called the shelter, she attempted to get the significant others of the resident to take her but was unsuccessful and that she called the assisted living facility who would not take her back. The DSS stated she spoke to the social worker at the shelter who told her they would take the resident. She stated she did not discuss the resident's medical [DIAGNOSES REDACTED]. During an interview on 1/30/2017 at 1:20 PM with the SW #2, he stated the resident was noncompliant with the smoking policy and the contract, which she signed. He stated she was creating a safety issue for the other residents and, typically, a resident would get a 30-day notice for discharge, but they felt it was a significant risk to the other resident's, and she had previous warnings, so they wanted to discharge the resident as soon as possible. He stated the resident's significant others would not take her or the assisted living where she previously lived. SW #2 stated it is SW's responsibility to ensure that the discharge summary was completed by all disciplines. SW #2 stated that he is not aware of a policy and procedure for discharging a resident to a shelter. He stated when the resident was being discharged he handed the resident the discharge notice which she would not sign, her belongings, and her medications and does not recall if the resident was on insulin. SW #2 stated the resident was alert and oriented and knew what medications she was on and that the MD was notified and signed off that the resident was a safe discharge. During an interview on 1/30/2017 at 3:05 PM with 7:00 AM-3:00 PM RNS #1, she stated the resident was getting insulin coverage, was not on a standing dose, and was not on insulin prior to her admission to the facility. RNS #1 stated that the discharge was quick so there was no patient teaching at that point. She stated she notified the MD that the resident was going to a shelter and he approved her discharge. RNS #1 stated that someone would have to assist the resident with medications; like to prepour them and that the resident would not be able to read the medication labels because of her vision impairment related to a retinal detachment and fibrosis. RNS #1 stated that the resident was mostly independent with her care, knew her medications, but could not read the medication labels. RNS #1 stated the resident did not have any one she could stay with so her future discharge plans were not clear as of January. She stated the facility was addressing her medical issues, ordered a prosthetic for her amputated leg, and the goal was to get the resident to her optimal functioning level of care in case there was somewhere she could be discharged to. During an interview on 1/31/2017 at 10:44 AM with the 7:00AM-3:00PM, Licensed Practical Nurse (LPN #1), she stated the resident could not visualize her medications in the med (medication) cup but was aware of the medications she was taking. During an interview on 1/31/2017 at 10:59 AM with the Physical Therapist (PT), he stated the resident was discharged from the program on 12/7/2016 because she reached her maximum practical level; she had one leg and could hop with a walker and transfer to the wheelchair independently. He stated the plan was when the prosthesis was ready, they would start therapy again. The PT stated the obstacle with her care was that the diabetes was affecting her vision which was getting progressively worse. The PT stated the resident told him that she was told by the ophthalmologist that her vision would be gone within 6 months and because of her visual deficits; the resident required visual and verbal cues like watching for obstacles while turning in the wheel chair during therapy and would need them after discharge. He stated the resident was independent with bed to chair, chair to bed, and sit to stand transfers. He stated that he believed, based on the last time he worked with the resident, she would need someone at home or elsewhere to help her secondary to the vision loss. During a telephone interview on 1/31/2017 at 11:50 AM with the 3:00PM-11:00 PM RNS #2, she stated she was alerted by the receptionist that the resident was back at the facility and wanted to be admitted so she called the DON and DSS, and they told her the resident was discharged and that they could not take her back. The DSS instructed her to tell the resident she was discharged and they couldn't take her back and that the resident stated the shelter told her she was missing paperwork, and would not accept her. RNS #2 stated the resident had the discharge paperwork in her hand and the people at the shelter told her she was missing shelter paperwork so she relayed it to the DSS, who told RNS #2 to tell the resident she must go back but the resident refused. RNS #2 stated she told the DSS this was not a nursing problem and was told to call 911, so she did, and again she explained to the resident why they could not take her back. She stated the police came trying to assist with the situation, while RNS #2 attempted to reach the shelter but no one answered the phone. The police told the resident that they could take her to the hospital and she agreed but her belongings were boxed up and couldn't fit in the car. The DSS told RNS#2 that they could hold the boxes in storage for the resident until she could pick them up. During an interview on 1/31/2017 at 3:49 PM with the Administrator (ADM), The ADM stated residents are sent with their Identification, medications, medication lists, and the discharge summary and it has not been an issue in the past. He stated they pay for the taxi to ensure the resident gets to their destination and that the resident was safely discharged , He added that if the shelter felt they could not take in or accommodate the resident's needs, they should have sent her to the Hospital, and he was told that the resident wanted to come back to the facility, did not want to go into shelter, and that the shelter did not turn her away, she chose to leave. During a telephone interview with SW #3 (SW Director of Social Services for Homeless services) on 3/23/17 at 1:00 PM, she stated that Resident #1 arrived to the shelter on 1/25/17. The resident did not arrive during the hours of 9 AM to 5 PM, which are the normal intake hours. The shelter did not receive notice that the client was coming. The client (Resident #1) was not turned away. The client was discharged inappropriately to the shelter. A shelter packet should have been completed, but was not. A shelter packet includes a shelter outreach referral form, demographics, ambulatory status, functional status, clinical criteria, and client history. The packet is available online. If the facility called her, she could have scanned or faxed information to the facility. There is an onsite medical provider; however, the shelter packet would have been reviewed by the medical provider, the Shelter Director and herself to determine if the shelter was the appropriate facility for the resident. This review did not take place because the facility did not provide the necessary information. When the client arrived on 1/25/17, the shelter's staff placed a call to the facility, the facility staff (unknown) confirmed she was known to the facility and the client was sent back to the facility that evening. SW #3 did not know the exact conversation that transpired. SW #3 stated that she called the facility the following day and spoke with SW #2 but he was reluctant to share information. She also placed a call to the DSS, but never spoke to her. SW #3 stated that it could have been avoided if the proper paperwork was provided. 415.3(h)(1)(ii) (a-c)

Plan of Correction: ApprovedJuly 17, 2017

Disclaimer: Preparation and execution of the Plan of Correction does not constitute an admission or agreement by the Provider as to the truth or accuracy of the facts alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is developed and executed because it is required by Federal and State Laws and in accordance with regulations for continued Medicare/Medicaid certification.
I. Immediate Corrective Action:
1. Resident #1 no longer resides at the facility. Resident #1 was transferred to the hospital and was then discharged to friend?s home.
2. Educational counseling was provided by the administrator to the social workers and nurses with a focus on:
a. Requirements for medically related social services as per policy.
b. The discharge planning process for all residents to ensure a safe and effective resident discharge process. This included the requirement of educating all residents prior to discharge, with documentation, including self- administration of education/treatment with safe return demonstration.
c. The discharge planning process to a NYC Shelter as per the NYC Department of Homeless Services guidelines.
II. Identification of other residents:
1. The facility conducted a review of all discharged residents, including residents discharged to a shelter, for the past 90 days. There were no discharges to the shelter. Charts were reviewed for the residents discharged in the last 90 days and there were no outstanding concerns noted.
2. The facility conducted a review of all potential discharges in the next 30 days. A list was compiled onto a ?Discharge Tracking Log?.
3. All residents with potential for discharge within the next 30 days will be discussed at the weekly ?Discharge Meeting? that is held with the interdisciplinary team to ensure that all policies and procedures are being followed to facilitate a safe and orderly transition for the residents.

III Systemic Changes:
1. A new Policy and Procedure was written on ?NYC Shelter Discharges-DHS?.
2. The Policy & Procedure on ?Transfer and Discharge Requirements/Documentation? was revised.
3. The Policy & Procedure on ?Discharge Planning Process & Discharge Summary? was revised.
4. These policies all include safe discharge planning measures to ensure that all residents discharged to any location follow current regulations including, but not limited to:
1. A safe and effective discharge plan
2. Educating all residents prior to discharge with accompanying documentation including the potential for self- administration of medication/treatment with safe return demonstration.
3. Discharge instructions
5. The In-service coordinator/designee will provide education to the Social Workers, Interdisciplinary Care Plan team and Nurses regarding the above new or revised policies. The In-service will focus on:
? The requirement for safe discharge planning measures to ensure that all residents discharged to any location, including a NYC shelter, are safe.
? The requirement of educating all residents prior to discharge with accompanying documentation including the self- administration of medication/treatment with safe return demonstration.
? The requirement to provide residents/responsible party with a copy of the Discharge Instructions and to also fax a copy of the discharge Instructions to the receiving facility, if applicable.
? The requirement to maintain ongoing documentation of the resident?s discharge needs and the efforts being done to facilitate a safe and orderly discharge, including the contact names and phones numbers of the outside agencies involved in the discharge.
? The requirement that the social worker follow up, post-discharge, with the resident or the responsible party to verify the resident?s status and any address any outstanding concerns post discharge. This includes the contact at the NYC Shelter.
6. The Lesson Plan and education will be filed for validation.
7. The weekly ?Discharge Meeting? will be restructured to include all residents who are in facility on a short-term basis and updates will be discussed weekly with the interdisciplinary team.

IV. Quality Assurance Performance Improvement monitoring:
1. The facility will develop an audit tool to monitor compliance with the facility?s Policy and Procedure for discharging residents to all destinations, including a NYC shelter.
2. The audit will be completed for all discharges to any destinations, including a NYC shelter, monthly for the next 3 months then quarterly by the Director of Social Service/Designee.
3. Audits with negative findings will have immediate corrective actions and will be referred to the Administrator/designee for review and follow up.
4. The Director of Social Services/designee will report all audit findings to the Quality Assurance and Performance Improvement Committee on a quarterly basis for evaluation and follow-up. Additional corrective action will be implemented immediately, as indicated.
V. Responsible Discipline:
Director of Social Work/designee