Survey Report for 231514

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	231514	A. BUILDING __________ B. WING ______________	12/21/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
MEMORIAL HEALTHCARE	1975 W M21, SUITE 102, OWOSSO, MI, 48867
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0557
L0557	38304 Based on record review, policy review, and interview, it was determined the hospice failed to maintain coordination and sharing of information between disciplines, for 1 of 4 records reviewed (MR #1) for a lack of communication, resulting in the potential for unmet patient care needs. Findings include: **Agency Policy: "Occurrence Reporting" PP #860.04C stated, "The attending physician should be notified of any occurrence affecting the care of the patient or if the patient sustains injury. Document provider notification and care provided in the medical record." MR #1: The patient's start of care (SOC) was 10/6/20 with diagnoses of malignant neoplasms (cancer) of left kidney, lung, and other digestive organs. The patient resided at Olive Branch AFC (adult foster care) through 11/30/2020. On 12/21/2020, review of a skilled nursing (SN) clinical visit note dated 11/25/2020 documented the following: "Upon arrival patient sitting in wheelchair in common area, alert and oriented x1, noted to have pain in right leg, patient pulls leg back when touched, but continues to shake leg when sitting in wheelchair, reluctant to bear weight, RN informed by staff patient had a fall on 11/23/20, patient c/o (complains) pain but can not provide details... Vital signs within limits for this patient... Discussion with staff on pain management... will continue to monitor and support." The remaining assessment by SN noted no other abnormal/significant clinical findings. However, no documentation was found that the physician was notified of the patient's fall (11/23/20) or the clinical findings noted by SN on 11/25/2020. The IDG (interdisciplinary group) note, also on 11/25/20, was reviewed. IDG note documented a SN assessment on 11/23/20 with no changes in the patient's recent baseline health. No documentation concerning the discovery of the patient's fall that day by SN were found within the IDG meeting notes, which is held every two weeks. These findings were reviewed with and confirmed by the administrator (Adm-A) during an interview on 12/21/20 at 1:15 PM., who reported, "That nurse no longer works here and we'll work on making sure all significant clinical findings are communicated with the physician." The hospice agency failed to notify the physician of a significant patient injury as stipulated by agency policy.