HospitalInspections.org

Based on a review of the medical record, staff interviews, policies and procedures, Medical Staff Bylaws, complaint and grievance log, it was determined that the facility failed to provide an opportunity for the patient to appeal and object to a premature discharge thereby reducing the factors leading to preventable hospital readmissions for one patient of 4 sampled (Patient #1).

Cross reference A-0802 as it relates to the facility's failure to ensure a safe and appropriate discharge for one patient of 4 sampled (Patient #1).

Based on a review of the medical record, staff interviews, policies and procedures, Medical Staff Bylaws, complaint and grievance log, it was determined that the facility failed to provide an opportunity for the patient to appeal and object to a premature discharge thereby reducing the factors leading to preventable hospital readmissions for one patient of 4 sampled (Patient #1).

Findings included:

A review of P#1 medical record revealed that P#1 presented to the facility on 1/1/2022 at 9:31 a.m., with a cough and had lost his voice for one week. P#1 denies shortness of breath or chest pain.
A review of P#1 medical record revealed that P#1 signed the patient rights and responsibilities form on 1/1/21 at 9:32 a.m. Further review of the form revealed that P#1 had the right to object to a premature discharge and appeal a discharge through the discharge appeals process.
Patient #1's vital signs during the initial physical exam at the ED by 9:34 a.m, were as follows: Temperature: 99:5 Fahrenheit (High) (range was 96 to 99.1). Heart Rate: 75 (normal range was normal 60-100) Respiratory Rate: 17 (normal range was 12-20) Blood pressure: 92/56 (Low) (range was 100-120/60-80) Oxygen saturation: 92% (normal range was 94-100%).
Physical examination revealed that P#1 had wheezes and rales (rattling sounds) in his lungs. A review of systems revealed that P#1 was positive for cough and shortness of breath.
ED physician orders entered on 1/1/22 at 10:21 am included:
1. Labs (COVID PCR test, blood culture, complete blood count (CBC W/DIFF) with differentials, BMP, procalcitonin, c reactive protein).
2. Chest X ray.
3. Electrocardiogram (EKG).
4. Medication.

On 1/1/22 at 10:57 a.m. P#1's X-ray result showed no abnormality, lungs were cleared.
On 1/1/22 at 11:38 a.m. P#1's PCR test result was positive for COVID.
Patient #1 was admitted from the ED to the hospital's inpatient unit on 1/1/22 at 12:23 a.m. P#1 admission diagnosis was an upper respiratory tract, COVID- 19 virus infection.

On 1/1/22 at 5:05 p.m. P#1 CBC results included the following:
i. White blood cell (WBC): 4.20 (low) (normal 4.8 to 10.8 10*3/ul) (low WBC indicate possible infection)
ii. Hemoglobin :13.5 (low) (normal 14.0 to 18.0)
iii. Red blood cell (RBC): 3.85 (low) (normal 4.7 to 6.1 10*6/ul)

P#1 medications included but were not limited to the following:
i. Ondansetron (antiemetic, prevent vomiting).
ii. Enoxaparin (anticoagulant, prevent clot formation).
iii. ipratropium-albuterol (bronchodilator, improving air passage to lung making breathing easier).
iv. zinc sulfate (support immune system).
v. dexamethasone (corticosteroid relieves inflammation).
vi. remdesivir (antiviral, stopping viruses from spreading)
vii. bamlanivimab - etesevimab (monoclonal antibodies, treatment of covid).

On 1/2/2022 at 4:53 p.m a review of the physician's daily progress note revealed that P#1 stated that he felt a little bit better. The physician noted he witness some shortness of breath and cough otherwise no other complaints.
On 1/3/22 review of P#1 lab results revealed the following:
i White blood cell (WBC): 7.6 (normal 4.8 to 10.8 10*3/ul)
ii. Hemoglobin :13.3 {low} (normal 14.0 to 18.0)
iii. procalcitonin level was 0.8 ng/ml (High) (normal < 0.5 ng/ml) (high level may indicate possible bacterial infection or risk of sepsis).

On 1/3/22 at 4:18 p.m. Case Manager (CM), GG completed P#1's discharge planning evaluation. P#1 support systems were his family members, P#1 had home health through his insurance, and was to return home with his family upon discharge. CM GG noted that P#1's son will transport him home.

On 1/4/22 at 9:08 a.m. Physician(P) BB documented that P#1 reported he was feeling better today. P#1 denied having chest pain, shortness of breath, fever, chills nausea vomiting. P #1 reported chronic (long time) right shoulder pain and pain on both feet.
On 1/5/22 at 12:07 p.m., the physical therapist (PT) evaluated P#1 and noted P#1 was generally weak and had impaired mobility. P#1 would require 24 hours care. Due to the extensive burden of care, cognitive status, and advanced age, PT recommended P#1 be discharged to an inpatient setting to optimize mobility, safety and decrease fall risk and injury, if P#1's family were unable to provide the extensive care.

On 1/5/2022 at 2:50 p.m. Licensed practical nurse (LPN) (II) documented that P#1 informed her that P#1 wasn't feeling well enough to go home. LPN II noted that P BB was notified, and no new orders were placed.
On 1/5/22 at 3:39 p.m., the Social worker (SW) EE noted that she was informed that P#1's son would not be able to pick P#1 up on 1/5/21. SW EE documented that she called P#1's son and told him he would need to pick up P#1 because P#1 was medically cleared and ready for discharge. SW EE noted that P#1's son asked if he could pick up P#1 at 2:00 a.m. because he needed to travel back to the facility from a vacation. SW EE documented she informed P#1's son he could pick P#1 at 2:00 a.m. SW EE notified nursing staff and CM GG.

On 1/5/22 P BB completed P#1's discharge summary. P BB documented that P#1 was medically stable for discharge. P#1's discharge disposition was with his family. P#1 discharge diagnosis was upper respiratory tract infection, COVID-19 virus infection, and generalized weakness. P BB noted that P#1 was seen and examined by her. P#1 was doing well, denied any shortness of breath or fevers, and was ready to go home.
Patient #1's vital signs on the day of discharge at 3:46 p.m. were as follows: Temperature: 96.9 F (range was 96 to 99.1). Heart Rate: 71 (normal range was normal 60-100) Respiratory Rate: 18 (normal range was 12-20) Blood pressure: 143/75 (range was 100-120/60-80) Oxygen saturation: 93% (normal range was 94-100%).

Patient #1's lab result on the day of discharge included the following:
i. White blood cell (WBC): 8:6 (normal 4.8 to 10.8 10*3/ul)
ii. Hemoglobin :13.7 (low) (normal 14.0 to 18.0)
iii. Red blood cell (RBC): 3.92 (low) (normal 4.7 to 6.1 10*6/ul) (low may indicate anemia)
iv. Procalcitonin level: 1 (high) (normal < 0.5 ng/ml)
v. D-Dimer, Quant: 913.00 (high) (normal <=500 ng/mL) (protein fragment that's made when a blood clot dissolves in your body. High level may indicate higher risk of blood clot)
vi. C- reactive protein (CRP): 5.6 (high) (normal <=1.0 mg/dL) (protein made in liver, may be high in inflammation or recent infection)
vii. Lactate dehydrogenase (LDH) :287 (high) (normal 100 - 200 U/L)
viii. INR (international normalized ratio): 1.10 (normal 0.8 - 1.1) (indicates how well the blood is able to clot, high means high risk of clot)

P#1 was scheduled for a follow-up with his primary care physician, P#1 was discharged from the facility on 1/6/22 at 1:31 a.m.
An interview with the Director of Patient relations (DPR) CC took place on 1/18/22 at 4:14 p.m. DPR CC explained that her role was to oversee the grievance process and management of patient rights and responsibilities. DPR CC explained that her first encounter with P#1 was after she received a voice message from P#1's family explaining they were upset with P#1 being discharged from the facility at 2 a.m. in the morning. DPR CC explained that she contacted P#1's daughter-in-law and spoke with her that the facility was going to investigate the complaint and get back to her. DPR CC said the hospital immediately held a leadership meeting involving the Medical Director (MD) AA, Dir of Nursing, CNO to review the patient experiences. DPR CC explained that the facility's leadership also spoke with the staff involved in P#1's care. DPR CC said there was a communication from the nursing staff that P#1 expressed concerns he wasn't feeling too well to be discharged and this was relayed to the physician however the physician believed that P#1 was medically stable and could be discharged. DPR CC said they found out that when the facility staff spoke with P#1's son about P#1 getting discharged, P#1's son said he was on a vacation and would be able to pick up P#1 at 2 a.m. DPR CC explained that after reviewing and thoroughly investigating the complaint they realized there can be an improvement in communication between providers and the patient's family and this was relayed by the medical director to the physicians.

An interview with the Medical Director (MD) AA took place on 1/19/22 at 9:08 a.m. MD AA explained that patients admitted at the facility for COVID are not required to have a retest before they are discharged except they are being discharged to a nursing home. MD AA said the COVID test may stay positive for up to 6 months. MD AA said he was aware of P#1's complaint and spoke with the provider involved, MD AA explained that the provider believe P#1 was medically stable for discharge. MD AA said from a physician's perspective his recommendation to P BB was an improvement in communicating with patient families' discharge needs and giving them updates. MD AA said patients have the right to appeal discharge through Medicare and Medicaid and if a patient had a concern about the discharge process the clinical staff would address the concerns. MD AA explained that if a nursing staff was informed by the patient about concerns related to discharge the staff will be able to reach out to the physician and if the physician refuses to address the patient's concern, the nursing staff can escalate to the program director. MD AA said the facility's providers were reminded periodically about communication between the patient's family and providers and it will also be discussed in their next medical staff meeting.

An interview with the Physician (P) (BB) was conducted on 1/19/22 at 9:19 a.m. P BB acknowledged that she recalled P#1. P BB said P#1 was admitted to the facility's COVID floor where she met him. P BB explained that P#1 was treated and ready for discharge. P BB wrote discharge orders, notified the social worker (SW) EE and the Case Manager (CM) GG that P#1 was ready for discharge. P BB said P#1 was medically cleared and ready to go. P BB said around 3 pm SW EE told her that P#1 was still at the facility and that SW EE called P#1's family however P#1's family said they were on vacation and do not know when they would pick up P#1. P BB explained that the physical therapist had earlier seen P#1 and recommended P#1 be placed in a rehabilitation facility. P BB said she told SW EE that the hospital can place P#1 in a rehabilitation center. SW EE thereafter contacted P#1's family again and said they can place P#1 in a rehabilitation facility which the family declined and said they are six hours away and can get P#1 at 2 a.m. P BB explained that it was the family that recommended getting P#1 at 2 a.m. P BB explained that providers communicate directly with families especially if they are critically ill and update them regularly about changes in their conditions. P BB said she did not communicate directly with P#1's family and it was the social worker that was communicating with the family. P BB explained that when she was notified by the nurse that P#1 felt he was not ready for discharge she spoke with the physical therapist who agreed that P#1 should be placed in rehab, P BB said she communicated with case management to place P#1 in rehab, and they notified the family but P#1's family declined. P BB said in her opinion P#1 needed to be in rehab and not discharged home. P BB said P#1's labs were normal and medically stable for discharge. P BB explained that the facility does not perform a repeat Covid test for patients discharged home except they are going to a nursing home because nursing homes request a COVID negative test before discharge.

An interview with the Director of Case Management (DCM) FF took place on 1/19/22 at 10:12 a.m. DCM FF said she had been working at the facility for three years. DCM FF recalled that P#1's family contacted the facility's patient advocate who reached out to her. DCM FF said from her investigation P#1 had a plan to be discharged home with his son. P#1 did not need any home equipment. DCM FF said on the day P#1 was discharged, SW EE reached out to P#1's son and P#1's son said he was on vacation and would get P#1 at 2 a.m. which the facility agreed. DCM FF said from her perspective P#1 had a safe discharge, discharge plan was discussed with family and P#1's family agreed to it. DCM FF sad she did not see anything to say P#1 was inappropriately discharged. DCM FF explained that patients on Medicare can appeal their discharge however P#1 was on veteran insurance. DCM FF said the facility can work with any patient that has concerns about being discharged early. DCM FF explained that the provider will talk to the patient that was not ready to go home and resolve their concerns. DCM FF said that the common practice is to collaborate with the patient's family on placement and she believed the provider was trying to notify P#1's family of the options of placement.

An interview with the Case Manager (CM) GG took place on 1/19/22 at 10:41 a.m. at the conference room. CM GG said she had been working at the facility for three years. CM GG explained that her role included talking with patients and their families about discharge planning. CM GG said she recalled P#1, CM GG said she called P#1's son and he gave information about the patient during the initial discharge planning. P#1 was to be discharged home with his son and had no concerns. CM GG said on the day of P#1's discharge, she witnessed the nurse telling SW EE that P#1's son said he would not be able to pick up P#1 because he was on a vacation. CM GG said SW EE notified P BB and P BB insisted that P#1 was medically cleared and needed to go home. P BB told SW EE she had to call P#1's son and told him if they do not come to pick up P#1 he would be placed in a nursing home, and they would make a referral to adult protective services (APS). CM GG said it is not standard practice at the facility to threaten families with APS. CM GG said if family members said they could not pick up their loved ones the facility would work with them. CM GG said most of the time physicians and nurse updates patient family about health status especially if the patient is not doing good.

An interview with the Social Worker (SW) EE took place on 1/19/22 at 10:58 a.m. in the conference room. SW EE said she recalled P#1. SW EE explained that she works hand in hand with the case manager. The case manager will assess the patient's needs and those needs will be implemented by the social worker. SW EE said the provider informed her that P#1 was ready to go home, she called P#1's family. P#1's family told her they were six hours away on a vacation. SW EE said P#1's family asked her if they can pick P#1 in the morning, the next day. SW EE said she asked CN HH and was told P#1's family can pick P#1 at any time. SW EE said P#1's family said they would come at 2 a.m. to pick up P#1. SW EE said she was given recommendations by the physician to notify the family that if they find it difficult to pick P#1 up they can recommend that the patient be taken to a nursing home.
An interview was conducted with the Chief Nursing Officer (CNO) DD on 1/19/22 at 11:10 a.m. in the conference room. CNO DD said he recalled the incident with P#1 and was involved in investigating the grievance. CNO DD said he meet with MD AA, DPR CC, DCM FF to discuss the patient encounter. CNO DD explained that he was made aware that the facility staff reached out to P#1's son, that P#1 was stable for discharge. P#1's son indicated they were on vacation. CNO DD explained he was also made aware that there were concerns P#1 wasn't ready to go however the doctor (P BB) felt P#1 was ready to be discharged. CNO DD said the staff contacted P#1's family who said because of P#1's son's work schedules the best time to pick up P#1 was at 2:00 a.m. which the facility accepted. CNO DD said thereafter P#1's family contacted the facility and expressed concerns about the discharge process, P#1's family felt P#1 was discriminated against at the facility because he is a veteran. CNO DD said the facility does not discriminate against anyone and he is a veteran as well. CNO DD explained that from his perspective he did not see anything concerning about the discharge. CNO DD said he had conversations with MD AA and from his understanding P#1 was medically stable for discharge. CNO DD said he was not able to confirm if comments made by the physician regarding APS were true. CNO DD said such comments were not the standard practice at the facility. CNO DD explained that they always try to provide a safe and effective discharge to all patients and since the incident occurred the facility had put in place telehealth follows up with patients after they had been discharged from the facility.

A phone interview took place with the Licensed practical nurse (LPN) II on 1/19/22 at 11:47 a.m. LPN II explained that she recalled P#1, LPN II said P#1 was super quiet on the day he was being discharged and when she asked him if he was being discharged, P#1 told LPN II to notify the physician (P) BB that he wasn't feeling well to be discharged. LPN II said that she notified P BB and P BB said P#1 was stable to be discharged home. LPN II said she told P#1 and P#1 said his son was not present and asked if she could help him get his son. LPN II said she called P#1's son who told her he wasn't in town. LPN II said she notified P BB and P BB insisted P #1 should be discharged and that the facility staff can find a placement, nursing home for P#1, or get APS involved. LPN II said she inform the charge nurse (CN) HH of the situation and CN HH said LPN II should notify SW EE what P BB said, and SW EE said she would contact P#1's son.

An interview with the charge nurse (CN) HH occurred on 1/19/22 at 12:04 p.m. CN HH explained that LPN II came to meet her at the nursing station and told her that P#1 was not feeling good and wanted to stay another day at the hospital. CN HH said she told LPN II to let the doctor know and that he can stay another day. CN HH said LPN II notified P BB, but P BB insisted that P#1 was discharged and if P#1's son can't come to get P#1, protective services would be involved. CN HH said she explained to LPN II to notify SW EE. CN HH explained that SW EE contacted the family, and thereafter asked her if it was okay for P#1's family to pick up P#1 at 2 a.m. CN HH explained that she said they can come anytime. CN HH said that it was not the hospital standard to call protective services and that if patients request, they are not ready for discharge they would recommend patient waiting for another day.

An interview took place with the registered nurse (RN) JJ on 1/19/22 at 12:19 p.m. RN JJ said she remembered P#1 but was not at work on the day he was discharged. RN JJ said her only involvement with P#1 was to cosign when administering potassium (k) and help bathe him. RN JJ said discharge planning starts from admission dates and the facility staff would identify if patients admitted are to be discharged home or a skilled nursing facility. RN JJ said once the provider put in a discharge order the nursing staff would go thru the paperwork with the patient. RN JJ explained that the facility staff discusses with patients' families about the health status of their loved ones and depending on the state of the patient, they contact them every day and document the conversation in the note. RN JJ also said the staff would contact the family before discharging the patient. RN JJ said she had never called protective service on a patient, and it was not the hospital standard.

A review of the facility's policy number 1.006, titled ''Patient Rights and Responsibilities'' last revised 3/20/2019 revealed that the purpose of the policy is to outline the basic rights and responsibilities of the facility patients.
BASIC PATIENT RIGHTS
1. To object to and appeal a premature discharge through appeals procedures established by the facility.
2. To ask questions and have concerns addressed.
3. To request and refuse care, treatment, and services as allowed by law.


A review of the facility document titled "apogee physician" revealed that on 1/18/22 MD AA sent a message to the hospitalist physicians at the facility addressing that P BB had been provided coaching and education on 1/7/22 to involve patients and families as part of the discharge planning process. Further review revealed that other hospitalists will be provided similar coaching at the next monthly team meeting.

A review of the facility's grievance report revealed that on 1/6/22 P#1's daughter-in-law contacted the facilities' patient relations stating that she had concerns P#1 was discharged too early from the facility. Further review of the report revealed that on 1/7/22 at 2:30 p.m. the facility leadership which included DPR CC, MD AA, CNO DD, DCM FF, Director of Risk Management, Director of Quality Improvement, Director of Nursing met to discuss P#1's encounter and concerns around safe adequate discharge, kindness courtesy, and respect through experience. Facility leadership decided to continue following up with their respective staff and regroup the following week. A review of the report revealed that on 1/7/22 at 6:00 p.m. CNO DD reached out to P#1's son but he declined to speak with CNO DD. On 1/12/22 at 3:24 pm review of the report revealed that MD AA spoke with P BB, P BB reported that she did not directly speak to P#1's family. P BB denied using the word neglect or reporting to APS. On 1/12/22 at 3:30 p.m., the facility leadership regrouped and discussed coaching their respective staff. On 1/13/22 a grievance final letter which included acknowledgment of grievance and apology was sent to P#1's family.

A review of the complaint and grievance log from 7/9/21 to 1/15/22 revealed there were two complaints (P#1,4) related to early discharges.