HospitalInspections.org

Based on interview and record review, it was determined the hospital's governing body failed to provide appropriate oversight, quality medical care, and overall management of its operations.

Findings include:

1. The hospital's governing body failed to promote and protect each patients' rights.
(Refer to tag A-0115)

2. The hospital's governing body failed to systematically analyze the root causes of a sentinel event and appropriately implement preventive actions to ensure it would not happen again. (Refer to tag A-0263)

3. The hospital's governing body failed to ensure medical staff assessed a patients ability to walk and need for post-hospital care, which led to an adverse health event after her discharge. (Refer to tag A-0338)

4. The hospital's governing body failed to ensure nursing staff followed policy and procedures resulting in a adverse health event of a patient. (Refer to tag A-0385)

5. The hospital's governing body failed follow their discharge planning process that applied to all patients; this resulted in a finding of Immediate Jeopardy (IJ). (Refer to tag A-0799)

Based on interview and record review, it was determined the hospital failed to promote and protect each patients' rights.

Findings include:

The hospital failed to ensure patients participated in the development and implementation of his or her plan of care. (Refer to tag A-0130)

Based on interview and record review, it was determined the hospital did not ensure patients participated in the development and implementation of his or her plan of care. Specifically, for 1 of 13 sampled discharged patients the hospital did not ensure the patient participated in the development and implementation of their discharge plan. (Patient identifier: 7)

Findings include:

Patient 7 was admitted on 12/14/22 with diagnoses of diabetic ketoacidosis, renal vein thrombosis, and urosepsis.

Patient 7's medical record review was completed on 2/7/23 and revealed the following:

On 12/15/22 at 12:41 PM, a case manager (CM) performed a discharge assessment on patient 7. It was documented the patient was projected to be discharged on 12/17/22 to home with home health. Functional impairments were listed as: functional, cognitive, visual, hearing, speech, and language. Prior to admission she required a cane to walk. Learning barriers were documented as: cognitive/memory and energy level. It was further documented in a CM note. "She usually takes Metformin for DM (diabetes mellitus) but has never been insulin dependent. She has no history of home health or SNF (skilled nursing facility). She is open to maybe having home health come in but has no preference. CM will continue to follow until discharge."

(Note: It was documented in patient 7's medical record that she had a stage 2 pressure ulcer, was a 1 to 2 person assist, required frequent reorientation, had confusion, and was a newly insulin dependent diabetic as well as newly on a blood thinner.)

On 12/16/22 at 2:12 PM, the following was documented in a CM note. "Patient will be having a Renal Thrombectomy today, then patient may need some home health when it is time for discharge. CM to follow."

No other follow-up documentation from a case manager or discharge planner could be provided regarding home health services or other post discharge care needs.

On 12/17/22 at 11:42 AM, a discharge order was written.

On 12/17/22 at 3:42 PM, the discharging nurse documented the following: patient 7 stated her daughter was coming to pick her up, after her daughter did not arrive patient 7 stated her boyfriend would come get her. According to documentation patient 7 became increasingly aggressive and agitated when asked about her transportation. (Note: per interview with the discharging physician, he was not aware patient 7 had a change in attitude about discharging). There was no documented evidence in patient 7's medical record of anyone attempting to contact the physician, or any family or a support person.

On 12/19/22, the security guard that escorted patient 7 to the bus stop documented the following in a report. "The nurse said [name] (patient 7) did not want to leave. [name] (Patient 7) told me she still needed medical help. [name] (patient 7) expressed much pain in the knees as she stood to get in the wheelchair. The nurse and I helped her." The report stated the security guard tried to assist patient 7 in putting on the jacket the hospital provided for her, but she instructed him to place it on the bench so she could sit on it. The security guard documented he told patient 7, "The bus driver would help her on." The security guard further documented he went to check on her around 2:30 PM but did not make contact with patient 7. At that time, he noticed the bus go by without noticing or stopping for patient 7. The report stated the security guard checked again around 7:30 PM, but from a distance. He documented that he thought he could only see a trash can.

Note: The hospital could not provide evidence anyone went outside to check on patient 7 after she was left at the bus stop.

In summary, patient 7 was escorted out by security on 12/17/22 around approximately 3:45 PM. She was wheeled out in a wheelchair and left at a bus stop without any means to make it on or off the bus. She did not have any assistive devices to help her walk on or off the bus. Patient 7 was found dead near the bus stop the following morning (12/18/22). According to an Internet search, the outside temperature between the hours of 3:30 PM on 12/17/22 to 7:00 AM on 12/18/22, ranged from 15 to 27 degrees.

The hospital could not provide sufficient evidence to show patient 7 actively participated in the development and implementation of appropriate care planning that would meet her needs once discharged, included further assessing and informing a physician of her reluctance to leave the hospital at discharge. Additionally, there was no documented evidence as to what education the patient was provided regarding insulin, blood thinners, or wound care.

Based on interview and record review, it was determined the hospital failed to develop, implement and maintain and effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that involved all hospital departments and services. Specifically, the hospital failed to appropriately investigate and implement systematic improvements after a sentinel event led to a patient's death.

Findings include:

The hospital's quality assurance team failed to systematically analyze the root causes of a sentinel event and appropriately implement preventive actions to ensure it would not happen again. (Refer to tag A-0286)

Based on interview and record review, the hospital did not adequately analyze and investigate adverse patient events and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Specifically, for 1 out of 2 sampled patient events that resulted in death, the hospital did not systematically analyze the causes of a sentinel event and appropriately implement preventive actions to ensure it would not happen again. (Patient identifier: 7)

Findings include:

An incident report dated 12/21/22 was reviewed and revealed the following:

An incident with patient 7 occurred on 12/17/22. The hospital was notified of the incident on the morning of 12/18/22. The incident report was not created until 12/21/22, three days after being notified of the incident.

According to documentation, the hospital rated the incident as a severity level- 4 catastrophic. Patient 7 reportedly froze to death at a bus stop outside the hospital after being discharged. Patient 7 did not have transportation lined up and was assisted by the nurse and the security guard into a wheelchair and wheeled out by security to a bus stop where she was left.

(Note: It was documented in the patients' medical record that she had some confusion and required assistance with walking; however, there was no documented evidence of knowledge, or an assessment, by clinical staff of patient 7's ability to walk.)

The hospital's incident report documented that a root cause analysis (RCA) and chart review were completed and done. The final follow-up summary had some of the following listed: No corrective action identified, referred to peer review, RCA performed, staffing education performed, and staffing practice/policy modified. The incident was recorded as closed on 1/13/23 by the quality/risk manager. When further documentation of the hospital's findings from their review of the incident was requested, no documented evidence of a complete review could be provided.

On 1/25/23 at 12:03 PM, the quality/risk manager was asked for documentation of any education or policy changes that occurred as a result of the investigation. On 1/25/23 at 3:09 PM, she responded via email the only education was to security. The education was a memo that was posted. The memo stated they would now be sheltering any discharge patient in the lobby area during any severe weather, or if they had no means of transportation. She also stated they were looking into changing a discharge policy to make it so patients could shelter in the lobby during severe weather or if they had transportation issues. She stated, no changes had been made yet. No other education other than a posted memo was provided. Additionally, there was no evidence of a completed policy change.

On 1/26/23, the RCA that was documented as being completed was requested. On 1/26/23 at 10:17 AM, an email was sent from the Quality/risk manager. It read, "Honestly, I do not have a full RCA to send for (name of patient 7). After I got back from my holiday and there was not anything done, I started compiling everything for me to write up the RCA. I have medical records printed, email communications with the questions I had. I met with CM (case manger) Director about the meeting, because I was on vacation for the RCA meeting after this event. I wanted to get attendance for that meeting. I talked to security and got the security report. I reviewed the action items from the initial meeting but I still want to do a timeline. There is no excuse but that is where I am on it."

On 1/26/23, the quality/risk manager was asked what had been found after their record review investigation. On 1/26/23 at 2:44 PM, an email was sent from the quality/risk manager. It read, "Normally our process for investigation would include our ICU (intensive care unit) nurse who is the Patient Safety and Quality Specialist in my office do a medical record review. This had not happened yet. I did print and review the discharge summary but a full record review has not been done yet."

On 1/26/23 at 11:00 AM, the CMO was interviewed. He was asked if he was aware of the incident of the patient that died at the bus stop. He stated he was not made aware of the incident until right before the surveyor's interview. He further stated he expects to be notified of serious events such as this. The CMO stated that ideally, he would like to be notified within 24 hours and would want a root cause analysis started as soon as possible. He stated he did not think it occurred to people that the hospital did anything wrong, therefore it was not escalated to him. The CMO was asked if a RCA and a full review of the medical record should have been done. He replied, yes, his expectation was to begin the process within seven days and the conclusion would depend on moving parts.

On 1/30/23 at 11:00 AM, an interview was conducted with the quality/risk manager. She was asked about the incident report documenting the investigation was closed. She stated she was not sure, because it was clearly not closed. She further stated, they started working on the RCA on Saturday (1/28/23).

On 2/7/23, a review of the policy titled "Incident Reports: Sentinel Events" was completed. It stated, sentinel events (events that resulted in severe harm or death) should be reported to the hospital's chief medical officer (CMO). The following information was also noted in the policy:

Initial response to the event should include:
-Evaluation and immediate corrective action to obvious system failures to mitigate future risk to other patients.
The review process should include:
-The Chief Medical Officer and the Hospital Risk Manager/designee, in consultation with the Director, Quality and Safety will determine whether or not a sentinel event has occurred and initiate a root cause analysis. There will be communication to all key personnel as indicated from review of the event. This preliminary review process should ideally occur within 24 hours of the event or discovery of the event based on severity of the event reported.
-The Chief Medical Officer supported by the Quality and Safety Department will identify the members of the Root Cause Analysis Team. (Within 3 days).

It was determined that the quality assurance performance improvement program did not appropriately and timely investigate this level-4 catastrophic event involving the death of patient 7, including identifying system causes in order to prevent future sentinel events of this nature.

Based on interview and record review, it was determined the hospital failed to have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital.

Findings include:

The hospital medical staff failed to assess a patients ability to walk and need for post-hospital care, which led to an adverse health event after her discharge. (Refer to tag A-0358)

Based on interview and record review, it was determined the medical staff did not complete an adequate history and physical. Specifically, for 1 of 13 discharge patients, the medical staff did not assess a patients ability to walk and need for post hospital care, which led to an adverse health event after her discharge. (Patient identifiers: 7)

Findings include:

Patient 7 was admitted on 12/14/22 with diagnoses of diabetic ketoacidosis, renal vein thrombosis, and urosepsis. Patient 7 was discharged on 12/17/22 and passed away within 24 hours of being discharged from the hospital.

1. Patient 7's medical record review was completed on 2/7/23 and revealed the following:

On 12/15/22 at 12:41 PM, a case manager (CM) performed a discharge assessment on patient 7. It was documented the patient was projected to be discharged on 12/17/22 to home with home health. Functional impairments were listed as: functional, cognitive, visual, hearing, speech, and language. Prior to admission she required a cane to walk. Learning barriers were documented as: cognitive/memory and energy level. It was further documented in a CM note. "She usually takes Metformin for DM (diabetes mellitus) but has never been insulin dependent. She has no history of home health or SNF (skilled nursing facility). She is open to maybe having home health come in but has no preference. CM will continue to follow until discharge."

On 12/17/22 at 12:08 PM, patient 7's last assessment before discharge was completed. Under "altered thought process" it documented patient 7 had "confusion." Under neurological assessment signs and symptoms "confusion" was also documented. Under comprehension ability it was documented as "impairment." Under gait (ability to walk) it was documented as "unable to assess". (Note: There was no documented evidence any of the nurses assessed patient 7's gait throughout her stay.) Under activities of daily living, it was documented patient 7 required "frequent reorientation." And, her level of independence was a 1 person assist. Patient 7 also had a stage 2 pressure ulcer documented. (Note: per interview and record review patient 7 was discharged without an evaluation from a physical therapist and without home health ordered). Patient 7's last vital signs before discharge on 12/17/22 at 12:45 PM, showed elevated respirations of 34. Patient 7 had an elevated blood sugar before discharge at 11:30 PM, of 343. Patient 7's Hemoglobin was 10 g/dL (grams per deciliter) and hematocrit was 33.4% at 8:50 AM (normal range for women was 12.1 to 15.1 g/dL and 36 to 48 percent, respectively).

In summary, documentation revealed patient 7's had a stage 2 pressure ulcer, was a 1 to 2 person assist, required frequent reorientation, had confusion, and was a newly insulin dependent diabetic and blood thinner recipient.

2. According to a security officer's statement in a report, it documented that on 12/17/22 around approximately 3:45 PM after patient 7 was discharged and did not obtain a ride to come pick her up, she was escorted out of the hospital by security. She was wheeled out in a wheelchair and left at a bus stop without any means to make it on or off the bus. She did not have any assistive devices to help her walk on or off the bus such as a cane. Patient 7 was found dead near the bus stop the following morning (12/18/22). According to an Internet search, the outside temperature between the hours of 3:30 PM on 12/17/22 to 7:00 AM on 12/18/22, ranged from 15 to 27 degrees.

3. On 1/26/23 at 5:15 PM, patient 7's discharging physician (physician 1) was interviewed. Physician 1 was asked if he was aware patient 7 needed assistance with ambulating (walking). He replied he never saw patient 7 ambulate. He stated if a patient was not up and ambulating, he would never clear the patient for discharge. He further stated, if a patient was never observed walking, he never would have had the patient wheeled out. Physician 1 stated they had interdisciplinary rounds during the day (Note: per interview with the discharge planner they did not do rounds on the weekends, when the patient was discharged) where any concerns about a patient should be brought up. He stated he was not aware the patient had any issue ambulating or that patient 7 was agitated and refusing to leave before discharge. Physician 1 stated he would have expected to be informed of that and that he relies on the nurses to pass that information along. Physician 1 was asked about patient 7's elevated blood sugar of 343. He replied that was not a range that was concerning. He stated 200 would be the general goal. He stated he was not sure why the patients' blood sugar was not corrected. Physician 1 stated he should be called if it is over 300. He further stated he did not know what happened after his evaluation in the morning because he did not hear anything after he saw her. Physician 1 was asked if he was aware of patient 7's pressure ulcer. He stated he was trying to look back in his notes to see. He stated he could not say for sure he was aware. He could not see he documented anything on a pressure ulcer. He stated he relies on nurses to pass that information on to him.

On 1/30/23 at 2:11 PM, the weekend discharge planner was interviewed. She stated the hospital does not do rounding like during the week, on the weekends. She stated she was the discharge planner for the entire hospital on the weekends. She was asked what her process was during the weekend. She replied, she asks the attending physician if the patient has any needs; she was told patient 7 did not have any discharge needs by the discharging physician.

On 1/31/23 at 11:00 AM, an interview was conducted with the chief medical officer (CMO). The CMO was asked would a patient requiring assistance or assistive devices to ambulate be expected to take a bus home alone without such assistance. The CMO stated that if it was unknown if a patient was able to ambulate, that patient should not be put on a bus without support. The CMO was asked if it should have been identified or assessed during patient 7's admission history and physical assessment and assessment updates, completed by different physicians involved her care, that patient 7 had difficulty ambulating and was a 1 person assist. The CMO stated a physician should know whether a patient could ambulate, and it should be a part of the discharge plan; whether they observe, ask the patient, or verify with the nurse. The CMO stated, patient 7 probably would still be alive if she did not go out into the elements. A caring person should not leave someone in a dangerous situation.

4. The hospital's policy titled, "History and Physical Examinations. Chapter: Medical Staff. Policy Number: MS 08" it read, "The purpose of a medical history and physical examination is to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient."

The hospital's policy titled, "Pressure Injury Prevention and Management. Chapter: Provision of Care. Policy Number: POC 21" under "procedures" it identified the Braden Scale as the assessment tool used by the hospital.

Note: A Braden Scale is used to identify risk of a patient developing a pressure injury. The tool reviews risk in 6 categories or sub-scales including: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

The hospital's policy titled, "Admission, Transfer, and Discharge. Chapter: Medical Staff. Policy Number: MS 27" under "III. DISCHARGE. A. Discharge Planning" it stated, "The Attending Practitioner's decisions regarding the provision of ongoing care, treatment, and services, discharge, or transfer of his/her patients must be based on the assessed needs of the patient .... In addition, the Attending Practitioner shall cooperate with the Hospital's discharge planning staff to: 1. Alert staff 24 hours in advance of patient discharge or transfer whenever feasible; 2. Identify any needs the patient may have for psychosocial or physical care, treatment, and services after discharge or transfer; 3. Include the patient, the patient's family, practitioners, case coordinators, and other relevant staff involved in the patient's care, treatment, and services in planning for the patient's discharge or transfer; 4. Assist, when needed, in arranging for the services required by the patient after discharge in order to meet the patient's ongoing needs for care and services; and 5. Provide the patient and, where appropriate, the patient's representative information regarding: a. why he or she is being discharged or transferred; b. any alternatives to discharge or transfer; c. the types of continuing care, treatment, and services the patient will need after discharge; and d. how to obtain any continuing care, treatment, and services that the patient will need.

The hospital's policy titled, "Discharge / Transition of Care Planning. Department: Care Management. Policy Number: CM 02" under "Procedure" it read, "No patient with post-acute service requirements will be discharged until the hospital has ensured arrangements are completed. Every effort will be made to avoid discharge to a shelter or the street." And, under "General Guidelines" it read, "Each healthcare discipline assesses and reassesses needs for aftercare as part of the ongoing assessment and reassessment processes and communicates any changes relative to patient's condition, changes in available post-discharge support and/or changes to post-hospital care requirement to ensure an update/change to initial discharge plan to the interdisciplinary team."

5. The hospital could not provide sufficient evidence that patient 7 received appropriate assessments and discharge planning by the medical staff to determine her need for post-hospital care, which led to an adverse health event, and her death, after her discharge.

Based on interview and record review, it was determined the hospital failed to ensure nursing staff followed policy and procedures resulting in a adverse health event of a patient.

Findings include:

The hospital failed to ensure all licensed nurses who provided services in the hospital adhered to the policies and procedures of the hospital. (Refer to tag A-0398)

Based on interview and record review, it was determined the hospital did not ensure all licensed nurses who provided services in the hospital adhered to the policies and procedures of the hospital. Specifically, for 1 of 13 sampled discharge patients nursing staff did not follow the hospital discharge planning policies when discharging the patient; this led to an adverse health event occurring within 24 hours of the patient being discharged. (Patient Identifier: 7)

Findings include:

1. Patient 7 was admitted on 12/14/22 with diagnoses of diabetic ketoacidosis, renal vein thrombosis, and urosepsis.

Patient 7's medical record review was completed on 2/7/23 and revealed the following:

On 12/17/22 at 12:08 PM, patient 7's last assessment before discharge was completed. Under "altered thought process" it documented patient 7 had "confusion." Under neurological assessment signs and symptoms "confusion" was also documented. Under comprehension ability it was documented as "impairment." Under gait (ability to walk) it was documented as "unable to assess". Under activities of daily living, it was documented patient 7 required "frequent reorientation." And, her level of independence was a 1 person assist.

According to documentation, patient 7 also had a stage 2 pressure ulcer to her sacral (bottom) area. Additionally, there was no documented evidence in the medical record a nurse assessed patient 7's gait throughout her stay.

On 12/15/22 at 12:41 PM, a case manager (CM) performed a discharge assessment on patient 7. It was documented that the patient was projected to be discharge on 12/17/22, to home with home health. Functional impairments were listed as: functional, cognitive, visual, hearing, speech, and language. Prior to admission she required a cane to walk. Learning barriers were documented as: cognitive/memory and energy level. It was further documented in a CM note, "She usually takes Metformin for DM (diabetes mellitus) but has never been insulin dependent. She has no history of home health or SNF (skilled nursing facility). She is open to maybe having home health come in but has no preference. CM will continue to follow until discharge." (Note: It was documented she was being sent home with new prescriptions for insulin and a blood thinner.)

On 12/16/22 at 2:12 PM, the following was documented in a CM note. "Patient will be having a Renal Thrombectomy today, then patient may need some home health when it is time for discharge. CM to follow."

No other follow-up documentation from a case manager or discharge planner could be provided regarding home health services or education needs for insulin, blood thinners, or wound care.

2. On 12/17/22 at 3:42 PM, the discharging nurse documented the following, patient 7 stated her daughter was coming to pick her up, after her daughter did not arrive patient 7 stated her boyfriend would come get her. Patient 7 became increasingly aggressive and agitated when asked about her transportation. The nurse documented that if patient 7 could not produce a ride she would be escorted out by security.

Note: There was no documented evidence in patient 7's medical record of anyone attempting to contact any family or support person. And per interview with the physician and discharge planner, the change in behavior and inability to secure a ride home was not communicated with the discharging physician or discharge planner.

According to an incident report statement completed by a security guard, patient 7 was escorted out by security on 12/17/22 around approximately 3:45 PM. She was wheeled out in a wheelchair and left at a bus stop without any means to make it on or off the bus. She did not have any assistive devices to help her walk on or off the bus such as a cane. Patient 7 was found dead near the bus stop the following morning (12/18/22). According to an Internet search, the outside temperature between the hours of 3:30 PM on 12/17/22 to 7:00 AM on 12/18/22, ranged from 15 to 27 degrees.

On 1/30/23 at 2:11 PM, the weekend discharge planner was interviewed. She stated the hospital does not do rounding like during the week on the weekends. She stated she was the discharge planner for the entire hospital on the weekends. She was asked what her process was during the weekend. She replied, she asks the attending physician if the patient has any needs. She was told patient 7 did not have any discharge needs.

On 1/31/23 at 12:04 PM, the hospitals discharge planner was interviewed. She stated, they did not think patient 7 was going to be discharged over the weekend because of the thrombectomy done on 12/16/22. She further stated, if the patient did not discharge over the weekend "I guarantee 100% this would not have happened."

3. On 2/7/23, a review of the policy titled "Discharge/Transition of Care Planning" was completed. The following was documented in the policy:

-Nursing staff will screen patients upon admission and throughout the hospital stay to determine those
who may be at risk for an adverse health consequence post-discharge and the patient's need for
discharge planning. Referral to Care Management/Social Work if any concern is identified by
hospital staff, patient or family. Referrals to Care Management/Social Work are made either via
electronic health record system, in writing, or verbally.

-No patient with post-acute service requirements will be discharged until the hospital has ensured
arrangements are completed. Every effort will be made to avoid discharge to a shelter or the street.

-Through the Interdisciplinary Team (IDT) / PULSE meetings, a team approach is utilized by the
hospital in assessing and reassessing the discharge plan allowing all members to collaborate on a
patient's discharge needs timely. Changes in patient's condition throughout the hospitalization that
warrant adjustments to the discharge plan are brought forward during the IDT /PULSE meetings and
documented in the patient record. (Note: per staff interview, IDT was only held on weekdays, with no alternative for the weekend when patient 7 was discharged)

-Each healthcare discipline assesses and reassesses needs for aftercare as part of the
ongoing assessment and reassessment processes and communicates any changes relative to
patient's condition, changes in available post-discharge support and/or changes to post hospital
care requirement to ensure an update/change to initial discharge plan to the
interdisciplinary team.

4. The hospital could not provide evidence policy and procedures were followed by the nursing staff to ensure patient 7 had an appropriate assessment by an interdisciplinary team for post discharge support to prevent the risk of an adverse health consequence post discharge.

Based on interview and record review, it was determined the hospital staff failed follow their discharge planning process that applied to all patients.

This resulted in a finding of Immediate Jeopardy (IJ). The hospital was notified of this finding verbally and in writing via email on 2/1/23 at 10:59 AM.

The Hospital submitted an IJ removal/abatement plan on 2/2/23 via email at 10:42 AM, alleging removal as of 2/2/23 at 10:45 AM. The plan was accepted and the hospital was notified on 2/2/23 at 11:25 AM.

An onsite visit was conducted on 2/6/23, and determined the IJ was removed as of 2/2/23 at 10:45 AM. The hospital was notified of IJ removal on 2/6/23 at 5:20 PM.

Findings include:

1. The hospital failed to ensure patients received adequate discharge planning for their post hospital care needs. (Refer to tag A-0800)

2. The hospital failed to ensure discharge planning was timely and appropriate arrangements for post-hospital care were made prior to discharge. (Refer to tag A-0805)

Based on interview and record review, it was determined the hospital did not ensure a discharge planning evaluation that included the likelihood of the patient needing post-hospital services and the availability of those services. Specifically, the discharge planner did not ensure an appropriate discharge plan for the patient's capacity for self-care needs after discharge was completed for 1 of 13 sampled discharge patients. (Patient identifier: 7)

Findings include:

1. Patient 7's medical record review was completed on 2/7/23 and revealed the following:

Patient 7 was admitted to the ICU (intensive care unit) on 12/14/22 with diagnoses of diabetic ketoacidosis, renal vein thrombosis, and urosepsis.

On 12/15/22 at 12:41 PM, a case manager (CM) performed a discharge assessment on patient 7. It was documented that the patient was projected to be discharge on 12/17/22, to home with home health. Functional impairments were listed as: functional, cognitive, visual, hearing, speech, and language. Prior to admission she required a cane to walk. Learning barriers were documented as: cognitive/memory and energy level. It was further documented in a CM note, "She usually takes Metformin for DM (diabetes mellitus) but has never been insulin dependent. She has no history of home health or SNF (skilled nursing facility). She is open to maybe having home health come in but has no preference. CM will continue to follow until discharge."

Note: It was also documented patient 7 had a stage 2 pressure ulcer to her sacral (bottom) area, and she was being sent home with new prescriptions for insulin and a blood thinner.

On 12/16/22 at 2:12 PM, the following was documented in a CM note. "Patient will be having a Renal Thrombectomy today, then patient may need some home health when it is time for discharge. CM to follow."

No other follow-up documentation from a case manager or discharge planner could be provided regarding home health services or education needs on insulin, blood thinners, or wound care.

On 12/17/22 at 11:42 discharge orders were written for patient 7.

On 12/17/22 at 12:08 PM, patient 7's last assessment before discharge was completed. Under "altered thought process" it documented patient 7 had "confusion." Under neurological assessment signs and symptoms "confusion" was also documented. Under comprehension ability it was documented as "impairment." Under gait (ability to walk) it was documented as "unable to assess". Under activities of daily living, it was documented patient 7 required "frequent reorientation." And, her level of independence was a 1 person assist.

Patient 7's last vital signs before discharge on 12/17/22 at 12:45 PM, showed elevated respirations of 34. Patient 7 had an elevated blood sugar before discharge at 11:30 PM, of 343. Patient 7's Hemoglobin was 10 g/dL (grams per deciliter) and hematocrit was 33.4% at 8:50 AM (normal range for women was 12.1 to 15.1 g/dL and 36 to 48 percent, respectively).

In summary, documentation revealed patient 7's had a stage 2 pressure ulcer, was a 1 to 2 person assist, required frequent reorientation, had confusion, and was a newly insulin dependent diabetic and blood thinner recipient.

On 12/17/22 at 3:42 PM, the discharging nurse documented the following, patient 7 stated her daughter was coming to pick her up, after her daughter did not arrive patient 7 stated her boyfriend would come get her. Patient 7 became increasingly aggressive and agitated when asked about her transportation. The nurse documented that if patient 7 could not produce a ride she would be escorted out by security.

Note: There was no documented evidence in patient 7's medical record of anyone attempting to contact any family or support person. And per interview with the physician and discharge planner, the change in behavior and inability to secure a ride home was not communicated with the discharging physician or discharge planner.

According to an incident report statement completed by a security guard, patient 7 was escorted out by security on 12/17/22 around approximately 3:45 PM. She was wheeled out in a wheelchair and left at a bus stop without any means to make it on or off the bus. She did not have any assistive devices to help her walk on or off the bus such as a cane. Patient 7 was found dead near the bus stop the following morning (12/18/22). According to an Internet search, the outside temperature between the hours of 3:30 PM on 12/17/22 to 7:00 AM on 12/18/22, ranged from 15 to 27 degrees.

On 12/19/22, the security guard that escorted patient 7 to the bus stop documented the following in a report. "The nurse said [name] (patient 7) did not want to leave. [name] (Patient 7) told me she still needed medical help. [name] (patient 7) expressed much pain in the knees as she stood to get in the wheelchair. The nurse and I helped her." The security guarded documented, he tried to assist patient seven in putting on the jacket they provide for her, but she instructed him to place it on the bench so she could sit on it. The security guard documented he told patient 7, "the bus driver would help her on." The security guard further documented he went to check on her around 4:30 PM but did not make contact with patient 7 at that time. He noticed the bus go by without noticing or stopping for patient 7. He stated he checked again around 7:30 PM, but from a distance. He stated he thought he could only see a trash can.

Note: The hospital could not provide evidence anyone went outside to check on patient 7 after she was left at the bus stop.

2. On 1/26/23 4:00 PM, an interview with RN 1 was conducted. RN1 stated she did an assessment on patient 7 the morning she was discharged, the only thing she got wrong was the year and later she got it right. RN 1 was asked about patient 7's documented confusion. She replied, occasionally she was a little forgetful. RN 1 stated patient 7 was excited to go home, she helped patient 7 get dressed. RN1 further stated she asked patient 7 if she had a ride, patient 7 replied yes. RN 1 stated patient 7 kept changing her story about who was picking her up. She stated patient 7 started to become increasingly aggressive when asked about her ride. RN1 stated she called the house supervisor, and they determined patient 7 should be escorted out of the hospital. (Note: Per interview with the discharging physician he was not notified of the patient's new agitation/aggression or not having a ride home.) RN 1 was asked if they did a psych assessment. She replied they did not. RN1 was asked if she knew whether patient 7 could walk. She replied the patient told her she could walk. RN1 stated she did not see patient 7 walk that day other than helping her into the wheelchair to be escorted out. RN 1 further stated she seemed sore getting into the wheelchair. She stated she did not know how far patient 7 could walk and was unaware if the patient received physical therapy or not. RN 1 was asked about patient 7's elevated blood sugar of 343 before discharge. She replied she would personally consider that high, she further stated the doctor looks at those and determines that. RN1 was asked if the physician gets notified of high blood sugars. She replied we notify the physicians, but they do not always listen. RN 1 was asked if they document when they notify physicians, she replied they do not. RN 1 was asked if patient 7 had a pressure ulcer, she replied she could not remember.

On 1/26/23 at 5:15 PM, patient 7's discharging physician (physician 1) was interviewed. Physician 1 was asked if he was aware patient 7 needed assistance with ambulating (walking). He replied he never saw patient 7 ambulate. He stated if a patient was not up and ambulating, he would never clear the patient for discharge. He further stated, if a patient was never observed walking, he never would have had the patient wheeled out. Physician 1 stated they had interdisciplinary rounds during the day (Note: per interview with the discharge planner they did not do rounds on the weekends, when the patient was discharged) where any concerns about a patient should be brought up. He stated he was not aware the patient had any issue ambulating or that patient 7 was agitated and refusing to leave before discharge. Physician 1 stated he would have expected to be informed of that and that he relies on the nurses to pass that information along. Physician 1 was asked about patient 7's elevated blood sugar of 343. He replied that was not a range that was concerning. He stated 200 would be the general goal. He stated he was not sure why the patients' blood sugar was not corrected. Physician 1 stated he should be called if it is over 300. He further stated he did not know what happened after his evaluation in the morning because he did not hear anything after he saw her. Physician 1 was asked if he was aware of patient 7's pressure ulcer. He stated he was trying to look back in his notes to see. He stated he could not say for sure he was aware. He could not see he documented anything on a pressure ulcer. He stated he relies on nurses to pass that information on to him.

On 1/31/23 at 11:00 AM, an interview was conducted with the chief medical officer (CMO). The CMO was asked would a patient requiring assistance or assistive devices to ambulate be expected to take a bus home alone without such assistance. The CMO stated that if it was unknown if a patient was able to ambulate, that patient should not be put on a bus without support. The CMO was asked if it should have been identified or assessed during patient 7's admission history and physical assessment and assessment updates, completed by different physicians involved her care, that patient 7 had difficulty ambulating and was a 1 person assist. The CMO stated a physician should know whether a patient could ambulate, and it should be a part of the discharge plan; whether they observe, ask the patient, or verify with the nurse. The CMO stated, patient 7 probably would still be alive if she did not go out into the elements. A caring person should not leave someone in a dangerous situation.

On 1/31/23 at 12:04 PM, the hospitals director of discharge planning was interviewed. She stated the CM thought patient 7 could benefit from home health being newly insulin dependent. She stated the CMs did not anticipate patient 7 was going to be discharged over the weekend (12/17/22) based on the physician's progress note and the thrombectomy that was done on 12/16/22. She further stated, if the patient did not discharge over the weekend "I guarantee 100% this would not have happened." The director of discharge planning stated she did not feel patient 7 got appropriate post discharge care. She further stated there were things that should have been ordered that were not. She stated she should have been called after the patient became agitated and did not have a ride home. She further stated, "I hope nothing like this ever happens again. It is very disheartening."

3. On 2/7/23, a review of the policy titled "Discharge/Transition of Care Planning" was completed. The following was documented in the policy:

-No patient with post-acute service requirements will be discharged until the hospital has ensured arrangements are completed. Every effort will be made to avoid discharge to a shelter or the street.

4. The hospital could not provide evidence patient 7 had received an appropriate assessment by an interdisciplinary team for post discharge support, including discharge education for newly insulin dependence, blood thinners, and wound care, to prevent the risk of any adverse health consequences after discharge.

Based on interview and record review, it was determined the hospital did not perform discharge planning on a timely basis to ensure the appropriate arrangements for post-hospital care were made prior to discharge for 1 of 13 sampled discharge patients. (Patient identifier: 18)

Findings include:

1. Patient 18 was admitted to the hospital on 1/4/23, with diagnoses which included Symptomatic carotid stenosis, transient ischemic attack, volume depletion, acute kidney injury, hypoglycemia, severe anemia, and electrolyte abnormality.

Patient 18's medical record review was completed on 2/7/23.

The Discharge planner documented on 1/5/23, "Attempted to meet with patient and/or family today twice, however, the first time she was getting PICC (peripherally inserted central catheter) line placed. Then the second time, she had gone down to surgery. I am unable to verify all information on her face sheet and discuss discharge plans. CM (case manager) to follow up tomorrow after she is alert and oriented post-surgery with her or her family."

The certified physician assistant (CPA) documented on 1/7/23, "If she continues to do well and has no further hemodynamic derangement, anticipated discharge home with home health within the next 24- 48 hours".

The CPA documented on 1/8/23, "It is my opinion that it is safe for her to be discharged home to the care of her family with home health".

The attending physician documented on 1/8/23, "Plans were made to arrange for home physical therapy for several weeks to assist with her balance".

Patient 18 was discharged on 1/8/23. There was not documented evidence home health was ordered at the time of discharge.

2. In an email received from the risk manager on 2/2/23 at 3:34 PM, it was documented by the CM director, "Unfortunately we don't have a list of home health agencies offered to the patient or a patient choice form signed. This patient was discharged on 1/8/23 (Sunday). It is VERY (sic) unusual for this physician group to discharge anyone on a weekend. The screen shot below shows the disposition on the DC (discharge) summary as Home or Self-Care. The second screen shot shows the actual order for home health however it was not written until 1/9/23 which was the day after the patient was discharged. My ICU (intensive care unit) case manager was given the order on Monday after it was written, and she sent it to (name) home health which services the area the patient resides in and had staffing available. The attachment is the fax confirmation from the home health company showing they rec'd (received) it and the date they rec'd it on the top left-hand corner."

3. The hospital's Discharge/Transition of Care Planning policy was reviewed and revealed the following:

-No patient with post-acute care service requirements will be discharged until hospital has ensured arrangements are completed.

-The case manager/social worker will identify and offer alternative options to the patient and will document such measures.

-Care Management/Social Workers along with the interdisciplinary team will coordinate to determine the appropriate discharge needs of the patient.

4. The hospital could not provide evidence hospital staff secured appropriate post-hospital care arrangements prior to patient 18 being discharged.