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Based on record review and staff interviews it was determined that the hospital failed to follow its policy for prompt resolution of a patient or family members grievance regarding an unsafe discharge for 1 of 6 patients reviewed for discharge planning, (Patient ID #1).

Findings are as follows:

Review of the hospital policy titled," Complaint/Grievance Process" last reviewed 6/2023 states in part,

"...Purpose...To describe the process for prompt resolution of a patient grievance...
...Grievance Process...The Grievance Committee will assure that the grievance is investigated. Investigation is to occur in a timely manner..."

Review of a Patient Access Note dated 10/18/2024 at 11:45 AM by Staff L, Financial Counselor, revealed Patient ID #1's Power of Attorney (POA), ID # 10, had contacted the department to provide the patient's newly acquired Medicaid information to them. During her call she disclosed numerous complaints that she had about the patient's care and the overall hospital experience. The POA was provided with the name of the Patient Experience Manager, Staff K. After the phone call, the documentation revealed that Staff L then notified the Patient Access Manager of the details in the phone call and sent an email to Staff K.

Review of a hospital email sent on 10/18/2024 at 12:27 PM, indicated that Staff L sent the email to Staff K informing her of a phone call that she had with the patient's POA. Staff K provided the name and contact number of the POA and stated that the POA had disclosed multiple complaints she had about the patient's care and overall hospital experience.

During a surveyor interview on 11/21/2024 at 2:12 PM with the Patient Experience Manager, Staff K, she confirmed that she did receive the email from Staff. She explained she spoke to the Patient Access Manager about the email she had received from Staff L last week and he informed her that Staff L was on vacation, and he did not have the details. Staff K confirmed that she never reached out to Staff L or the POA to inquire and investigate the POA's concerns and stated that she was waiting for the patient and the POA to call her.

During a surveyor interview on 11/19/2024 with Patient ID #1's POA, ID # 10, she explained that she spoke with Staff L and voiced her complaints regarding the patient's discharge and the way that she/he was sent home without a physical therapy evaluation. She stated that Staff L was going to send her information to Staff K and let her know about her concerns. ID #10 confirmed that she never received a call from anyone at the hospital about her concerns and complaints.








43881

43881


Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet §482.22 Condition of Participation: Medical Staff after the following was identified:

- The hospital failed to ensure that medical staff responsible for the quality of medical care provided to the patient was in accordance with the rules and regulations of the medical staff relative to discharging patients from the hospital (A-0353).

- The hospital failed to ensure that the appropriate medical staff maintained their Basic Life Support training and their Advanced Cardiac Life Support training up to date (A-0353).

The failure related to discharge resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment, or death to all patients.

Findings are as follows:

A CMS authorized Substantial Allegation Survey was conducted from 11/19/2024 through 11/27/2024, at Landmark Medical Center to determine compliance with the requirements of §482.22 Condition of Participation: Medical Staff following a community reported complaint that alleged a patient was discharged home in unstable condition without the appropriate follow appointments, no medical insurance, no plan for after care nor hospice or palliative care, which resulted in the patient being readmitted to another acute care hospital within fifteen hours.

On 11/25/2024, a finding which constituted an Immediate Jeopardy (IJ) was identified under §482.22 Condition of Participation: Medical Staff , related to Patient ID #1 who was discharged home in unstable condition without an adequate discharge plan and appropriate and accurate follow up care.

As a result of the identified non-compliance, Patient ID #1 was readmitted to another acute care hospital the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge with a diagnosis of decompensated liver failure after presenting by ambulance to the emergency room with shortness of breath, severe abdominal pain and continued diarrhea. In addition, the patient's physical exam revealed that the patient's abdomen was distended with ascites and a positive fluid wave, indicating the presence of free fluid, his/her skin was jaundiced, the whites of the eyes were yellow, and she/he had pitting edema of the lower extremities.

The hospital's Director of Practice Improvement was informed of the Immediate Jeopardy on 11/25/2024 and was provided with the Immediate Jeopardy templates at approximately 12:00 PM on this date.

On 11/25/2024, the hospital submitted an Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented:

- An updated list of community physicians and clinic residents with names and contact information will be emailed to the medical staff and residents and provided to the nursing units and case management on 11/26/2024 by 10:00 AM.

- A memo will be sent on 11/26/2024 to Residents and medical staff that an order for a PT consult is required when there is a change in functional status and if a patient has a new oxygen requirement, an ambulatory trial will be ordered.

- An attestation will be signed by residents, medical staff and registered nurses beginning 11/25/2024 at 4:30 PM and continuing until substantial compliance is met to address staff agreement and understanding of the above that in addition includes the requirement to follow the chain of command for any patient safety issues.

- A conference will be held on 11/26/2024 for the residents to present the case in question and to review the following:

- If decreased mobility, order a PT consult.
- If new oxygen requirements, order an ambulatory trial.
- Document patient goals of care.
- Document hospice instructions.
- When restarting blood pressure medications, conduct a trial.
- Document family/patient discussions.
- Document outpatient instructions for managing paracentesis.

On 11/26/2024, interviews with staff on duty were conducted by the State Surveyors on the Labor and Delivery Unit, the Behavioral Health Unit, 1 East Medical Surgical Unit, the Progressive Care Unit, and the Intensive Care Unit to confirm staff agreement and understanding of the IPOC. The State surveyors verified that the updated list of community physicians and clinic residents was posted on the units that were toured. In addition, the State Surveyors attended the resident conference conducted on 11/26/2024 at 12:00 PM to confirm that the case was presented as outlined on the IPOC and signed attestations were reviewed to ensure that residents, attendings, and registered nurses received and understood the new requirements as stated on the IPOC. The hospital's IPOC was verified as being fully implemented as of 11/27/2024 and the IJs were abated.

Based on record review and staff interview, it has been determined that the hospital failed to enforce rules and regulations established by the hospital for the medical staff relative to patient discharges for 1 of 6 patients reviewed (Patient ID #1). Additionally, the hospital failed to ensure 13 medical staff were up to date with their Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications in accordance with hospital policy (Employees A, H, K, N, O, P, Q, R, S, T, U, V, and W).

Findings are as follows:

1. The hospital's "Medical Staff Rules and Regulations" last revised on 10/1/2023 state in part,

"...1.5 Discharge of Patients

...1.5 (d) The Attending Physician/LIP or designee shall keep the patient and the patient's family informed concerning the patient's condition throughout the patient's term of treatment...The Attending Physician or designee shall ensure that the patient (or the appropriate family member...) is provided with information that includes, but is not limited to, the following:

...(3) The clinical basis for the discharge;

(4) The anticipated need for continued care following discharge;

(5) When indicated, educational information regarding how to obtain further care, treatment, and services to meet the patient's needs, which are arranged by or assisted by the hospital; and

(6) Written discharge instructions in a form and manner that the patient or family member can understand..."

Record review revealed that Patient ID #1 presented to the hospital's Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism.

During the evaluation, the patient's physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician, were unable to pay for some of their medications and would like help getting insurance.

The patient was subsequently admitted to the Progressive Care Unit due to abnormal bloodwork and a concern for spontaneous bacterial peritonitis (an acute fluid infection in the abdomen). Additionally, the patient's diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection).

During the patient's admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters.

Review of the patient's last Internal Medicine progress note dated 10/10/2024 at 11:25 AM authored by Employee F, Medical Resident failed to reveal evidence of the clinical basis to discharge the patient. The note further identified that the patient's oxygen saturation was 98% but failed to state that the patient had been using 3 liters of oxygen since 12:39 AM on 10/10/2024. The note continued to state that the patient was "hemodynamically stable for discharge" even though Employee F described the patient as having abdominal distention "again" despite having 4 liters of fluid removed from the abdomen the day before.

The patient was discharged home from the hospital on 10/10/2024 by wheelchair accompanied by a Registered Nurse and the patient's family member, ID # 10.

Review of the patient's Discharge Summary dated 10/10/2024 at 1:15 PM authored by Employee F, revealed the patient had a diagnosis of liver failure. Further review failed to reveal evidence that future appointments were established for this patient. The patient was instructed to follow up with Employee H from Gastroenterology. However, Employee H does not have an outpatient practice and therefore does not see patients outside of the hospital.

Review of the patient's After Visit Summary dated 10/10/2024, revealed that the patient was instructed to "get ascitic fluid drained outpatient as needed," however, no educational information or instructions on how to obtain this service were provided to the patient. Additionally, the patient was instructed to resume their home dose of Lisinopril, a medication used to treat high blood pressure, after it had been withheld during the entire inpatient stay due to "low blood pressure. On the day of discharge, the final blood pressure reading was 95/57 at 3:44 PM. The medical record failed to reveal evidence that a trial to restart the medication was conducted prior to discharge to ensure the patient was safe to take the medicine.

Patient ID #1 was then readmitted to another acute care hospital the following day on 10/11/2024, approximately 15 hours following discharge.

Record review of the patient's readmission record from the other acute care hospital revealed that the patient was transferred by ambulance to the emergency room per the patient and family's request on 10/11/2024 at 11:52 AM with a chief complaint of shortness of breath, severe abdominal pain and continued diarrhea. The patient's physical exam described the patient's abdomen as distended with ascites and positive fluid wave. The patient was diffusely jaundice with sclera icterus (whites of the eyes appear yellow), and pitting edema of the lower extremities was observed. The patient was then admitted to the acute care hospital with a diagnosis of decompensated liver failure.

In addition, the patient was found to have Hepatorenal Syndrome, a serious complication of kidney function in individuals with liver failure, his/her BUN/Creatine (kidney function markers) continued to rise, and dialysis was initiated.

During a surveyor interview on 11/24/2024 with the Gastroenterologist, Employee H, he revealed that he only saw the patient once during his/her hospitalization and that he had performed the upper endoscopy on the patient. When asked if he provided any follow up instructions to the patient or the physicians, he replied that he does not see any patient on an outpatient basis and that his office has been closed since 2020. He then stated that his current role at the hospital is as a Gastroenterology Hospitalist and Proceduralist. He went on to say that the Internal Medicine Physicians are in charge of making the follow up referrals for the patients upon discharge. When asked if he would be involved in arranging an outpatient paracentesis for the patient, he indicated he would not be.

During a surveyor interview on 11/20/2024 with Employee F, Internal Medicine Resident, in the presence of Employee G Assistant GME Program Director, Employee F revealed that the patient asked her about what she/he should do when the fluid in his/her stomach reaccumulates and she told the patient to call Gastroenterology to set up an appointment without further details. Employee F stated that she does not remember being told that the patient was on oxygen or that the patient's nurse and family had concerns over the patient being discharged. When asked about the patient 's follow up at the time of discharge, Employee F explained that if a patient does not have a Primary Care Physician, they are instructed to call the Residents Clinic to set up an appointment. When asked if they are able to call the clinic to set up the appointment for the patient before they leave, she stated that they do not have the ability to do this.

Employee G then explained that the hospital does not have a Gastroenterology Physician on staff that specializes in Hepatology (medical specialty that focuses on the treatment of liver disorders) and they do not have the same connections as some of the academic medical centers. Employee G indicated that they have reached out to transplant centers in the past, however, they usually stabilize the patient and transfer them to a larger hospital for follow up care.

During a surveyor interview on 11/27/2024 at approximately 11:00 AM with Employee I, Third Year Medical Resident, she revealed that as a Resident, she and the other resident's do have the ability to request an appointment for a patient at the Resident Clinic through the medical record system. However, not all Residents are familar with the process.

During a surveyor interview on 11/21/2024 with Employee A, Attending Physician, he indicated that the nurses did not tell him about the patient having concerns related to his/her discharge and indicated that the patient's initial Case Management evaluation showed that the patient was independent and did not use any visiting nurses at home. When asked if he had any conversations regarding the patient's goals of care with the Residents who cared for the patient, he revealed that the Residents told him they called the patient's family and saw the patient and expects the Residents to document these encounters in the medical record.

During a surveyor interview on 11/19/2024 with Patient ID #1's family member, ID #10, she explained that she received a call from the patient's Case Manager, Employee C, on 10/10/2024 around noon informing her that the patient was going to be discharged from the hospital on this day. ID #10 revealed that she voiced her concerns to Employee C about the patient not being able to walk without being short of breath and never being evaluated by Physical Therapy and revealed that Employee C told her that the patient did not need Physical Therapy. ID #10 revealed that while at the hospital, the patient told her that she/he had spoken to the Attending Physician, Staff A, about how she/he did not feel safe to go home and ID #10 asked the patient's nurse, Employee E, that she would like to speak to one of the physican's, but no physician came to speak with her.

2. The hospital's policy titled, "BLS [Basic Life Support] & ACLS [Advanced Cardiac Life Support] Requirements" last revised in August of 2022 states in part,

"...Policy

The following individuals must maintain certification in BLS and ACLS: all LIPS who are credentialed to perform procedures with moderate sedation; all intensivists; all Hospitalists and Nocturnists; all Anesthesiology providers; all emergency Medicine providers..."

Record review of the medical staff credentialing filed on 11/21/2024 revealed that the following individuals had expired BLS and ACLS certifications:

- Employee A, MD: BLS and ACLS certifications expired on 9/7/2024
- Employee H, MD: BLS and ACLS certifications expired on 1/1/2000
- Employee N, MD: BLS certification expired on 5/31/2024
- Employee O, MD: BLS certification expired on 9/22/2024
- Employee P, CNP (Certified Nurse Practitioner): BLS certification expired on 9/24/2024
- Employee Q, MD: BLS certification expired on 3/10/2023
- Employee R, PA (Physician Assistant): BLS and ACLS certifications expired on 6/30/2024
- Employee S, MD: BLS certification expired on 9/30/2023
- Employee T, NP: BLS certification expired on 10/3/2024
- Employee U, MD: BLS certification expired on 3/31/2024 and ACLS certification expired on 4/28/2024
- Employee V, APRN (Advanced Practice Registered Nurse): ACLS certification expired on 11/5/2024
- Employee W, MD: BLS certification expired on 9/16/2024
- Employee X, PA (Physician Assistant): BLS and ACLS certifications expired on 8/31/2024

During a surveyor interview on 11/21/2024 and on 11/25/2024, the Medical Staff Coordinator, Employee Y, was unable to provide evidence that the above-mentioned individuals were up to date with their BLS and ACLS certifications in accordance with hospital policy.

43881

Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet §482.43 Condition of Participation: Discharge Planning after the following was identified:

- The hospital failed to re-evaluate the patient's change in condition and reflect these changes in the patient's discharge plan relative to new oxygen requirements, deteriorating renal and mobility status, and increasing abdominal distention that required the removal of excess fluid in the abdomen multiple times (A-0802).

- The hospital failed to ensure the patient's discharge evaluation included a referral to an existing outpatient Gastroenterology service following discharge (A-0807).

- The hospital failed to complete the patient's initial discharge evaluation (A-0808).

These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment, or death to all patients.

Findings are as follows:

A CMS authorized Substantial Allegation Survey was conducted from 11/19/2024 through 11/27/2024, at Landmark Medical Center to determine compliance with the requirements of §482.43 Condition of Participation: Discharge Planning following a community reported complaint that alleged a patient was discharged home in unstable condition without the appropriate follow appointments, no medical insurance, no plan for after care nor hospice or palliative care, which resulted in the patient being readmitted to another acute care hospital within fifteen hours.

On 11/25/2024, a finding which constituted an Immediate Jeopardy (IJ) was identified under §482.43 Condition of Participation: Discharge Planning, related to Patient ID #1 who was discharged home in unstable condition without an adequate discharge plan and appropriate and accurate follow up care.

As a result of the identified non-compliance, Patient ID #1 was readmitted to another acute care hospital the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge with a diagnosis of decompensated liver failure after presenting by ambulance to the emergency room with shortness of breath, severe abdominal pain and continued diarrhea. In addition, the patient's physical exam revealed that the patient's abdomen was distended with ascites and a positive fluid wave, indicating the presence of free fluid, his/her skin was jaundiced, the whites of the eyes were yellow, and she/he had pitting edema of the lower extremities.

The hospital's Director of Practice Improvement was informed of the Immediate Jeopardy on 11/25/2024 and was provided with two Immediate Jeopardy templates at approximately 12:00 PM on this date.

On 11/25/2024, the hospital submitted an Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented:

- An updated list of community physicians and clinic residents with names and contact information will be emailed to the medical staff and residents and provided to the nursing units and case management on 11/26/2024 by 10:00 AM.

- A memo will be sent on 11/26/2024 to Residents and medical staff that an order for a PT consult is required when there is a change in functional status and if a patient has a new oxygen requirement, an ambulatory trial will be ordered.

- An attestation will be signed by residents, medical staff and registered nurses beginning 11/25/2024 at 4:30 PM and continuing until substantial compliance is met to address staff agreement and understanding of the above that in addition includes the requirement to follow the chain of command for any patient safety issues.

- A conference will be held on 11/26/2024 for the residents to present the case in question and to review the following:

-If decreased mobility, order a PT consult.
-If new oxygen requirements, order an ambulatory trial.
-Document patient goals of care.
-Document hospice instructions.
-When restarting blood pressure medications, conduct a trial.
-Document family/patient discussions.
-Document outpatient instructions for managing paracentesis.

On 11/26/2024, interviews with staff on duty were conducted by the State Surveyors on the Labor and Delivery Unit, the Behavioral Health Unit, 1 East Medical Surgical Unit, the Progressive Care Unit, and the Intensive Care Unit to confirm staff agreement and understanding of the IPOC. The State Surveyors verified that the updated list of community physicians and clinic residents was posted on the units that were toured. In addition, the State Surveyors attended the resident conference conducted on 11/26/2024 at 12:00 PM to confirm that the case was presented as outlined on the IPOC and signed attestations were reviewed to ensure that residents, attendings, and registered nurses received and understood the new requirements as stated on the IPOC. The hospital's IPOC was verified as being fully implemented as of 11/27/2024 and the IJs were abated.

Based on record review and staff interviews, it was determined that the hospital failed to re-evaluate the patient's change in condition and reflect these changes in the patient's discharge plan relative to new oxygen requirements, deteriorating renal and mobility status, and increasing abdominal distention that required the removal of excess fluid in the abdomen multiple times, for 1 of 6 patients reviewed for discharge planning, (Patient ID #1).

Findings are as follows:

Review of the hospital policy titled," Discharge Planning" last reviewed 2/2023 states in part,

"...Reassessment...A patient's discharge plan is reassessed by the multidisciplinary team as needed throughout the patient's stay. Factors that may trigger a reassessment include an extended stay, change in condition or function..."

Record review revealed that Patient ID #1 presented to the hospital's Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism.

During the evaluation, the patient's physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician and were unable to pay for some of their medications and would like help getting insurance. Additionally, the patient's diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection) and the patient was admitted to the hospital.

During the patient's admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters.

Review of the patient's last Internal Medicine progress note dated 10/10/2024 at 11:25 AM, failed to reveal any documentation that the patient was using oxygen. The note further identified that the patient's current oxygen saturation was 98% but failed to state that the patient was using 3 liters of oxygen since 12:39 AM on 10/10/2024.

Review of the patient's initial discharge planning note by Case Manager RN, Staff B, dated 10/3/2024 revealed that the patient lives with their family in a private residence and is independent with activities of daily living and drives. The note went on to say the patient's discharge plan will be discussed further with Social Work. During the interview the patient was unsure of the number of steps to their residence.

The patient's medical record failed to reveal evidence that the patient's initial discharge plan was updated to reflect the changes in the patient's condition or functional status.

The patient was then discharged home from the hospital on 10/10/2024 by wheelchair accompanied by a Registered Nurse and the patient's family member.

During a surveyor interview with the Attending Physician, Employee A on 11/21/2024 he was asked if he was aware that the patient was still requiring oxygen on the day of discharge, to which he replied that that he did not remember, despite stating that he had just reviewed the patient's medical record. When he was asked if he or any of the Residents contacted the patient's family regarding their concerns over the discharge, he indicated that the Residents told him that they spoke to the family, but stated, "I am not sure what the conversation was about". He then stated that it is his expectation that the Residents document all family conversations in the medical record, however, the patient's medical record lacked evidence of any family discussions.

The Attending was then asked the reason why the patient was not evaluated by Physical Therapy, to which he responded that the patient was not very mobile, but was getting up to walk. However, the patient's medical record showed no documentation that the patient was walking. Additionally, the Attending was asked if he was aware that the patient's family requested a Physical Therapy evaluation, to which he indicated he was was not aware.

During a surveyor interview with Case Manager Staff B, on 11/20/2024, at 12:48 PM, she stated that she only was assigned to Patient ID #1 on 10/3/2024 and she never had the patient again. Staff B remembered that the patient was unable to answer a question about his/her home and number of stairs. However, she stated that the completion of the discharge plan should be updated by the covering Case Manager.

During a surveyor interview with Case Manager, Registered Nurse Staff C, on 11/19/2024 at 2:45 PM, she stated that she could not recall Patient ID #1, however she did remember a patient with end stage liver disease and stated that she did not know anything about "liver failure". When asked if she remembered any time that palliative care services were mentioned, she replied "that would be initiated by the physician, and she would not be involved". Staff C stated, she was not aware of any conversations that the physicians may have had with the patient or family regarding any discharge concerns. She then stated she vaguely remembered that the patient had a family member that was a nurse. Staff C went on to say, "if the physician does not tell me there is a change in the patient's condition, I would not know". Staff C was then asked to explain about the length of stay rounds (LOS) that are held weekdays at 11:00 AM, to which she replied that she does attend the LOS rounds and any changes in the patient's condition would be discussed there.

During a surveyor interview with the Director of Case Management, Staff D on 11/19/2024 at 10:00 AM, she acknowledged that after reviewing Patient ID #1's medical record, there is no evidence of any follow up notes by Case Management after the initial discharge planning note on 10/3/2024. She then stated that it is her expectation that a reassessment of the patient's discharge plan would have been completed per the hospital's policy. She also acknowledged that there was no documentation from the physicians that the patient was on oxygen the morning of their discharge. She stated that the record failed to reveal evidence of a walk test prior to discharge to evaluate the patient's oxygen needs while walking. The Director confirmed that the discharge planning note did not accurately reflect the patient's condition at the time of the discharge on 10/10/2024.

During a surveyor interview on 11/19/2024 with Patient ID #1's family member, ID # 10, she explained that she had received a call from the patient's Case Manager, Employee C, on 10/10/2024 around noon informing her that the patient was going to be discharged from the hospital "today." She stated that she voiced her concerns about the patient not being able to walk without being short of breath and never being evaluated by Physical Therapy to Employee C who told her that the patient did not warrant physical therapy. The patient's family member then stated that she came to the hospital and spoke to the patient's nurse, Employee E, regarding her concerns about the patient's unsafe discharge due to his/her increased level of care and acute medical issues. She stated that the nurse also stated that she agreed that the patient was not ready for discharge and the nurse contacted the Physician. ID #10 stated that the Physician never came up to speak to her before the discharge and although the nurse stated that she voiced her concerns about the discharge to the Physician, the nurse indicated there was nothing she could do and the patient would still be discharged.

During a surveyor interview with Registered Nurse, Employee E, on 11/20/2024, she explained that she was the patient's nurse from 7:00 AM to 7:00 PM on 10/10/2024. When she came on duty, Patient ID # 1 had been using 3 liters of oxygen most of the day. After Physician and discharge rounds, she was notified that a discharge order was entered for the patient. She then stated that she went to speak to the Residents about not feeling comfortable with the patient's discharge and that the patient was still using oxygen at 3 liters and needed assistance to get out of bed and to use the commode. The Physician told her to take him/her off the oxygen and "see how [she/he] does."

Employee E stated that the patient's family member, ID #10, arrived at the hospital and voiced her concerns over the patient's discharge. She stated that the family was concerned about the patient having to go up 17 stairs at home. The nurse confirmed that she informed the Case Manager, Employee C, about the patient still requiring oxygen and the concerns about the patient not being ready for discharge and she was told that the patient was still going to be discharged later. Employee E was then asked if she used the chain of command to voice her concerns regarding the patient's unsafe discharge, and she stated she did not.









43881

Based on record review and staff interview, it has been determined that the hospital failed to include an accurate discharge planning evaluation of a patient's need for post hospital discharge services for 1 of 6 patients reviewed (Patient ID #1).

Findings are as follows:

Record review revealed that Patient ID #1 presented to the hospital's Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism.

During the evaluation, the patient's physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician and were unable to pay for some of their medications and would like help getting insurance. Additionally, the patient's diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection) and the patient was admitted to the hospital.

During the patient's admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters.

The patient was discharged home from the hospital on 10/10/2024 by wheelchair accompanied by a Registered Nurse and the patient's family member.

Review of the patient's Discharge Summary dated 10/10/2024 at 1:15 PM authored by Employee F, revealed the patient had a diagnosis of "Liver failure." Further review failed to reveal evidence that future appointments were established for this patient. The patient was instructed to follow up with Employee H from Gastroenterology. However, Employee H does not have an outpatient practice and therefore does not see patients outside of the hospital.

Review of the patient's After Visit Summary dated 10/10/2024, revealed that the patient was instructed to "get ascitic fluid drained outpatient as needed," however, no educational information or instructions on how to obtain this service were provided to the patient.

During a surveyor interview with the patient's family member, ID #10, on 11/19/2024, she revealed that she is a nurse that is currently working as a Case Manager and indicated that she voiced her concerns about the patient's discharge and his/her deconditioned status to the Case Manager, Employee C, and the patient's Primary Nurse, Employee E. ID #10 revealed that she told Employee C she wanted the patient to be seen by Physical Therapy because she/he still required assistance getting in and out of the bed, she/he was only able to go from the bed to the chair or commode, and she/he was not ambulating while in the hospital, but her request was denied since Employee C said that the patient did not need Physical Therapy.

She also stated that she was concerned that the patient was told that she/he needed to contact physicians to make follow up appointments and call the state health insurance program establish health insurance, but at this point she felt that the patient was in no condition to be making phone calls. She then revealed that after the patient was sent home, she/he became more short of breath and 15 hours later she needed to call rescue and the patient was brought to an acute care hospital per the patient and family request. The patient was then admitted to the hospital and was transferred to an out of state hospital for a liver transplant evaluation on 10/17/2024.

During a surveyor interview on 11/24/2024 with the Gastroenterologist, Employee H, he revealed that he only saw the patient once during his/her hospitalization and that he had performed the upper endoscopy on the patient. When asked if he provided any follow up instructions to the patient or the physicians, he replied that he does not see any patients on an outpatient basis and that his office has been closed since 2020. He then stated that his current role at the hospital is as a Gastroenterology Hospitalist and Proceduralist. He went on to say that the Internal Medicine Physicians are in charge of making the follow up referrals for the patients upon discharge. When asked if he would be involved in arranging an outpatient paracentesis for the patient, he indicated he would not be.

During a surveyor interview on 11/20/2024 with Employee F, Internal Medicine Resident, in the presence of Employee G, the Assistant GME Program Director, Employee F revealed that the patient asked her about what she/he should do when the fluid in his/her stomach reaccumulates and she told the patient to call Gastroenterology to set up an appointment without further details.

Employee G then explained that the hospital does not have a Gastroenterology Physician on staff that specializes in Hepatology (medical specialty that focuses on the treatment of liver disorders) and they do not have the same connections as some of the academic medical centers. Employee G indicated that they have reached out to transplant centers in the past, however, they usually stabilize the patient and transfer them to a larger hospital for follow up care.















43881

Based on record review and staff interviews, it was determined that the hospital failed to complete the patient's initial discharge planning evaluation for 1 of 6 patients reviewed for discharge planning, (Patient ID #1).

Findings are as follows:

Review of the hospital policy titled," Discharge Planning" last reviewed 2/2023 states in part,

" ...Objectives ...Promotes high quality patient care, which identifies early in the hospitalization patients at risk for discharge planning barriers or with extended length of stay related to inadequate resources ..."

Record review revealed that Patient ID #1 presented to the hospital's Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism.

During the evaluation, the patient's physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician and were unable to pay for some of their medications and would like help getting insurance. Additionally, the patient's diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection) and the patient was admitted to the hospital.

During the patient's admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters.

Review of the patient's initial discharge planning note by Case Manager RN, Staff B, dated 10/3/2024 it was documented that the patient lives with their family in a private residence and is independent with activities of daily living and drives. The note went on to say the patient's discharge plan will be discussed further with social work. During the interview the patient was unsure of the number of steps to their residence.

The patient's medical record failed to reveal any evidence that the patient's initial discharge plan was updated to reflect the changes in the patient's condition or functional status.

Review of Internal Medicine progress notes from 10/10/2024 failed to reveal evidence of the clinical basis to discharge the patient and further identified that the patient's oxygen saturation was 98%, but documentation failed to state that the patient had been using 3 liters of oxygen since 12:39 AM on 10/10/2024 consistently. The patient was described as "hemodynamically stable for discharge" even though the Medical Resident described the patient as having abdominal distention "again" despite having 4 liters of fluid removed from the abdomen the day before.

The patient was discharged home from the hospital on 10/10/2024 with a discharge diagnosis of Liver failure but was readmitted to another acute care hospital with a diagnosis of decompensated liver failure the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge.

During a surveyor interview with Case Manager Staff B, on 11/20/2024, at 12:48 PM, she stated that she only was assigned to Patient ID #1 on 10/3/2024 and she never had the patient again. Staff B remembered that the patient was unable to answer a question about his home and number of stairs. However, she stated that the completion of the discharge plan should be updated by the covering case manager.

During a surveyor interview with Case Manager, Registered Nurse Staff C, on 11/19/2024 at 2:45 PM, she stated that she could not recall Patient ID #1, however she did remember a patient with end stage liver disease and stated that she did not know anything about "liver failure". Staff C stated, she was not aware of any conversations that the physicians may have had with the patient or family regarding any discharge concerns. She then stated she vaguely remembered that the patient had a family member that was a nurse. Staff C went on to say, if the physician does not tell me there is a change in the patient's condition "I would not know." Staff C was then asked to explain about the length of stay rounds (LOS) that are held weekdays at 11:00 AM. Staff C stated that she does attend the LOS rounds and any changes in the patient's condition would be discussed there. When asked when would you update a patient's discharge plan, she responded by saying when there is a change in the patient the plan would be changed to accommodate the patient's needs.

During a surveyor interview with the Director of Case Management, Staff D, on 11/19/2024 at 10:00 AM she acknowledged that after reviewing Patient ID #1's medical record there is no evidence of any follow up notes or changes made by Case Management after the initial discharge planning note on 10/3/2024. She also acknowledged that the number of stairs in the patient's home was never clarified during his/her admission nor added to the inital discharge planning note.








43881

Based on record review and staff interviews, it has been determined that the hospital failed to ensure Social Services staff effectively participated in the arrangement of the patient's discharge plan and follow up care for 1 of 6 patient's reviewed for discharge planning, (Patient ID #1).

Findings are as follows:

The hospital's policy titled, "Social Service General Policy" last revised in April of 2020 states in part,

" ...Scope of Service and Referrals:

Depending on the needs of the hospital and the surrounding community, the following services may be provided:

...Education/consultation for staff, patients and/or their families;

Family conferencing/counseling;

Financial/insurance counseling ...

...supportive counseling ...

Referral Process:

Referrals for service may be initiated by any party ..."

Record review revealed that Patient ID #1 presented to the hospital's Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism.

During the evaluation, the patient's physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician, she/he was unable to pay for some medications and would like help getting insurance.

The patient was subsequently admitted to the Progressive Care Unit due to abnormal bloodwork and a concern for spontaneous bacterial peritonitis (an acute fluid infection in the abdomen). Additionally, the patient's diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection).

Record review revealed that the patient was seen by Social Services on 10/3/2024 regarding his/her alcoholism, and not having a Primary Care Physician (PCP) nor health insurance. At this time, the Social Worker indicated that screening for state health insurance was pending and a Social Worker would follow up with the patient regarding this. However, the record failed to reveal evidence that Social Services followed up with this matter.

Review of the patient's initial discharge planning note dated 10/3/2024 revealed that the patient lived with their family in a private residence, she/he was independent with activities of daily living but was unsure of the number of steps to their residence. The note further indicated that the patient's discharge plan would be discussed further with Social Work. However, the record failed to reveal evidence that this coordination of care took place.

Record review revealed that on 10/4/2024, Employee J, Social Worker, attempted to see the patient twice on this day but the patient was either asleep or in a procedure.

Further record review failed to reveal evidence that additional attempts to see the patient were made by Social Services on 10/4, 10/5, 10/6, 10/7, and 10/8, until 10/9/2024, the day before the patient was discharged.

Record review of a Social Work note dated 10/9/2024 at 4:18 PM, revealed that Employee J saw the patient who reported she/he smoked cigarettes and used alcohol, she/he did not have a PCP nor health insurance. The note further indicated that the patient understood his/her possible limited accessibility to alcohol use programs due to his/her lack of insurance but was provided with resources for substance use treatment centers and programs anyway. The note failed to reveal evidence that the patient was provided with specific details about which program or center would provide services to him/her about his/her alcohol use without insurance.

Review of Internal Medicine progress notes from 10/10/2024 failed to reveal evidence of the clinical basis to discharge the patient and further identified that the patient's oxygen saturation was 98%, but documentation failed to state that the patient had been using 3 liters of oxygen since 12:39 AM on 10/10/2024 consistently. The patient was described as "hemodynamically stable for discharge" even though the Medical Resident described the patient as having abdominal distention "again" despite having 4 liters of fluid removed from the abdomen the day before.

Review of Social Services progress notes revealed that the patient was seen by Employee J on 10/10/2024, the day of discharge. Employee J indicated in her note that the patient was provided with information about shelters.

The patient was discharged home from the hospital on 10/10/2024 with a discharge diagnosis of Liver failure but was readmitted to another acute care hospital with a diagnosis of decompensated liver failure the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge.

During a surveyor interview with Employee A, Attending Physician, he indicated that he relies on the Social Worker to ask about issues at home if a patient indicated they did not feel safe going home.

During a surveyor interview on 11/25/2024 at 10:00 AM with Employee J, Social Worker, in the presence of the Director of Case Management, she indicated that she briefly remembered the patient and recalls the patient did not have health insurance and she gave the patient information related to his/her alcoholism. When asked if she was aware of the patient's diagnosis, she replied, "Kind of, not how severe it was." When asked if she spoke to the physician about the patient, she stated, "Just about length of stay." When asked if the patient voiced any concerns regarding his/her discharge plan, she indicated that she did not remember. When asked if she spoke to the patient's family or the patient's nurse about concerns related to discharge, she stated, "No," and acknowledged she did not have any conversation about goals of care for the patient with other providers. When asked if she was aware that the patient was on oxygen consistently, she indicated that she was not aware of the patient's oxygen use despite seeing him/her on the day of discharge.

When asked about what the protocol is related to assisting a patient with health insurance coverage, she indicated that "Patient Access" is usually in charge of this, and this was discussed during "rounds." When asked if she was aware that the patient voiced concerns related to his/her inability to afford his/her medications which was documented in the medical record, she stated she was not aware of this despite indicating that she had reviewed the patient's medical record.

When asked how often Social Services sees patients, Employee J indicated that there is no specific timeframe, but she will see the patient based on the need to follow up and stated that it is usually "not normal practice" to go without seeing a patient for 5 days. The Director of Case Management indicated that patients are seen according to what is appropriate for the patient and acknowledged that a change in condition would warrant a visit by Social Services. In addition, Employee J did not remember why she gave the patient information about shelters and indicated that she would have offered information related to his/her inability to purchase medications.









45769