HospitalInspections.org

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Based on interview and review of medical records, hospital documents and policies and procedures it was determined the hospital failed to assure the Condition of Participation for Governing Body. The Governing Body failed to implement systems and processes to address the discharge of patients to a safe environment with resources that meet the needs of the patients.

Failure to ensure a process was implemented to identify discharge criteria to direct Staff in providing a safe discharge plan potentially denied all patients their right to receive a discharge plan that meets their needs.

Findings include:

The hospital leadership, to include the Quality Chief Officer, Director of Case Management and Case Manager were aware of the incident regarding Patient #1 being discharged from the hospital the night of 4/22/2015 to home alone. The reasons given included; "Patient #1 wanted to go home, refused to return to a nursing home and a physician wrote a discharge order (4/22/2015)." A home health referral was made for services.

The hospital (Hospital A) leadership was aware of Patient #1's complex condition on 4/22/2015. The medical record contained documentation that the patient was unable to care for his/herself.

The day after discharge (4/23/2015) the Director of Case Management at Hospital A was in contact the home health agency and learned Patient #1 had not received services since discharge due to confusion related to the patient's primary care provider. The hospital did not respond to the information and facilitate interventions to ensure the patient received appropriate care after discharge.

The hospital leadership was unaware of the outcome of Patient #1's discharge plan.

Patient #1 was admitted to another hospital (Hosptial B) within 24 hours of discharge requiring acute care. Patient #1 continued to be hospitalized at the time of this investigation.
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Based on interview and document review, it was determined that the hospital failed to ensure 1 of 12 patients (#1) received a safe discharge to home. The patient lived alone and was unable to accomplish self-care. The hospital's failure to discharge patients to a safe environment which meet the needs of the patients resulted in harm to Patient #1 and placed all patients who were discharged from the hospital at risk for harm.


Findings include:


On May 27th and 28th, 2015 the following policies were reviewed.


"1) Patient Rights and Responsibilities which included;
17. To expect that the hospital will give you necessary health services to the best of its ability. Treatment, referral or transfer may be recommended. If transfer is recommended or requested, you will be informed of risks, benefits and alternatives..."


"20. To be told of realistic care alternatives when hospital care is no longer appropriate."


On May 27th, 2015 the patient's record at Hospital A was reviewed. Patient #1 was admitted from a nursing facility to Hospital A on 4/9/2015 with complications of diabetes, respiratory failure requiring intubation and mechanical ventilation (mechanical breathing machine), lung infection, urinary tract infection and gastrointestinal bleeding with a low blood count. An entry in the nurses' notes indicated the patient developed a pressure ulcer on 4/21/16. Documentation indicated the patient was confused, had poor recall and poor judgment.

On 4/22/2015 at 2:30 p.m. a physician wrote an order to discharge Patient #1 to home with home health. Patient #1's record indicated the patient continued to be confused, had poor judgement, was unable to walk without assistance, unable to transfer from his/her bed to a toilet without assistance, unable to manage his/her medications had an indwelling urinary catheter, and was also unable to independently prepare food or obtain fluids to drink. The patient was unable to perform wound care for his/her pressure ulcer. The patient's blood sugars were noted to be unstable on 4/21/2015 and 4/22/2015; the day of discharge.

Patient #1 was discharged from the hospital on 4/22/2015 and arrived to his/her home at 9:00 p.m. The patient was bed bound. Patient #1 did not have a wheelchair but was instructed to contact his/her physician to get one. The patient was given prescriptions but without discharge medications. Patient #1 required frequent testing of blood sugars but was unable to independently perform the tests. Patient #1 had a pressure ulcer without a means to provide treatment. The patient was left in bed with no means of meeting his/her needs. The patient did not have someone in the home to care for him/her. A friend of the patient stated s/he would stop by and check on the patient periodically.

On 5/15/2015 Patient #1's state AAA case manager stated s/he was made aware of the discharge on 4/22/2015 to assist with the discharge plan. The AAA case manager stated the patient previously had in home care providers (prior to nursing home placement) but it wasn't possible to place in home care services in the home on such short notice.

On 4/23/2015 the state AAA case manager for the COPES (home care program) visited Patient #1 and found the patient confused and hallucinating. Patient #1 thought the nurses were in the room. Patient #1 was unable to access a phone. A neighbor had visited Patient #1 and fed him/her. Patient #1's indwelling catheter bag was full. Emergency Medical Services (911) was summoned, along with the police and Patient #1 was transported to Hospital B. Patient #1 was admitted and continued to be hospitalized at Hospital B as of 5/29/2015.


On May 27th, 2015 an interview took place at Hospital A with the Chief Quality Officer. S/he stated Patient #1 was discharged to home because s/he refused to go to a Nursing Home.

Patient #1 did not have a Power of Attorney for health care to assist with making decisions about treatment and care. Although the patient was hospitalized for 13 days and the facility was aware the patient refused to return to a Nursing Home, and no efforts were made to obtain long-term assistance with decision-making such as a Power of Attorney or a court appointed Guardian ad Litum. No additional interventions were pursued to assist the patient.

Documentation in Patient #1's record indicated the patient was refused admission to nursing homes, " ...due to ... historical non-compliance with care."

A conference was held on 4/22/2015 with an interdisciplinary team which discussed the patient's need for on-going health care for post hospitalization care and insulin management. Although it was known to the hospital that the patient had confusion and poor judgment, they sent Patient #1 home because s/he refused to be placed in a nursing home.

Interview on 5/27/2015 with the Director of Case Management revealed the Discharge Policy and Procedure did not include specific discharge criteria for nurse Case Managers, responsible for discharge planning, to follow. There were no Hospital level criteria for the medical staff to follow. The Policies and Procedures did not include criteria related to determining patients' conditions which require ongoing hospitalization due to a need for diagnostic or therapeutic intervention, careful monitoring, social factors or if the discharge plan was appropriate.
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Based on record review and staff interview, the hospital failed to ensure that the medical staff consistently adhered to acceptable standards of patient care for 1 of 12 sampled patients (#1) reviewed.

Failure of the medical staff to identify the needs of patients may result in a discharge from Hospital A to an unsafe environment with readmission to a hospital and possible irreparable harm to their health and well-being.



Findings include:


Patient #1 was admitted from a nursing facility to Hospital A on 4/9/2015 with complications of diabetes, respiratory failure, lung infection, urinary tract infection and gastrointestinal bleeding with a low blood count. An entry in the nurses' notes indicated the patient developed a pressure ulcer on 4/21/16. Documentation indicated the patient was confused, had poor recall and poor judgment.

The patient's care was provided by Hospitalists, medical staff #A (discharging physician), and medical staff #B (admitting physician).

On 4/22/2015 at 2:30 p.m. medical staff member (#A) wrote an order to discharge Patient #1 to home with home health. Patient #1's record indicated the patient continued to be confused, had poor judgement, was unable to walk without assistance, unable to transfer from his/her bed to a toilet without assistance, unable to manage his/her medications and indwelling urinary catheter and unable to independently prepare food or obtain fluids to drink. The patient was unable to perform wound care for his/her pressure ulcer. The patient's blood sugars were noted to be unstable on 4/21/2015 and 4/22/2015; the day of discharge.

According to the patient's physician's Discharge Summary dated 4/22/2015, "Multiple discussions were held with patient regarding discharge planning by myself, case management. On the day of discharge we had discussion with patient, CM, and staff from ...SNF and tried to persuade patient to transition to SNF and be compliant with medical therapy. Patient refused to go to ...SNF and express wish to discharge home. We have explained patient need further rehab and would be best to transition to rehab. Pt refused. She was discharged to home with home health." The Discharge Instructions included; "The patient instructed to follow up with primary care physician in 1 week and also discuss referral to a nephrologist."

Attempt to interview medical staff member #A via telephone on 5/29/2015 was unsuccessful.

In an interview on 5/28/2015 with one of the Hospitalists, s/he stated that the medical responsibilities for discharging a patient from a hospital included/but not all inclusive, are ensuring the patient is strong enough and evaluated by physical therapy, have family support, provide needed equipment and provide home health services as needed.

Review of the Medical Staff Bylaws stated the medical responsibilities included the provision of discharging a patient when medically ready with the needed resources, services and medications.

Hospital medical staff failed to address the patient's needs for discharge and document the patient's inability to provide self-care, confusion, social factors to include a lack of support in the home, and inability to ambulate. With the knowledge the patient was not safe to go home alone, a discharge order was written and the patient was discharged within 6 hours of the order written.

A referral to the home health agency was not initiated due to confusion realted to primary care provider. The home health agency would only provide intermittent visits but not provide the 24 hour a day 7 days a week care the patient required. The hospital discharged Patient #1 from the hospital because s/he didn't want to go to a nursing home and nursing homes had refused to accept him/her. No alternative discharge plan was formulated. The State AAA case worker was not notified before the discharge date and did not have an opportunity to have input into the discharge plan.


The cumulative effect of these failures resulted in the hospital's inability to ensure the provision of quality health care to Patient #1 and was evidence that this Standard Level of Condition of Participation was NOT MET.
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Based on interview and document review of hospital policies and procedures and staff interview, the hospital failed to ensure that Nursing staff implemented approved policies and procedures addressing patient assessment and plan of care and/or treatment delivered by the interdisciplinary team (medical, nursing and pharmacy)..

Failure to assess patients for discharge needs placed all residents at risk for being discharged to an unsafe environment.


Findings include:


On May 27th and 28th, 2015 the following policies were reviewed.


1) Plan For The Provision of Care, Treatment, and Services
Department: Organization -Wide


"D. Assessment and Care Planning
Patients are assessed and reassessed to determine the care, treatment, and services necessary to meet their initial and continuing needs throughout the course of care, treatment, and services. CMC has defined the scope and content of screening, assessment, and reassessment in policy .... "


"E. Criteria for Determining Eligibility for Care, Treatment, and Services
At the point of first contact with person seeking care or treatment, an assessment process is initiated to obtain the appropriate and necessary information to match the person ' s health care needs with the level of the level of care provided within the hospital organization and the greater health care community. Admission is by order from a physician member of the CMC active or courtesy medical staff."


The Policy and Procedure did not include criteria related to determining patients' conditions requiring ongoing hospitalization due to a need for diagnostic or therapeutic intervention, careful monitoring, and social factors or for determining if the discharge plan was appropriate.


On May 27th, 2015 the patient's record at Hospital A was reviewed. Patient #1 was admitted from a nursing facility to Hospital A on 4/9/2015 with complications of diabetes, respiratory failure requiring intubation and mechanical ventilation (mechanical breathing machine), lung infection, urinary tract infection and gastrointestinal bleeding with a low blood count. An entry in the nurses' notes indicated the patient developed a pressure ulcer on 4/21/16. Documentation indicated the patient was confused, had poor recall and poor judgment.

A conference was held on 4/22/2015 with an interdisciplinary team which discussed the patient's need for on-going health care for post hospitalization care and insulin management. Although it was known to the hospital the patient had confusion and poor judgment, they sent Patient #1 because s/he refused to be placed in a nursing home.

On 4/22/2015 at 2:30 p.m. a physician wrote an order to discharge Patient #1 to home with home health.

An entry in the last nurses' note 4/22/2015 at 7:55 p.m. indicated the patient's intravenous access was discontinued and the indwelling urinary catheter was in place, vital signs were stable and the patient had no questions regarding his/her discharge. There was no indication that there was concern regarding this confused, bed bound patient with multiple needs including management of unstable blood sugars and inability to perform self care being discharged to home alone. There was no documentation to support the patient understood the discharge plan and what was expected of her to do independently.

Patient #1 was discharged from the hospital on 4/22/2015 and arrived to his/her home at 9:00 p.m. The patient was bed bound and alone. Patient #1 did not have a wheelchair but was instructed contact his/her physician to get one. The patient was given prescriptions but without discharge medications. Patient #1 required frequent testing of blood sugars but was unable to independently perform the tests. Patient #1 had a pressure ulcer without a means to provide treatment. The patient was left in bed with no means of meeting his/her needs. The patient did not have someone in the home to care for him/her. A friend of the patient stated s/he would stop by and check on the patient periodically.

On 5/15/2015 Patient #1's state AAA case manager stated s/he was made aware of the discharge on 4/22/2015 to assist with the discharge plan. The AAA case manager stated the patient previously had in home care providers (prior to nursing home placement), who provided non-medical personal care, but it wasn't possible to place in home care services in the home on such short notice. Also, the patient required complex nursing care outside the scope of home care services.

The state AAA case manager visited Patient #1 on 4/23/2015 and found the patient confused and hallucinating. Patient #1 thought the nurses were in the room. Patient #1 was unable to access a phone. A neighbor had visited Patient #1 and fed him/her. Patient #1's indwelling catheter bag was full. Emergency Medical Services (911) was summoned, along with the police and Patient #1 was transported to Hospital B. Patient #1 was admitted and continued to be hospitalized at Hospital B as of 5/29/2015.

Interview with a Registered Nurse (RN) Case Manager on 5/28/2015 who arranged the discharge plan stated s/he was directed to implement a discharge plan on 4/22/2015. The RN Case Manager stated the routine for the case management team was to carry out the physician discharge order when written. The Case Manager stated s/he was unaware of the hospital using any policy or procedure which included specific discharge criteria.

Patient #1's record did not include a final comprehensive nursing assessment to include the patient's problems, identified patient needs and how those needs would be met in the home.


In Patient #1's record was a Home Health Care-Rapid Referral Form for home health services initiated the day of discharge (4/22/2015). The form identified, "Patient would not be able to manage medication or be independent with basic needs. "The document included," ...unable to ambulate-lives alone-does not drive-very uncontrolled diabetic mgmt. [management]-needs are great-for medication mgmt., social worker, wound care, labs, physical therapy."


No nursing documentation was found in the record to support Patient #1 was comprehensively assessed to ensure the arranged interventions were appropriate.


The home health services were not initiated due to confusion regarding the patient's primary care provider but this was not learned by the hospital until 4/23/2015. No alternate intervention was implemented when the hospital learned the patient was at home alone, without home health services and had signs and symptoms of a deterioration in condition.


The home health agency would provide intermittent visits but not provide the 24 hour a day 7 days a week care the patient required. The hospital knew the patient was confused, bed bound and lived alone but gave him/her instructions to coordinate with his/her physician in the community to arrange getting a wheelchair, obtain his/her own prescribed medications and make an appointment with a nephrologist but discharged him/her from the hospital because s/he didn't want to go to a nursing home and nursing homes had refused to accept her. No alternative discharge plan was formulated. The State AAA case worker was not notified before the discharge date and did not have an opportunity to have input into the discharge plan.


The Cumulative effect of these systemic problems resulted in the hospital's inability to ensure Nursing Services provided the provision of quality health care in a safe environment for discharge to home, and was evidence that this Condition of Participation was NOT MET.
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Based on interviews, record review, review of hospital documentation and policies and procedures it was determined that the hospital failed to provide an appropriate discharge plan to a safe setting for 1 of 12 patients (Patient #1) reviewed for discharge planning process. Patient #1 was discharged to home alone without the ability to provide self-care, perform wound care, manage medications, manage an indwelling urinary catheter, obtain medications and needed equipment or the ability to call for help. It was determined that hospital policies and procedures for the Discharge Planning CONDITION was not met.

The failure of the hospital to develop and implement policies and procedures to provide direction for appropriate discharge criteria resulted in an unsafe discharge to an inappropriate setting for Patient #1 who required readmission to Hosptial B within 24 hours of discharge.

Findings include:

The Department of Health received a complaint that a bed bound patient was inappropriately discharged from the hospital (Hospital A) to home alone at 9:00 p.m. on April 22, 2015.

During a telephone interview on 5/15/2015 Patient #1's state assigned Area Agency on Aging (AAA) case manager stated s/he was notified on the day of discharge (4/22/2015) that the patient would be transferred home because Patient #1 refused to go to a Nursing Home and needed to be discharged from hospital (Hospital A). Patient #1 was transported from Hospital A and arrived home via ambulance at 9:00 p.m. Patient #1 was bed bound, had a pressure ulcer and had an indwelling urinary catheter. Patient #1 did not have a wheelchair but was instructed to contact his/her physician to get one. The patient was given prescriptions but without discharge medications. Patient #1 required frequent testing of his/her blood sugar level but was unable to perform these tests. Patient #1 was left in bed with no means of meeting his/her needs.

The state AAA case manager visited Patient #1 on 4/23/2015 and found the patient confused and hallucinating. Patient #1 thought nurses were in the room. Patient #1 was unable to access a phone. A neighbor had visited Patient #1 and fed him/her. Patient #1's indwelling catheter bag was full. Emergency Medical Services (911) was summoned, along with the police and Patient #1 was transported to Hospital B. Patient #1 was admitted and continued to be hospitalized at Hospital B as of 5/29/2015.

The record from Hospital B revealed the emergency department physician, at Hospital B, documented on 4/23/2015 Patient #1 was confused, appeared chronically ill, malnourished, unkempt and noted the patient complained of being short of breath. Patient #1 was admitted with complications of diabetes, infection, blood loss, renal failure, abnormal urinalysis.

On May 27th, 2015 the patient's record at Hospital A was reviewed. Patient #1 was admitted from a nursing facility to Hospital A on 4/9/2015 with complications of diabetes, respiratory failure requiring intubation and mechanical ventilation (mechanical breathing machine), lung infection, urinary tract infection and gastrointestinal bleeding with a low blood count. An entry in the nurses' notes indicated the patient developed a pressure ulcer on 4/21/16.

On 4/22/2015 the patient was noted to be confused, had poor judgement, was unable to walk without assistance, unable to transfer from his/her bed to a toilet without assistance, unable to manage his/her medications and unable to independently prepare food or obtain fluids to drink. The patient was unable to perform wound care. The patient's blood sugars were noted to be unstable on 4/21/2015 and 4/22/2015; the day of discharge.

The initial hospital discharge plan was to return the patient to a nursing home. Patient #1 refused to return to the nursing home and insisted on going home. There was no indication the hospital pursued alternative placement for Patient #1 or in-home services other than home with home health.

Patient #1's physician wrote a discharge order, for Hospital A, initially on 4/19/2015 at 9:49 a.m. and cancelled this order later the same day. A second discharge order was written by the physician on 4/22/2015 at 2:30 p.m.

In an interview on 5/27/2015 with the Chief Quality Officer for Hospital A stated s/he supervised the case management program. S/He stated the patient was transported home because Patient #1 wanted to go home and refused nursing home placement.

Interview with a Registered Nurse (RN) Case Manager on 5/28/2015 at Hospital A, who arranged the discharge plan, stated s/he was directed to implement a discharge plan on 4/22/2015. The RN Case Manager stated the routine for the case management team was to carry out the physician discharge order when written. The Case Manager stated s/he was unaware of the hospital using a policy or procedure which included specific discharge criteria.

On the Home Health Care-Rapid Referral Form, completed by the Case Manager responsibile for implementing the discharge plan, the clinical findings to support the need for the home health skilled services and homebound status included, "considerable taxing effort to leave home-unable to ambulate-lives alone-does not drive-very uncontrolled diabetic mgmt [management]-needs are great-for medication mgmt., social worker, wound care, labs, physical therapy-frequent hospital stays-needs SNF (skilled Nursing Facility) - but refuses."

On 4/22/2015 Patient #1 was transported home by ambulance and arrived at 9:00 p.m. with referrals to Home health services, home health equipment and was given prescriptions for medications at the time of discharge on 4/22/2015. Documentation indicated a friend would check on Patient #1 but could not provide 24 hour 7 day a week care.

On 4/23/2015 the hospital was notified that the home health service had not initiated services due to confusion related to the primary physician following the patient.

Patient #1 was transported to Hospital B less than 24 hours after discharge from Hospital A and continued her hospital stay at Hospital B as of May 29, 2015.

Interview with the Director of Case Management at Hospital A revealed the Discharge Policy and Procedure did not include specific discharge criteria. The Policy and Procedure did not include criteria related to determining patients' conditions requiring ongoing hospitalization due to a need for diagnostic or therapeutic intervention, careful monitoring, and social factors or if the discharge plan was appropriate.

Review of the hospital DISCHARGE PLANNING REFERRALS OF PATIENTS TO POST-DISCHARGE PROVIDERS (revised 7/12) identified the Purpose of the process as follows; "To ensure patients are informed of their options and have a free choice in selecting their post-discharge provider/service, and have been informed of any financial interest that the Hospital may have with the extended care provider/service."
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Based on interviews, record review, review of hospital documentation and policies and procedures it was determined that the hospital failed to identify at an early stage of hospitalization 1 of 12 Residents (#1) discharge needs which resulted in readmission to Hospital B within 16 hours of discharge.
Failure to identify patients' medical stability, functional status, cognitive ability, post-hospital care patient requirements including requirements of services for health care, professionals or facilities, the availablity and capability of family and freinds to provide follow up care in the home, placed all patients at risk for adverse consequences including readmission to a hospital.
Findings include:
During a telephone interview on 5/15/2015 Patient #1's state assigned Area Agency on Aging (AAA) case manager stated s/he was notified on the day of discharge (4/22/2015) that the patient would be transferred home because Patient #1 refused to go to a Nursing Home and needed to be discharged from hospital (Hospital A). Patient #1 was transported from Hospital A and arrived home via ambulance at 9:00 p.m. Patient #1 was bed bound, had a pressure ulcer and had an indwelling urinary catheter. Patient #1 did not have a wheelchair but was instructed to contact his/her physician to get one. The patient was given prescriptions but without discharge medications. Patient #1 required frequent testing of his/her blood sugar level but was unable to perform these tests. Patient #1 was left in bed with no means of meeting his/her needs.
A discharge order was written by the physician on 4/22/2015 at 2:30 p.m.
Interview with a Registered Nurse (RN) Case Manager on 5/28/2015 at Hospital A, who arranged the discharge plan, stated the routine for the case management team was to carry out the physician discharge order when written. The Case Manager stated s/he was unaware of the hospital using a policy or procedure which included specific discharge criteria.
Patient #1 continued her hospital stay at Hospital B as of May 29, 2015.