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Based on interview and record review, the hospital failed to ensure one of four medical staff (Physician 3) met the requirement for Category II Basic Interventional Radiology Procedures. This failure created the risk for substandard health outcomes to the patients.

Findings:

Review of the hospital's Medical Staff General Rules and Regulation dated 5/24/23, showed it is expressly understood that the contents of the credential files constitute records and proceedings of Medical Staff and Peer Review Committees that are responsible for evaluation and improving the quality of care provided in the hospital.

On 10/1/24 at 1056 hours, a concurrent interview and record review was conducted with the Medical Staff Director and Director of Quality.

Review of Physician 3's credential file showed the Radiology Clinical Privilege Request Form dated 10/10/23, showing Category II Basic Interventional Procedures were requested, approved, and required proctoring. The form showed the category II required the board certification in radiology. The form also showed the date of credentials committee approval was 1/10/24, date of Medical Executive approval was 1/15/24, and date of GB approval showed 1/24/24.

The Medical Staff Director stated Physician 3 was released for Category 1 to 3 on March 2024 and currently working on Category 3B. The Medical Staff Director was asked for Physician 3's board certification in radiology. The Medical Staff Director stated Physician 3 had not taken his board certification as of yet. Physician 3 had to complete the list of steps to be eligible to take the board exam. The Medical Staff Director stated the verbiage on the Radiology Clinical Privilege Request Form for Category II Basic Interventional Procedures should be the same as the other categories to be Board Certified or Residency Trained in Radiology. However, the Radiology Clinical Privilege Request Form showed Category II required Board Certification in Radiology.

The findings were shared with the Director of Quality.

Based on interview and record review, the hospital failed to ensure the hospital's medical staff general rules and regulations were enforced for one of one sampled patient (Patient 1) when Patient 1's medical record was not maintained accurately. This failure created the risk of substandard medical care to the patients.

Findings:

Review of the hospital's Medical Staff General Rules and Regulations dated 5/24/23, showed the P&P establishes for medical records and approved by the MEC and the Boards will be followed by all members and medical Staff.

Review of the hospital's P&P tilted Protocol for Medical Charting effective dated 6/23/21, showed the following:

* All significant clinical information pertaining to a patient is entered in the medical records as soon as possible after its occurrence.

* Medical Records Requirements:

- All medical records include diagnostic and therapeutic orders, clinical observations including the results of therapy, reports of procedures, tests, and their results.

* Progress Notes: Progress notes give a pertinent chronological report of the patient's course in the hospital and reflect any change in condition and the result of treatment.

On 9/25/24 at 0746 hours, an interview and record review was conducted with the Director of Quality.

1. Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/7/24 and discharged on 9/10/24.

Review of the H&P examination electronically signed on 9/7/24 at 0430 hours, showed Patient 1 complained of headache after a fall from home.

Review of the Progress Note electronically signed by Physician 4 on 9/7/24 at 2028 hours, showed to continue IV antibiotic and pending cultures.

Review of the Progress Note electronically signed by Physician 4 on 9/8/24 at 1718 hours, showed to continue IV antibiotic and pending cultures.

The Director of Quality was asked about the pending cultures that was written on Physician 4's progress notes. The Director of Quality stated there was no order for cultures and there was no result of cultures for Patient 1.

2. Patient 1's medical record showed Patient 1 came to the hospital's ED on 9/10/24 at 2123 hours (or approximately three hours after the patient was discharged from the hospital).

Review of the ED Physician's Chart dated 9/10/24 at 2123 hours, showed Patient 1 was tachycardic and had slight increased work of breathing with some faint wheezing. The patient was treated for suspected asthma exacerbation. The decision was to admit the patient to ICU. Patient 1 was given three IV pushes of bicarb (a medication used to treat metabolic acidosis) for metabolic acidosis with pH of 7.04 (normal range is from 7.35 - 7.45).

Review of the H&P examination electronically signed by Physician 2 on 9/11/24 at 0953 hours, showed Patient 1 was discharged from the hospital to the family member. The patient was short of breath and was on room air. The patient was brought back to the ED because of SOB. The patient became much more obtunded. The laboratory demonstrated acidosis. The patient's HR was very tachycardic at 130's. The Assessment/Plan section showed the patient had acute metabolic encephalopathy; the cause was unclear, possible stroke but the brain CT was negative.

The Director of Quality was asked for the brain CT performed in the ED prior to admission to ICU. The Director of Quality stated there was no order for the CT scan of the brain in the ED.

The findings were shared with the Director of Quality.

Based on interview and record review, the hospital failed to ensure the nursing services were provided to one of one sampled patient (Patient 1) as evidenced by:

a. The nursing staff did not perform the neuro checks every four hours for Patient 1 as per the physician's order.

b. The telemetry RN failed to ensure Patient 1's reassessment was documented for a change of condition as per the hospital's P&P.

c. The telemetry RN failed to ensure Patient 1 reassessment was performed every six hours as per the hospital's P&P.

d. The ED RN failed to perform the focused assessment for Patient 1 for the patient's change in condition.

e. The nursing staff failed to ensure the treatment for MASD was implemented.

These failures created the risk for substandard health outcomes for the patients.

Findings:

Review of the hospital's P&P titled Assessment and Reassessment of Patient effective date 2/28/24 showed:

* Purpose: To provide guidelines to support a standardized approach for comprehensive and collaborative patients assessments.

* Definition of Terms:

- Physical Assessment: The assessment of the patient's physical status including vital signs, height, weight, systems assessment, and evaluation of pain.

- Focused Exam: concise assessment based on patient's chief complaint and immediate physiological needs.

* Policy: Throughout the patient's stay, the healthcare team performs reassessments based on individualized and prioritized needs to determine response to treatment, therapy, or educational sessions and to determine the effectiveness of the interventions undertaken by the healthcare team. The healthcare team also performs reassessments when there is a significant change in the patient's diagnosis or condition that necessitates change in the care plan. The physician is notified upon completion of the reassessment and informed of the changes. The RN should accompany the patient's physician during the physician's daily rounds whenever possible to provide updates on the patient's status and discuss any issues or concerns pertaining to the care and treatment.

* For telemetry unit, patient assessment and reassessment parameters include, but are not limited to:

- The reassessment time frame: the reassessment is to be performed every six hours and when condition changes.

On 9/25/24 at 0800 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Quality.

Patient 1's medical record showed the patient came to the hospital ED on 9/6/24 after a fall at home, complaining of headache. Patient 1 was discharged home with the home health on 9/10/24 at 1828 hours. The patient was returned to the hospital ED on 9/10/24 at 2131 hours.

a. Review of the physician's order dated 9/7/24 at 0425 hours, showed to perform neuro checks every four hours.

Review of the RN's assessment dated 9/9/24, showed the neurological assessment were performed at 0635 hours, 1248 hours (after approximately 6 hours and 30 minutes), 1840 hours (after approximately six hours); and on 9/10/24 at 0100 hours (after approximately 6 hours), and 0700 hours (after 6 hours).

The Director of Quality was asked for the documented evidence showing the neuro checks were performed every four hours for Patient 1. The Director of Quality was unable to show the documentation of neuro checks performed every four hours. The Director of Quality was asked if the physician's order for neuro checks every four hours was discontinued. The Director of Quality stated no.

The Director of Quality verified the neuro checks every four hours was not performed for Patient 1 as ordered by the physician.

b. Review of the physician's order dated 9/9/24 at 1932 hours, showed albuterol (bronchodilator, a medication that make breathing easier) 2.5 mg per 3 ml, 2.5 mg via HHN PRN every 4 hours for SOB or wheezing.

Review of the physician's order dated 9/10/24 at 0248 hours, showed albuterol 2.5. mg per 3 ml, 2.5 mg via HHN every 4 hours for SOB or wheezing to be given by the RT.

Review of the RN's pulmonary assessment for Patient 1 on 9/9/24 night shift (1800 to 0600 hours) did not show there was a focus assessment when Patient 1 needed a breathing treatment order.

Review of the RT' s progress notes showed the albuterol HHN respiratory treatments were administered for Patient 1's wheezing on 9/9/24 at 2037 hours, 9/10/24 at 0144 hours, 0328, 0730 hours, 1103 hours, and 1557 hours. However, review of the RN's assessment on 9/9/24 at 1932 hours and 9/10/24 at 0248 hours did not show the nursing staff conducted the patient's pulmonary assessment for the change in condition.

The Director of Quality was asked to show the RN's focused assessment at the time Patient 1 had a change in condition. The Director of Quality could not show the RN's documentation to show the nursing staff assessed Patient 1's change in condition.

The findings were shared with the Director of Quality.

c. Review of RN's assessment and reassessment on 9/10/24 day shift (0600 to 1800 hours), showed the telemetry RN performed physical assessment for Patient 1 at 0700 hours. Patient 1's pulmonary assessment showed Patient 1 had dyspnea on exertion and wheezing breath sounds.

However, there was no reassessment documented after six hours (or at 1300 hours) as per the hospital's P&P.

The Director of Quality was asked for the frequency of the patient assessment required for the telemetry RNs. The Director of Quality stated the reassessments were to be performed every six hours. However, the RN failed to show documented evidence Patient 1's reassessment was performed after 0700 hours on 9/10/24.

The findings were verified with the Director of Quality.

d. Review of the hospital's P&P titled Triage, Medical Screening Examination and Nursing Assessment dated 9/28/22, showed in part:

* Policy: A standardized 5 level Triage Acuity tool will be utilized to prioritize patients into categories based upon assessed severity of illness.

- Level 3 - Urgent - Requires prompt care, but some delay will not cause loss of limb or life. These conditions required diagnostic and therapeutic intervention to prevent complications and relieve suffering. These are potentially serious nature. Stable vital signs. Reassessment every 2 to 4 hours and as needed, to include full set of vital signs and again 30 minutes prior to discharge or admission.

* Nursing Assessment and Reassessment:

- Triage: Nursing triage assessment is performed on every patient in the ED.

- Patients then will be taken to the treatment area for further assessment, care, and treatment. Nursing care is based upon the assessment of patient needs by a RN starting with the initial complaint-focused assessment done at the time of presentation to the ED.

- Collaboration with other disciplines: Goals of collaboration with other discipline include to enhance the comprehensiveness of the assessment and improve effectiveness of the plan.

- Assessment and Reassessment by the Treatment RN includes but is not limited to: assessment and reassessment area continuing process during the patient's length of stay in the ED. Assessments are documented electronically in EHR. Further on-going assessment or reassessment is determined by changes in patient's condition, patient's response to treatment plan, or implementation of interventions.

Review of the Nursing Chart dated 9/10/24 at 2123 hours, showed Patient 1 was brought back to the ED (approximately three hours after discharged) by the ambulance. Per EMS, the family member called 911 when the patient's family member noticed the patient had difficulty of breathing while lying in bed. Patient 1 was admitted on 9/6/24 for UTI and was discharged on 9/11/24 at 1830 hours. Patient 1's chief complaint was fever five days ago. The patient's temperature level was 99.7 degrees F orally. Patient 1's symptoms included cough and shortness of breath. There was associated cough, lethargy, and weakness. The form showed the Triage Acuity level was 3 (urgent).

Review of the ED RN's Focus Assessment and Treatment Notes documentation for Patient 1 showed the following:

* On 9/10/24:

- At 2150 hours, the patient's RR was 30 breaths per minute and the patient's oxygen saturation was 96 %. The patient's cardiac rhythm was normal sinus rhythm. The patient's respiration was even and non labored. However, there was no documented evidence the ED RN assessed Patient 1's breath sounds. The ED RN documented the patient had a history of asthma.

- At 2155 hours, the patient's HR was 85 bpm. The patient's RR was 28 breaths per minute and the patient's oxygen saturation was 98 %. The patient was sitting and awake.

- At 2258 hours, Patient 1 was given prednisone (steroid) 50 mg by mouth.

- At 2328 hours, Patient 1's troponin level was 1.050 ng/ml (the normal level is from 0 - 0.04 ng/ml)

- At 2353 hours, Patient 1 was given the nebulizer treatment once.

* On 9/11/24:

- At 0051 hours, 3 liters/nc oxygen was provided to Patient 1.

- At 0454 hours, the patient's BP was 157/98 mmHg. The patient's HR was 150 bpm. The patient's cardiac rhythm was ST. The patient's RR was 28 breaths per minute. The patient's oxygen saturation was 98%. The patient was awake. The patient was given 3 liters/nc oxygen.

- At 0455 hours, Patient 1's HR was 140's to 150's. The patient had tachycardia. The patient appeared diaphoretic and had decreased in mentation. The ED Physician was informed of Patient 1's condition and gave an order to repeat the EKG. However, there was no documented evidence ED RN performed a focused assessment for the decreased mentation.

The Director of Quality was asked for the focused assessment for Patient 1 with the change in condition for the decreased in mentation. The Director of Quality stated the ED RN's focus assessment was the patient's decreased mentation, the patient's HR as of 150's, and diaphoretic. When asked for neurological assessment, the Director of Quality could not show the neurological assessment as the focused assessment for the change in mentation.

The findings were shared with the Director of Quality.

e. Review of hospital's P&P titled Skin Care Protocol: Prevention and Management of Skin Breakdown dated 10/26/22, showed in part:

* The purpose is to identify patient at risk for skin breakdown and to outline wound management plan for patients with the potential or actual skin breakdown.

* Moisture Associated Skin Damage (MASD) is a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus.

* Patients and families are notified of skin impairment or deteriorating changes in skin integrity by the bedside nurses or wound care specialist.

* The attending physician or surgeon is notified of skin impairment or deteriorating changes in skin integrity by the bedside registered nurse or wound care specialist.

* The Protocol includes the following:

- Initiate Skin Protocol for a Braden Scale of 18 or less and or wounds.

- Prevention interventions are followed per protocol. The Braden Scale of 12-10 indicates the patient is high risk for developing PI.

* The Nursing Care Interventions include the following:

- Prevention and Management of MASD include to apply barrier cream or spray and keep patient clean and dry.

* Documentation:

- Initial skin assessment is documented in the integumentary section of Interdisciplinary Plan of Care electronic form.

- Subsequent skin assessments are documented in the integumentary section of the assessment flow chart.

- Dressing changes and wound assessment are documented on the Skin and Wound Management Flowchart.

- Skin and Wound Management Flowchart and photographs are completed for patients with actual skin impairment.

Review of Patient 1's medical record was conducted with the Director of Quality on 10/1/24 at 1305 hours.

Patient 1's medical record showed on 9/11/24 at 0839 hours, Patient 1 was admitted to ICU. The initial skin assessment showed no skin breakdown. Patient 1's Braden Scale on admission was 12.

Review of Patient 1's Skin Assessment showed on 9/19/24 at 2100 hours, Patient 1 was assessed with the inner thigh skin tear or rash. The site was cleaned with NS and zinc cream. The Wound Care was consulted.

Review of the wound consult Progress Note dated 9/20/24 at 1112 hours, showed Patient 1 had a MASD. The wound location was at the right posterior thigh and perirectal. The wound bed was as erythemic rash with superficial skin rash and denuded skin surface. The WC recommended to clean the MASD with NS (normal saline, a solution of salt and water) or wound cleanser, apply zinc oxide (a topical ointment helping the wound healing) cream every 12 hours and as needed after pericare.

Review of the RNs documentation of treatment performed for Patient 1's MASD showed the following:

- On 9/20/24 at 1632 and at 1905 hours, the wound was cleaned with NS.

- On 9/2124 at 1403 hours, the wound was cleaned with NS.

The Director of Quality verified the prevention and management for Patient 1's MASD was not implemented.

The findings were shared with the Director of Quality.

Based on interview and record review, the hospital failed to ensure the plan of care was developed and updated for one of one sampled patient (Patient 1). This failure posed the potential to negatively impact the patient's health outcomes.

Findings:

On 9/26/24 at 1400 hours, an interview and record review were conducted with the Director of Quality.

Patient 1's medical record showed the patient was admitted to the hospital on 9/7/24, and discharged on 9/10/24 at 1828 hours. The patient was returned to the hospital ED on 9/10/24 at 2131 hours.

a. Review of the H&P examination dated 9/7/24, showed Patient 1's potassium level was 3.0 mmol/L (the normal level is from 3.6 to 5.0 mmol/L).

Review of the laboratory results showed the following:

- On 9/7/24 at 0821 hours, the patient's potassium level was 4.1 mmol/L.

- On 9/8/24 at 0623 hours, the patient's potassium level was 3.5 mmol/L.

- On 9/9/24 at 0600 hours, the patient's potassium level was 3.1 mmol/L.

- On 9/10/24 at 1369 hours, the patient's potassium level was 2.7 mmol/L.

Review of physician's orders showed the following:

- On 9/9/24 at 1933 hours, administer one dose of potassium chloride (a supplement) 20 mEq.

- On 9/10/24 at 1702 hours, administer one dose of potassium chloride 20 mEq tablet.

b. Review of the laboratory results showed the following:

- On 9/8/24 at 0623 hours, the patient's CO2 level was 17 mmol/L (the normal level is from 22 - 30 mmol/L)

- On 9/9/24 at 0600 hours, the patient's CO2 level was 15 mmol/L.

- On 9/10/24 at 1369 hours, the patient's CO2 level was 19 mmol/L.

Review of physician's orders showed on 9/9/24 at 2100 hours, sodium bicarb drip 1/2 NS 1000 ml added sodium bicarb 50 mEq per 50 ml to run at 80 ml per hour.

c. Review of physician's orders dated 9/7/24 at 0425 hours, showed to perform neuro checks every four hours.

d. Review of RN's Integumentary Assessment for Patient 1 dated 9/9/24 at 1025 hours, showed Patient 1 had skin tear at the right inner thigh buttock crease.

However, review of Patient 1's Interdisciplinary Plan of Care did not show the plan of care was developed for neurological intervention including the frequency of neurological assessment every four hours, cardiovascular including the expected or goals for fluid and electrolyte balance, and discharge planning. In addition, the patient's plan of care related to the integumentary was not updated when the patient had developed an impaired skin integrity at the right inner buttock crease.

The findings were verified with the Director of Quality.

Based on interview and record review, the hospital failed to ensure one of one sampled patient (Patient 1) was administered the drugs as evidenced by:

a. Patient 1 was placed on the oxygen therapy without physician's order.

b. The RN did not ensure the PTT baseline was obtained before administering the heparin (anticoagulant medication) IV bolus for Patient 1.

These failures posed the increased risk for the substandard health outcomes to the patient.

Findings:

On 9/25/24, review of Patient 1 medical record was initiated.

Patient 1's medical record showed the patient was admitted to the hospital on 9/7/24 and discharged on 9/10/24 at 1828 hours. The patient was returned to the hospital ED on 9/10/24 at 2131 hours.

a. Review of the hospital's P&P titled Oxygen Therapy dated 9/27/24, showed oxygen is a drug and requires a physician's order. RCP and RN can place low flow oxygen on a patient (i.e. nasal cannula). RCP will assess patients in oxygen therapy once per shift.

Review of the RN's vital signs documentation showed on 9/10/24 at 1159 hours, the patient was on 1 liter/nc oxygen.

Review of the RT's assessment for Patient 1 dated 9/10/24, showed at 1557 hours, the patient was on 1 liter/nc oxygen.

On 9/30/24 at 1040 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Quality. The Director of Quality was asked to show the order for the use of oxygen for Patient 1. The Director of Quality stated there was no order to use oxygen for Patient 1.

b. Review of the hospital's P&P titled Pharmacy Managed Continuous Heparin Protocol dated 11/24/21, showed in part:

- When the clinical pharmacy receives an order such as heparin per pharmacy, Heparin per pharmacy protocol, or similar language, the clinical pharmacist is authorized to initiate and adjust orders for continuous IV heparin dose and diagnostic testing such as PTT, PT/INR, CBC, and anti-XA level to monitor heparin therapy.

- The clinical pharmacist documents the required orders in the patient's medical record.

- The clinical pharmacist doses and monitors heparin therapy based on the "Guidelines for Continuous IV Heparin Therapy" as approved by the Pharmacy and Therapeutics and Medical Executive Committees.

- The clinical pharmacist appropriate appropriately assess the patient prior to initiating heparin therapy and documents the initial assessment in the medical record. The initial assessment includes, but not limited to indication for use; goal PTT; history of previous anticoagulant use; risk factors for adverse events; baseline PTT, PT/INR, H/H, and platelet count; and plan and recommendation.

On 9/25/24 at 1432 hours, review and concurrent record review of Patient 1's record was conducted with the Director of Quality.

Patient 1's medical record showed Patient 1 was readmitted to the hospital ED on 9/10/24 at 2123 hours.

Review of the ED Physician Chart dated 9/11/24 at 0726 hours, showed Patient 1's initial troponin level was markedly elevated 1.05 ng/ml and the repeated troponin level began to rise to 1.14 ng/ml and was concerning for NSTEMI. The EKGs did not show evidence of ischemia. The cardiology was consulted who recommended heparin bolus and infusion.

Further review of the ED Physician's Chart showed the following verbal orders:

- At 0500 hours, heparin drip per pharmacy protocol.

- At 0503 hours, PT/INR.

- At 0504 hours, PTT.

- At 0521 hours, heparin 5000 units/ml IV bolus.

Review of ED Nursing Chart dated 9/11/24, showed the following:

- At 0522 hours, heparin 5000 units/ml IV bolus was administered to Patient 1.

- At 0539 hours, the PT/INR and PTT blood tests were performed by ED RN.

Review of the laboratory result for PTT showed on 9/11/24 the blood for the PTT was collected at 0520 hours, received at 0539 hour, and resulted at 0638. The PTT level was more than 200 seconds (the normal range is from 25 - 38 seconds). The result was called and verified with the ED MD that Patient 1 was on heparin.

On 10/1/24 at 0917 hours, an interview and concurrent review of Patient 1's medical record review was conducted with the Pharmacy Coordinator, Director of Quality and Director of ED. The Pharmacy Coordinator was asked about the order of heparin drip for Patient 1 and the PTT result. The Pharmacy Coordinator stated there was a mismatch of the RN's documentation about the blood draw and the administration of heparin bolus with 2 minutes time difference and the result of PTT of over 200 seconds. The baseline PTT was needed for the adjustment of the heparin drip. The Director of ED was asked for the practice in ED. The Director of ED stated the RN would draw the blood and then give the heparin IV bolus.

The findings were verified with the Director of Quality.

Based on interview and record review, the hospital failed to ensure the hospital's P&P for discharge planning was implemented for one of one sampled patient (Patient 1) when Patient 1's discharge planning was not timely evaluated. This failure posed an increased risk for unsafe discharge the patient.

Findings:

Review of the hospital's P&P titled Assessment and Reassessment of Patient effective date 2/28/24, showed an assessment of discharge planning needs is initiated within 24 hours of admission and is ongoing throughout the hospitalization. This is a collaborative process involving patient, family, and qualified individuals of the healthcare teams appropriate. Case management, nursing staff, including CSMs with physicians, and physical therapist or occupational therapist, if available participate in morning huddles to discuss current patient status and safety or other issues affecting the patient from being discharged. Documentation occurs in the Initial Discharge Assessment and is updated every 72 hours on the Case Management Flow Chart in the EMR. The role of the case manager is explained to the patient and or family and document on the Interdisciplinary Plan of Care.

Review of the hospital's P&P titled Discharge Planning dated 1/9/19, showed in part:

* Purpose: To provide patients with timely, coordinated, and safe discharge plan for smooth transition from hospital to discharge destination that meets the needs and acuity of the patient.

* Policy:

- Discharge planning evaluations or services are triggered through the screening process or are available upon request of the physicians, nurses, patient, patient's representative, and caregiver or family members.

* Procedure:

- Initial Assessment: Discharge planning begins at admission assessment by the admitting within 24 hours of admission. The RN identifies patient at risk for discharge planning needs and facilitates the interdisciplinary support for requested consultations for continuing care coordination. The CM department (Case Manager, RN, LVN, and Social Workers) have a comprehensive knowledge and experience in discharge planning. A screening process is utilized in determining which patients are at increased risk of adverse health consequences if discharge planning is lacking. Screening for discharge planning needs includes those likely to need post-hospital services, high risk cases and appropriate referrals, but is not limited to: over 65 years of age and lives alone or with someone who is compromised

- Discharge Planning: As part of the discharge or transition, planning process the case manager meets with the patient or family on the day of admission or as early as appropriate to understand the patients care needs, insurance benefit limitations or resources, barriers to discharge and to establish realistic care goals and transition plan. The CM or SW will discuss the discharge plan or goals with the patient or patient's legal representative.

- Implementation includes to assess the stability of the patient prior to discharge or transfer, notify the physician of any changes in condition.

Review of hospital's P&P titled Discharge Planning dated 9/25/24, showed the primary are of responsibility for coordinating the discharge planning process rests with the case managers. The clinical social worker will assist as needed.

On 9/26/24 at 1118 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Utilization Management and Director of Quality.

Patient 1's medical record showed the patient was admitted to the hospital on 9/7/24 and discharged on 9/10/24.

Review of the Case Management Initial Review dated 9/9/24 at 1522 hours, showed Patient 1 was admitted on 9/7/24.

The Director of Utilization Management was asked about the hospital's discharge process. The Director of Utilization Management stated the hospital had a designated discharge planner. The SW would do the initial assessment for the patient. When asked about the initial screening as per the hospital's P&P, the Director of Utilization Management stated the SW would do the initial screening. The CM would attend the daily huddles at 0800 hours with the CSM, CNO, houses supervisor and discuss patients who were on observation status, patients who had longer than five days stay, patients who would be discharged home or transferring. On the weekend, they also had huddles and got the reports from the CSMs or bedside RNs. For the newly admitted patients, the discharge process started by the following day of admission. The Director of Quality was asked for the screening for Patient 1's discharge planning. The Director of Quality could not show documented evidence the screening for the discharge planning was done or performed by the SW. The Director of Quality showed the Case Management Initial Review dated 9/9/24 at 1522 hours; however, the form was not completed. The Director of Utilization Management stated the patient was discharged home on 9/10/24.

The findings were verified with the Director of Quality.