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Based on record review and interview, the facility failed to fully document and investigate grievances regarding discharge planning issues in 2 of 6 records reviewed. (Patient IDs# 1 & 3).

Findings included:
Record Review of facility's "Patient Complaints and Grievances Policy", last reviewed 6/3/2022, stated "A patient grievance is a formal or informal written or verbal complaint that is made to the health care system by a patient, or patient's representative, regarding the patient's care ..."

Record Review of facility's "Patient Complaints and Grievances Procedure", last reviewed 06/03/2022, stated "Action: 7. Department leadership will investigate the grievance including, as appropriate clinical reviews and staff interviews. 8. Document findings in hospital approved electronic tracking tool or send results to Patient Relations team/ADA coordinator to document."


Patient ID #1:
HHSC Intake received 9/25/23 via online intake for Patient ID #1. Complainant stated on 9/1/23 patient ID #1 was released from the facility after feeding tube surgery. The "hospital rushed the complainant to the house and nothing came with him which included food to be used in the feeding tube." The patient's hospice agency said the hospital should have "given the feeding tube food to the patient" since it was a long holiday weekend until delivery could be arranged from hospice. Patient ID #1 "went without food from 9/1/23 until 9/2/23. On 9/2/23, the complainant sent someone to go to the hospital to pick up food for the feeding tube." The complainant "did report her concerns to hospital administration." She received a letter dated 9/14/23, "that the hospital would take care of her concerns and investigate."

Record review of electronic grievance and complaint log revealed a grievance opened on 9/8/23 as a "Treatment - Concern/Issue" and closed on 10/6/23 as "closed, able to satisfy" for Patient ID #1.

Record review of electronic grievance and complaint correspondence and investigation tracking revealed an email by Patient Relations Representative Staff ID # 58 drafted on 9/8/23 to multiple clinical leadership identifying numerous complaints/grievances. It stated " ..... Case Management: Can you please review and provide feedback due to equipment/food concerns?" The response received on 9/19/23 via email from Director of Case Management Staff ID #72 stated "Patient was referred to home hospice and once we confirmed about the hospice acceptance we discharged patient home with hospice. I am not seeing any rush to discharge patient based on my review."
Interview with Director of Quality Staff ID #51 on 10/19/23 at 2:30 pm confirmed this email response failed to fully answer the questions which were being asked for investigation purposes related to equipment and food concerns.

Patient ID#3
HHSC Intake received 9/5/23 via telephone intake for Patient ID #3. Complainant stated on they "were told by the nurse at the hospital the nursing facility had been given all orders and was all set. The patient's medications and services will be ready when she arrives." They were "given an envelope and informed to give to the nursing facility's charge nurse. The envelope contained the physical original orders. The nursing facility only had three of the medications and did not have any insulin for the patient." The complainant was informed "the hospital did not give orders for insulin."

Medical record for Patient ID #3 was reviewed with Nurse Manager Staff ID #57. Entry by case manager staff ID #67 on 9/5/23 at 09:41 am stated "Call received from patient's (redacted). They left SNF AMA and having trouble getting her medicines from NH. Ombudsman number provided to assist. He also intends to get pt's records to determine if they should have been aware of pt insulin needs."

Record review of electronic grievance and complaint log failed to reveal any grievance or complaint for Patient ID #3.

Interview with Director of Case Management Staff ID #63 on 10/19/23 at 2:45 pm, confirmed there was no evidence from the documentation that case management staff had notified leadership of the issues or patient relations for grievance and complaint investigation process.

Based on record review and interview, the medical staff failed to ensure two of seven hospital inpatients had thorough Discharge Summaries (DC) completed and documented per Medical Staff Bylaws and Rules/Regulations (Patient # 1 & 3):

Findings included:
Record review of facility "Medical Staff Rules & Regulations" , dated May 2023, stated: ... "Patient Medical Record - Record of care, treatment and services. A. The practitioner in attendance and any consultants are responsible for the preparation of a timely, complete and legible medical record for each patient. The medical record should contain sufficient information to identify the patient, support the diagnosis and treatment and document the results. B. Each medical record contains the following clinical information: ...9. Any observations relevant to care, treatment and services. 10. The patient's response to care, treatment or services ... 13. Any medications ordered or prescribed. 17. Treatment goals, plan of care and revisions to the plan of care... 22. Any records of communication with the patient ..." The rules and regulations further stated "Documentation - Discharge Summaries. A. A narrative discharge summary shall be recorded on each patient discharged ... B. The narrative summary shall include a concise review of the reason for hospitalization, the procedures performed; the care, treatment and services provided; the patient's condition at discharge and information provided to the patient and family.


Patient ID #1
Record review of Patient ID #1 medical record:
Discharge Summary signed 9/2/23 by Staff MD #84 stated "hospital course: for the last few months, low appetite, eventually stopped eating ...he was unable to be alert enough to actually be able to eat so he was fed though an NG tube during his hospitalization. Goals of care discussion conducted with family and they decided to go forward with a PEG tube and to take him home with home hospice given poor prognosis. Disposition: Home with hospice."

Interview on 10/19/23 at 1:00 pm with medical record review with Nurse Manager Staff ID #57 confirmed patient ID #1 had been receiving enteral tube feeds DiabetaSource AC at 70 cc/hr continuous through an NG tube in the hospital until it was held on 8/31/23 at 12 midnight for a planned Percutaneous Endoscopic Gastrostomy (PEG) placement procedure. She confirmed the feedings had never been resumed or re-ordered post-procedure. She confirmed that there was no evidence of tube feedings ordered at discharge on 9/1/23. She confirmed the discharge summary failed to state what the feeding tube formula or plan at discharge would be regarding tube feedings. The discharge patient instructions stated "Tube feeding: Continue previous home tube feeding." The patient had no prior history of home tube feeding.

Patient ID #3
Record review of Patient ID #3 medical record:
Discharge Summary signed 9/1/23 by Staff MD #70 stated "Discharge Plan: 1.Fracture of femoral neck, right. Discharge Skilled nursing facility ....9. Diabetes Mellitus. Discharge Instructions: Wound care details ... Equipment and supplies: walker, Please notify your physician if any of the following occur: Nausea. Follow up: ...Orthopedics within 1-2 weeks. Follow up with primary care provider:" (nothing listed). Hospital Course failed to mention that patient received any anti-hyperglycemic management including daily lantus insulin 5 units subcutaneously on 8/25/23, 8/27/23, 8/28/23, 8/29/23, 8/30/23, and 8/31/23 and accuchecks with sliding scale insulin three times daily and at bedtime during the course of the stay. Patient received a total of 8 doses of sliding scale insulin between admission on 8/25/2023 and discharge on 9/1/2023 per the medical record.
Interview on 10/19/23 at 1:30 pm with Nurse Manager Staff ID #57 confirmed patient ID #3 had been ordered to receive lantus insulin and accuchecks with sliding scale insulin during the course of her hospital stay. She confirmed she was unable to locate this information in the physician discharge summary, discharge mediation reconciliation or discharge patient instruction packet in the medical record.

Interview on 10/19/23 at 1:50 pm with Assistant Vice President of Medical Operations Staff ID # 64. He confirmed there was no communication of diabetic glucose management in the discharge summary and he could not locate evidence of instructions or orders for glucose management for Patient ID #3 who was being discharged to a post-acute facility. He stated that he would expect the provider to "state what they are doing for glucose management" or state if they are "electing not to treat/manage due to a specific reason. He stated that many times individual facilities have their own protocols for management of diabetic hyperglycemia."

Based on interview and record review, the facility failed to ensure comprehensive transmission of patient's necessary medical information/orders/care which resulted in the delay of the provision of services for tube feeding and medications by the post-acute providers for Patient IDs #1 & 3.

Findings included:
Record Review of Facility Policy "Discharge Planning Procedure", last reviewed 05/16/23 stated "3. Care Management/Nursing will facilitate the patient's transfer of care to appropriate facilities, agencies or outpatient services, as ordered. For patients who are transferred (from the facility), medical information that is necessary for the transfer will be sent to the accepting facility or agency. The necessary medical information may include, but is not limited to: ...b. Brief description of hospital course of treatment ... d. Medication list (reconciled to identify changes made during the patient's hospitalization) including prescription and over-the-counter medications and herbal supplements. For patients discharged homes CM/SW/RN may provide the following: a. Brief description of care instructions reflecting training provided to patient and/or family or other informal caregivers."

Record Review of Facility Policy "Home Medication Reconciliation Procedure", last reviewed on October 3, 2018, stated "6. A complete list of patient's medications will be communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization."

Patient ID #1
HHSC Intake received 9/25/23 via online intake for Patient ID #1. Complainant stated on 9/1/23 patient ID #1 was released from the facility after feeding tube surgery. The "hospital rushed the complainant to the house and nothing came with him which included food to be used in the feeding tube." The patient's hospice agency said the hospital should have "given the feeding tube food to the patient" since it was a long holiday weekend until delivery could be arranged from hospice. Patient ID #1 "went without food from 9/1/23 until 9/2/23. On 9/2/23, the complainant sent someone to go to the hospital to pick up food for the feeding tube."

Medical record entry by Case manager Staff ID # 67 dated 9/1/23 09:12 am stated "Patient daughter asking the (facility) provide 4 feedings since Monday is a holiday." Entry 9/1/23 10:37 am. Hospice admission confirmed. Hospice nurse to be there at 2pm. AMR EMS setup for 13:00. Daughter notified."

Interview on 10/19/23 at 1:00 pm with medical record review with Nurse Manager Staff ID #57 confirmed patient ID #1 had been receiving enteral tube feeds DiabetaSource AC at 70 cc/hr continuous through an NG tube in the hospital until it was held on 8/31/23 at 12 midnight for a planned Percutaneous Endoscopic Gastrostomy (PEG) placement procedure. She confirmed the feedings had never been resumed or re-ordered post-procedure. She confirmed that there was no evidence of tube feedings ordered at discharge on 9/1/23. She confirmed the discharge summary failed to state what the feeding tube formula or plan at discharge would be regarding tube feedings. The discharge patient instructions stated "Tube feeding: Continue previous home tube feeding." The patient had no prior history of home tube feeding. There was no evidence of family education on care of PEG tube and PEG tube feeding instructions/orders.

Patient ID #3
HHSC Intake received 9/5/23 via telephone intake for Patient ID #3. Complainant stated on they "were told by the nurse at the hospital the nursing facility had been given all orders and was all set. The patient's medications and services will be ready when she arrives." They were "given an envelope and informed to give to the nursing facility's charge nurse. The envelope contained the physical original orders. The nursing facility only had three of the medications and did not have any insulin for the patient." The complainant was informed "the hospital did not give orders for insulin."

Record review of Patient ID #3 medical record: Discharge Summary signed 9/1/23 by Staff MD #70 stated "Discharge Plan: 1.Fracture of femoral neck, right. Discharge Skilled nursing facility ....9. Diabetes Mellitus. Discharge Instructions: Wound care details ... Equipment and supplies: walker, Please notify your physician if any of the following occur: Nausea. Follow up: ...Orthopedics within 1-2 weeks. Follow up with primary care provider:" (nothing listed). Hospital Course failed to mention that patient received any anti-hyperglycemic management including daily lantus insulin 5 units subcutaneously on 8/25/23, 8/27/23, 8/28/23, 8/29/23, 8/30/23, and 8/31/23 and accuchecks with sliding scale insulin three times daily and at bedtime during the course of the stay. Patient received a total of 8 doses of sliding scale insulin between admission on 8/25/2023 and discharge on 9/1/2023 per the medical record.

Interview on 10/19/23 at 1:30 pm with Nurse Manager Staff ID #57 confirmed patient ID #3 had been ordered to receive lantus insulin and accuchecks with sliding scale insulin during the course of her hospital stay and it had been administered as ordered. She confirmed she was unable to locate this information in the physician discharge summary, discharge medication reconciliation or discharge patient instruction packet in the medical record, which are the components of the discharge packet sent to the post-acute facility.

Interview on 10/19/23 at 1:50 pm with Quality Manager Staff ID #55 confirmed that per email follow-up by Staff Informaticist Staff ID #85, the
lantus and lispro sliding scale insulin was not listed as an admission medication. It had been added on 8/25/23, the day following admission as a new order. The discharge medication reconciliation history for both insulins stated "do not convert", which Informaticist Staff ID #85 described as meaning that the discharging hospitalist Staff ID #70 had not identified/intended to continue as a home medication or convert to a prescription. Neither lispro or lantus insulin had been reflected in the admission medication reconciliation completed on admission. In addition, neither insulin was reflected on discharge medication reconciliation, discharge summary or during course of care summary. There was no evidence of alternative anti-hyperglycemic management or education.