HospitalInspections.org

Based on interviews and record review (RR), the facility failed to assess one Patient's (P)1 ability to care for herself with the resources she had and did not develop a safe discharge plan. The investigation revealed the facility discharge planning process was not effective for P1 in both the inpatient and outpatient (Emergency Department) setting. This deficiency resulted in P1, being discharged on more than one occasion without appropriate discharge planning. As a result of this deficiency, P1 returned to the Emergency Department (ED) several times, readmitted once and discharged and ultimately readmitted on 03/21/2024, after Adult Protective Services (APS) involvement. The cumulative effect resulted in a Condition level deficiency.

Findings include:

1) P1 is a 77 year old female with a complex medical history that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, metabolic encephalopathy (disease that affects the brain and causes altered mental state and confusion), past drug abuse, delusions and dementia. She lived alone, had no involved family in the area, and was suppose to be receiving some home health (HH) aide services. P1 used a front wheel walker for short distances and was dependant on supplemental oxygen. She had an Advanced Health-Care Directive (AHCD) designating her sister Power of Attorney (POA).

2) RR reviewed P1's hospital visits from 12/24/2023 to 03/01/2024 included:
12/24/2023, seen in the ED after a fall, which resulted in lacerations on both legs that required steri-strips and sutures. At that time she had no home health assistance to change the dressings as directed.
12/31/2023, seen in the ED because she could not reach her wounds to change the dressings and did not have help. The dressings were crusted and she required antibiotics.
01/06/2024, seen in the ED, for confusion, and difficulty breathing. Emergency Medical Services (EMS) reported that P1 had issues managing her oxygen equipment, and had contacted them multiple times. The ED progress notes documented "She would likely benefit from additional social work services given her declining baseline health status, advanced age and living alone." Admitting diagnosis included left leg cellulits (bacterial skin infection). P1 was discharged home on 02/05/2024 with no additional resources.
02/16/2024, seen in the ED for hallucinations and discharged home.
03/12/2024, seen in the ED for shortness of breath and discharged home. EMS reported P1 contacted them four times in the past two days, and she had issues managing her oxygen equipment.
03/21/2024, seen in the ED and admitted. Hospitalist note included "...She (P1) was treated in the ED apparently could not be discharged as she did not have a safe discharge plan. Adult Protective Services apparently involved ..."

2) Cross Reference A-802
The hospital failed to ensure one patient (P)1 had a safe discharge plan. The hospital did not reevaluate the resources needed and capacity for P1 to care for herself safely when discharged from the hospital on 02/05/2024, or from the Emergency Department (ED) on 03/12/2024. She returned to the hospital on 03/21/2024 at which time there was involvement of Adult Protective Services (APS), who deemed it unsafe to discharge P1 home again. The discharges put her at high risk of adverse outcome.

Based on interviews, document and medical record review (RR), the hospital failed to ensure one patient (P)1 out of a sample size of three had a safe discharge plan. The hospital did not reevaluate the resources needed and capacity for P1 to care for herself safely when discharged from the hospital on 02/05/2024, or from the Emergency Department (ED) on 03/12/2024. As a result of this deficiency, she returned to the hospital on 03/21/2024 at which time there was involvement of Adult Protective Services (APS), who deemed it unsafe to discharge P1 home again. The discharges put her at high risk of adverse outcome.

Findings include:

1) P1 is a 77 year old female with a complex medical history that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, metabolic encephalopathy (disease that affects the brain and causes altered mental state and confusion), past drug abuse, delusions and dementia. She lived alone, had no involved family in the area, and was suppose to be receiving 40 hours of home health (HH) aide services. P1 used a front wheel walker for short distances and was dependant on supplemental oxygen. She had an Advanced Health-Care Directive (AHCD) designating her sister Power of Attorney (POA). P1 had multiple ED visits and hospitalizations.

2) Reviewed P1's ED visits and hospitalizations from 12/24/2023 to 03/01/2024. RR revealed the entries that included, but not limited to following:
12/24/2023: Seen in the ED for skin tear/lacerations sustained when she lost balance after standing and managed to pull over the kitchen table. The lacerations were closed with sutures and steristrips, and she was discharged home with instructions how to care for the wounds and to follow up with primary care provider (PCP).

12/31/2023: Seen in the ED for leg pain. The ED Provider documented "...Patient had stitches done on both legs one week ago. She is unable to change her dressings as she couldn't get the gauze off without immense pain. Patient does not have a home health nurse and has no one else to help her. ...Her dressings were crusted on arrival. ... I did request case management to make arrangements to have home health see the patient for dressing changes in her home as she has limited mobility and does need dressing changes in [sic] can not reach her legs.
12/31/2023: Case Management (CM) clinical Note: "Chart reviewed for ED consult regarding Home Health needs for BL (bilateral) leg pain and dressing changes needs. Call to F/U (follow up) ED visit and she (P1) will see her PCP tomorrow. She declined CM (case management) needs. ... ED consult closed."

01/06/2024: Seen in the ED, admitted and discharged on 02/05/2024.
01/06/2024: ED Provider note included: "...presents to the Emergency Department for evaluation of altered mental status. Per ED nurse, patient contacted EMS (emergency medical services) for difficulty breathing. She developed increased lethargy (drowsy) and frequent urination. She has a oxygen compressor at home but had issues with her oxygen tank and today noted low oxygen intake and "hooked the hose directly to her oxygen tank" and experienced minimal relief... She reports that she has a lack of resources at home, she has a sister who lives in the mainland who cares for her and has help aides that shop for her but has not seen them recently. She also states that she has home health aides that are scheduled to come every few days but they have not been visiting often. ...Per ED nurse, patient has contacted EMS frequently for the past several weeks and has been contacting them multiple times in the past few days. ...She was oxygen dependent and case management is not available this weekend to help facilitate obtaining oxygen concentrator. ...consulted medicine for admission. She would likely benefit from additional social work services given her declining baseline health status, advanced age and living alone."
01/09/2024 Internal Medicine Progress note: "... Patient with history of dementia, very agitated overnight-argumentative with the staff/aggressive, will start Seroquel (antipsychotic)."
Nursing Progress notes included:
01/06/2024: "Family Member, sister called, states she is POA, informed RN that her behavior and memory issues has been happening for up to 3 months now and has become progressively worse."
01/08/2024 08:53 AM: "Pt is AOx2-3 (alert and oriented to person, place and time, not situation) confused and forgetful. Frequent reorientation provided. ...Pt can be impulsive and restless. ...New orders for safety sitter. ..."
01/11/2024 ...Pt was agitated this evening and not directable-removing nasal cannula and getting OOB (out of bed) without assistance. ..1:1 safety sitter at bedside."
01/30/2024 09:38 AM: "...Unaware of safety limitations although noted to have steady gait when ambulating; refuses to use walker at times and needs reminder to utilize for safety. ... -Pt is unable to safely bathe without minimal assistance and supervision. -Pt can groom/dress self with cueing (can dress, but unable to choose or lay out clothes. -pt is disoriented (partially or intermittently)..."
01/30/2024 10:56 PM: "On ICF level of care (Intermediate Care Facility level of care- Criteria includes functional limitations to include self-care rather than acute medical needs) uncooperative, anxious, angry, refuses due medications to take. Came in to the next patient's bed, trying to hit CNA (certified nurse assistant) staff with call bell, patient said: "I go pee on the floor I don't care to all of you" and "where is the man with a kid with bubbles on his mouth. ...transferred to other room...due to unacceptable behavior. ..."
01/31/2024 01:58 AM: "...Confused- "there were 2 men right outside my window" re-oriented patient. ..."
02/02/2024 06:09 PM: "..A&x2. ...Constant redirection required. Patient with increased somnolence. ..."
02/04/2024 02:59 PM: "...Constant redirection required...Mental/Behavior: -pt is disoriented (partially or intermittently)..."
02/04/2024 11:08 PM: "...still wakes up at night saying "there's a man inside the room with a boy, they are sitting on the second chair. ..."
02/05/2024 09:02 AM: "...Refused labs this morning despite education. ...forgetful/confused and irritable at times. ...Plan: return home today with HH for PT/OT (physical/occupational)..."
02/05/2024 10:04 AM, Hospitalist Discharge Summary: "...Dementia with behavioral issues-now improved, f/u with PCP..."
01/29/2024 Case Manager note: "ICF waitlist since 1/19/24. ...Pt is in the acute hospital, waiting for CG (caregiver/HH aide) to return from vacation, supposedly to return on 02/04/2024. ...No identified social support resources and other: no available caregivers to provide approved...services and pt not safe to live alone. Spoke to Home Health, who confirmed CG will return on the 4th. ...also mentioned she is the only CG that can handle P1. Plan: Return home when services are available. Pt does not meet ICF NF pts (points to meet level of care)..."

The day before discharge, although P1 was assessed to be forgetful, needed redirection and continued to have delusions at night, she was discharged home to the same environment, living alone with the same resources.

02/16/2024 11:50 AM: Seen in ED and discharged.
ED provider notes: ".... brought in by medics to the Emergency Department for evaluation of hallucinations. She states she went to a clinic ...but is unable to recall why she went there. Per medic report, patient was at Dr. ...office where patient reported visual hallucinations of children crawling on the roof. She states she has been sober from methamphetamines "for at least a month now. ... 02:53 PM: Patient well, no acute distress, awake and alert, clear headed. Unclear why she had any altered mental status ... stable for discharge at this time. Prior to leaving the department, the patient has a plan for discharge, has decision making capacity, and acknowledges an understanding of the verbal and written discharge instructions."

03/12/2024 Seen in ED and discharged.
ED provider notes: "...Per EMS (emergency medical services), patient has activated EMS 4 times in the past 2 days due to shortness of breath. Upon arrival to the patient's home, they have found her nasal cannula cut, then taped and tied together and is unable to remember how to hook it up to oxygen tank. ... Consults: 03/12/2024 08:56 PM Spoke to Hospitalist about the case at length. Will review chart. 03/12/2024 09:12 PM. Spoke to Hospitalist. Updated on patient's next course of action as she will be able to be discharged home via transport from Medic 10. ...Through shared decision making it was decided by the patient of [sic] myself that she could be safely discharged home. We arranged for the patient to be transported by ambulance with oxygen. I also put in for social work consult to evaluate her at her home for difficulties with her oxygen tank. ..."
ED Nursing Notes:
07:43 PM: "Medics report multiple 911 phone calls from pt because pt can't remember how to operate her home oxygen and she requires home O2 ... Medics reports pt seems to be having cognitive decline. Pt lives at home alone. She reports that she does have family on island but they are not involved in her life and the only family that she has that is involved with her life live on the mainland. ...Pt reports she can never remember how to take off the oxygen or hook it up to the new oxygen tank. ..."
08:47 PM: "Attempted to trial pt on room air. Pt desatted (oxygen level dropped) to 88%. MD aware, Pt put back on 2LNC (2 liters nasal cannula)."
Social Services Note: "Reason for Referral ...Pt needing help learning how to use home O2. Has made frequent calls to paramedics for assistance with oxygen. Needs assistance with getting meals and ADL's (activities of daily living). ..." Social Work Involvement: "Pt was discharged. SW (Social Worker) call to HH service coordinator ...requesting follow up with pt in the community and to call SW if further questions."

03/21/2024 Seen in the ED and admitted.
Provider notes: "...Medical Decision Making: ... presents to the Emergency Department for evaluation of dyspnea (Shortness of breath) ... she is on home oxygen and has breathing treatments available at home however she has dementia lives alone and has had poor compliance with treatment. On her home oxygen her oxygen levels are at baseline, she is not in respiratory distress, chest xray does not show signs of pneumonia or significant pulmonary edema. She was observed in the ER did not have additional findings. I discussed findings with the patients sister who reports that she is the POA. The patient's sister insists that the patient needs to be admitted to the hospital that she is unsafe discharge and that Adult Protective Services had advised to seek admission in the hospital until she can be placed on April 5. I discussed with Hospitalist who declined admission at this time requesting instead social work and case management in the morning. ..."
Hospitalist Admission History and Physical: " ...COPD oxygen dependent and dementia who lives alone and was in the process of being placed at a facility due to her inability to live on her own. ...She was treated in the ED apparently could not be discharged as she did not have a safe discharge plan. Adult Protective Services (APS) apparently was involved and confirmed that the patient would not have placement until April 5th. Medicine Service asked to admit."

At the time of survey, P1 remained hospitalized waiting for placement.

3) On 06/12/2024 at 04:10 PM, interviewed the ED Provider (MD)1 for ED visit 03/12/2024. He explained the ED does not have Social Services (SS) available at night, so the provider will often order a consult and SS will follow up with the patient after discharge. MD1 said from his recall, P1 had been to the ED several times, had dementia, lived alone and used oxygen at home. Discussed the provider notes, and MD1 said the hospitalist didn't want to admit her because she didn't meet criteria, so he made a referral to Social Services.

On 06/12/2024 at 04:30 PM, during an interview with the discharge ED RN (Registered Nurse) on 03/12/2024. She recalled the ED visit and said P1 "had trouble connecting the cannula (nasal tubing) to the tank (oxygen) and called the paramedics to the house multiple times and they showed her how to connect it. The fourth time they brought her to the ED because they felt she may need more resources at home to manage." RN1 said she left at 10:00 PM that day and did not know if the Social Worker had seen P1 in the ED or not. She went on to say when she left, the plan was to send her home. When asked how she felt about that, she said "we could of maybe acknowledged the issue more." RN1 said she did not know the conversation between the MD and the hospitalist. She said if patients don't meet admission criteria, we can get Social Services involved to assist with outside resources. RN1 said it is a problem when the hospitalists don't want to admit and often disagree on the level of care the patient needs.

On 06/13/24 at 11:30 AM, interviewed Social Worker (SW)1 who responded to the ED consult for P1 on 03/12/2024. She said the ED has SS coverage till 04:30 PM, and it is "Consult based." She went on to say if a consult is requested and they in the hospital, they will see the patient at that time. Otherwise, when they come in the morning they check for consults requested off hours, follow up and document a note in the medical record. She explained they "connect with community resources" after the patient is discharged. SW1 said for P1's consult, she identified who her service coordinator was and called her. SW1 said she did not have a conversation with the service coordinator, but "left a message." Asked specifically what the message was, and she replied "just informed her that P1 had been in the Emergency Room." Inquired further if SW1 provided the service coordinator any specifics or that the follow up needed to be a priority because P1 was dependant on oxygen and couldn't figure out her equipment, and she replied "no." SW1 said SS is not involved in discharge planning, but focus on "connecting with community resources."
Discussed P1's next visit to the ED and admission on 03/21/2024. SW1 said she had been told APS spoke with the Case Manager and said it was not safe to discharge P1 home.

4) Review of P1's AHCD signed by her on 01/22/2022. In Part 1 of the AHCD, P1 identified her daughter as primary agent "to make health care decisions authorized in this document." P1 checked the box that read: "If I mark this box my Agent's and/or my alternate agent's authority to make healthcare decisions for me takes effect immediately. I retain the authority to make my own decisions while I have capacity. P1 also checked the box in the AHCD that said " If I mark this box, I do not want to be hospitalized or put in a convalescent or similar home as long as it is reasonable to maintain me in my personal residence."

5) Reviewed the policy titled "Discharge Planning" last revised 7/2020. The policy included:
"Policy Statement: A discharge plan for post-hospital or Emergency Department follow-up care is addressed by the interdisciplinary team. ..."
Purpose: "2.1 To outline a process ..., to identify patients, with potential discharge planning needs, conduct discharge planning assessments, facilitate safe transitions in care, prevent avoidable readmissions ..."
Provisions/Procedures: "Scope/Coverage: "5.1 Discharge Planning (DCP) begins on admission and identification of a hospitalized patient with care transition needs. ..."
"5.3 The Case Manager and/or Social Worker performs an initial discharge planning assessment for patients who are likely to have discharge planning needs, with high risk for readmission, or other circumstances that increase the risk of an unsuccessful transition from the hospital setting. ...Triggers for DCP may include: ..."
"5.3.3. Unscheduled readmission within 30 days of last discharge. ..."
"5.3.7 Age >75."
"5.3.8 Diagnosis Specific ...g. Congestive Heart Failure h. Chronic Obstructive Pulmonary Disease ..."
"5.3.9 Psych/Social ...c. Patients with significant self-care deficit related to chronic condition. ..."
"5.4 The Discharge Plan will be reassessed throughout the patient's stay... Factors that may trigger a reassessment include ...changes, in medical condition or function, or requests by any member of the clinical team, by the patient or by a person acting on the patient's behalf. The plan may be modified based on the patient's clinical status and as needed ..."