HospitalInspections.org

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that patient safety incidents were accurately reported into the incident reporting system for 3 of 10 events reviewed (Patients #101, #103 and #104) (ITEM #1). The hospital also failed to ensure that adverse events were recognized and reported to the State for 2 of 6 events reviewed (Patients #103 and #106) (ITEM #2).

Failure to ensure patient safety and adverse events are recognized and reported, limits the hospital's ability to enact measures that prevent or mitigate patient harm.

Findings included:

ITEM #1 - Reporting Failed Discharges

1. Document review of the hospital's policy titled, "Incident Reporting Information System (IRIS) Guidelines and Management, 418.00," revised 06/2020, showed that an incident is anything that is not consistent with the routine care and could have an impact on a patient, to include violations of established procedures, quality of care issues, or any unusual event. Reporting of all incidents is encouraged as a means to improve processes and systems to enhance patient safety.

Document review of the hospital's policy titled, "Care Coordination Discharge Planning," effective 11/21/22, showed that the hospital defined "discharge" as documentation that the patient was no longer receiving acute care treatment in the hospital, or the patient had left the hospital.

2. Review of the medical records showed the following:

a. On 01/21/22 at 1:26 PM, Patient #103, a 55-year-old with dementia and diabetes was discharged from the hospital by taxi to an unknown location. The medical record showed that the discharge was not coordinated with the patient's adult living facility (ALF), memory care unit. On 01/22/22, the ALF called the hospital for an update on the patient's status. Hospital staff documented the phone call with the ALF staff in the medical record but failed to enter an incident report. At the time of the inquiry, the patient's location and physical safety were unknown. Evidence of an incident report or internal investigation could not be found.

b. On 12/18/22 at 4:56 PM, Patient #101, a 71-year-old non-ambulatory female with an inpatient admission diagnosis of cellulitis was discharged by ambulance to a skilled nursing facility (SNF). On 12/18/22 at 5:29 PM, the patient was returned to the hospital by ambulance. The hospital documentation showed no evidence of a discharge evaluation, coordination with the SNF, the SNF accepting the patient, insurance authorization for SNF placement, or report to the receiving facility. The patient's discharge order was cancelled, and the patient remained an inpatient at the hospital until she was discharged home with home health services and durable medical equipment on 02/12/23. An incident report related to these events could not be found.

On 02/18/23, Patient #101 called the hospital to inquire about her home health services. The medical record showed that the hospital failed to coordinate home health services for the patient. The patient remained at home without home health services until she was taken by ambulance to another hospital on 02/19/23 for related medical complaints. An incident report for these events could not be found.

c. On 01/19/23 at 7:17 PM, Patient #104, an 83-year-old male with a primary complaint of an unwitnessed fall was discharged back to his adult family home (AFH) residence via cabulance. The patient had a history of dementia, and his daughter was documented as his legal medical decision maker. The AFH staff reported that they were not notified that Patient #104 was ready for discharge. Documentation of communication with the patient's daughter or AFH could not be found. An incident report for this event could not be found.

3. On 10/17/23 at 12:52 PM, Investigator #1 and Investigator #2 interviewed the Manager of Case Management (Staff #205). Staff #205 confirmed that they were unaware of these events and that these incidents should have been entered into the incident reporting system and investigated.

4. On 10/12/23 at 2:55 PM, Investigator #1 and Investigator #2 interviewed a Case Manager (Staff #208) assigned to Patient #101 and Patient #103's discharge planning and implementation process. Staff #208 stated that they were unaware of situations where patients returned to the hospital secondary to failed discharge plans.


ITEM #2 - Adverse Events

References:

National Quality Forum. "List of Serious Reportable Events - Patient Protection Events" - "Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person (updated)."

1. Document review of the hospital's policy titled, "Incident Reporting Information System (IRIS) Guidelines and Management, 418.00," revised 06/2020, showed that an incident is anything that is not consistent with the routine care and could have an impact on a patient.

Document review of the hospital's policy titled, "Sentinel (Adverse) Event Policy, 460.00," revised 05/2023, showed that a Determination Team, consisting of an executive, medical staff leader, and administrator from the Patient Safety Department, determines whether an event is reportable to state or federal authorities. The Patient Safety Officer is assigned to report adverse events as determined by the Determination Team.

2. Review of the medical records showed the following:

a. On 01/21/22 at 1:26 PM, Patient #103, a 55-year-old with dementia and diabetes was discharged from the hospital by taxi to an unknown location. The medical record showed that the discharge was not coordinated with the patient's adult living facility (ALF), memory care unit. On 01/22/22, the ALF called the hospital for an update on the patient's status. At the time of the inquiry, the patient's location and physical safety were unknown. Evidence of an incident report, internal investigation, or a report to the state regarding an adverse event could not be found.

b. On 02/16/22 at 2:02 PM, Patient #106, a Spanish-speaking 36-year-old female with downs syndrome and respiratory illness was discharged to her sister's house by taxi. Hospital documentation showed that the patient's sister stated that she found the patient standing on her porch in the cold. The patient's sister reported that she was not notified of the patient's discharge from the hospital. The medical record did not indicate if a call was made to the patient's sister regarding the time of discharge or mode of transportation. The patient's sister notified the hospital, but evidence of an internal investigation or a report made to the state as an adverse event could not be found.

3. On 10/17/23 at 12:52 PM, Investigator #1 and Investigator #2 interviewed the Manager of Case Management (Staff #205). Staff #205 confirmed that adverse event reports were not filed for Patient #103 or Patient #106.

4. On 10/17/23 at 12:30 PM, Investigator #1 and Investigator #2 interviewed the Patient Safety Specialist (Staff #206). Staff #206 stated that adverse events were primarily discovered and evaluated through the incident reporting system. Staff #206 also stated that they prioritized each incident report by amount of harm caused to the patient. Incidents that had been determined to have caused significant patient harm are forwarded to the Determination Team. The Determination Team determined if the event needs to be reported to state or federal authorities. Staff #206 confirmed that Patient #106 had an incident associated with her discharge home, but that the event was evaluated and coded as a "no-harm" event and did not trigger adverse event reporting.
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Based on interview and document review, the hospital failed to implement an effective discharge planning process.

Failure to implement an effective discharge planning process puts patients at risk for inadequate care and an unsafe discharge home.

Findings included:

The hospital failed to arrange for the initial implementation of the patient's discharge plan.

Cross Reference A820 (See Item #1 below)

The hospital failed to cousel family or interested persons to prepare them for post-hospital care.

Cross Reference A820 (See Item #2 below)

The hospital failed to reassess its discharge planning process on an on-going basis to ensure they're responsive to discharge needs..

Cross Reference A843 (See Item #3 below)

Due to the scope and severity of deficiencies cited under 42 CFR 482.43, the Condition of Participation for Discharge Planning was NOT MET.

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ITEM #1 - Hospital Arrangment and Initial Implementation of Discharge Plan

Based on interview and document review, the hospital failed to implement its policy regarding discharge planning for 9 of 15 patient records reviewed (Patient #101, #103, #104, #105, #106, #107, #108, #109, #110).

Failure to implement a discharge plan puts patients at risk for inadequate care and an unsafe discharge home.

Reference: A0820. CFR: 482.43(c)(3) Discharge Planning - Implementation of the Discharge Plan.
"The hospital is required to arrange for the initial implementation of the discharge plan..."

Findings included:

1. Document review of the hospital's policy and procedure titled, "Common Spirit Health System Administrative Policy," Policy number: Clinical A-016, Effective Date 10/2022, showed that the discharge plan ensured a safe transition which met the patients' post-acute care needs and reduced factors that could lead to a preventable hospital readmission.

Document review of the hospital's policy and procedure titled, "Discharge Planning Policy, 922.00," PolicyStatID: 6922577, Effective date 10/2019, showed the following:

a. Needs are addressed to the degree that there is a safe plan in place for the patient's discharge based on the patient and/or surrogate decision maker's agreement with the purposed plan and payer benefits and eligibility.

b. The discharge plan will include medical services and education provided by the hospital and referral agencies for the highest level of safety that the client will allow.

c. The hospital will consider a facility's acceptance of a patient as proof that the facility is able to meet the needs of the patient.

Document review of the hospital's policy and procedure titled, "Discharge of In-Patient to Home Procedure, 755.00," PolicyStatID: 5539209, Effective date 11/2018, showed the following:

a. The RN will ensure appropriate arrangements have been made regarding discharge.

b. The RN will confirm that the patient is medically stable and appropriate for discharge.

c. RN will document discharge date, time, mode of transportation, destination, accompanied by whom, and condition of patient at time of discharge.

Document review of the hospital's policy and procedure titled, "Transfer/Discharge to a residential Care Facility Policy 844.55," PolicyStat ID: 6925769, Effective date 10/2019, showed the following:

a. There must be documented conversation with the accepting facility, that confirm they accept the patient, and can meet the level of care required by the patient.

b. Documentation by the RN of patient discharge date and time and report given to receiving facility prior to patient discharge.

2. On 10/12/23 from 3:45 PM to 5:00 PM and on 10/16/23 from 3:00 PM to 5 PM, Investigator #1, Investigator #2, the Regulatory Compliance Program Manager (Staff #201), and the Clinical Nurse Manager (Staff #203) reviewed the medical records of 10 discharged patients. The review showed the following:

a. On 01/12/22 at 5:45 PM, Patient #105, a 53-year-old female with chronic disease processes declined to be placed at an adult family home (AFH). The medical record showed that an inquiry regarding support at home for a safe discharge was pending, but that the patient could not stay at her friend's house due to rules against extra residents in the house. The hospital discharged the patient to the patient's friend's house and the patient was subsequently returned to the hospital via ambulance. The patient was readmitted to the hospital. Evidence that the discharge plan was confirmed before discharge could not be found.

b. On 01/21/22 at 1:26 PM, Patient #103, a 55-year-old with dementia and diabetes was discharged from the hospital by taxi to an unknown location. The medical record showed that the discharge was not coordinated with the patient's adult living facility (ALF), memory care unit. On 01/22/22, the ALF called the hospital for an update on the patient's status. At the time of the inquiry, the patient's location and physical safety were unknown. Evidence that the discharge plan was confirmed before discharge could not be found.

c. On 02/16/22 at 2:08 PM, Patient #106, a 36-year-old female with downs syndrome and respiratory illness was discharged to her sister's house by taxi. The patient's sister reported that she found the patient standing on her porch in the cold. The patient's sister stated that she was not notified of the patient's discharge from the hospital. The medical record did not indicate if a call was made to the patient's sister regarding discharge.

d. On 03/24/22 at 6:29 PM, Patient #107, a 62-year-old female with a primary diagnosis of pneumonia was discharged to an adult family home (AFH). The patient was on 2 liters of oxygen at the time of discharge but no orders for continued oxygen could be found. The patient was brought back to the hospital the same day and admitted for an additional 5 days. The patient was discharged home again on 03/29/22 with oxygen provided. Evidence that the discharge plan was confirmed before discharge could not be found.

e. On 05/18/22 at 7:30 PM, Patient #108, a 65-year-old female with weakness and chronic obstructive pulmonary disease (COPD) was discharged to an AFH via ambulance. The patient had an order for home oxygen, but none was provided. The patient was readmitted later the same day and stayed for an additional 3 days in the hospital. The patient was discharged home again on 05/21/22 with oxygen for transportation and home oxygen verified. Evidence that the discharge plan was confirmed before the initial discharge could not be found.

f. On 7/21/22 at 2:35 PM, Patient #109, 54-year-old female with multiple chronic illnesses and substance use disorder was discharged via cabulance to a shelter. The patient was returned to the hospital by the cabulance when they discovered that the shelter was closed. The shelter had been closed for over 2 years but was never verified by the hospital. The patient was subsequently readmitted to the hospital until discharge on 07/23/22.

g. On 12/18/22 at 4:56 PM, Patient #101, a 71-year-old non-ambulatory female with an inpatient admission diagnosis of cellulitis was discharged by ambulance to a skilled nursing facility (SNF). On 12/18/22 at 5:29 PM, the patient was returned to the hospital by ambulance. The hospital documentation showed no evidence of a discharge evaluation, coordination with the SNF, the SNF accepting the patient, insurance authorization for SNF placement, or report to the receiving facility. The patient's discharge order was cancelled, and the patient remained an inpatient at the hospital until she was discharged home with home health services and durable medical equipment on 02/12/23.

On 02/18/23, Patient #101 called the hospital to inquire about her home health services. The medical record showed that the hospital failed to coordinate home health services for the patient. The patient remained at home without home health services until she was taken by ambulance to another hospital on 02/19/23 for related medical complaints.

h. On 01/19/23 at 7:17 PM, Patient #104, an 83-year-old male with a primary complaint of an unwitnessed fall was discharged back to his adult family home (AFH) residence via cabulance. The patient had a history of dementia and his daughter was documented as his legal medical decision maker. The AFH staff reported that they were not notified that Patient #104 was ready for discharge. Documentation of communication with the patient's daughter or AFH could not be found.

i. On 5/18/23 at 2:00 PM, Patient #1010, a 73-year-old female with the primary diagnosis of acute pulmonary emboli and cancer of unknown origin was discharged from the hospital via cabulance to an outpatient gynecological cancer clinic located in another hospital. The patient arrived at the clinic in severe pain, vomiting and unable to walk. The patient was subsequently sent to the emergency department and admitted to the hospital for further treatment.

3. At the time of the review, Staff #201 and Staff #203 confirmed that fully implemented discharge plans were not documented in 9 of the 15 medical records reviewed.

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ITEM #2 - Discuss Results with Patient or Representative

Based on interview and document review, the hospital failed to coordinate patient discharges with the family, caregiver, and/or receiving agency for 10 of 15 patient records reviewed (Patient #101, #103, #104, #105, #106, #107, #108, #109, #110, #111).

Failure to coordinate patient discharges puts patients at risk for an unsafe discharge disposition and poor patient outcomes.

Reference: A-0820. CFR: 482.43(c)(5) Discharge Planning. "As needed, the patient and family member or interested persons must be counseled to prepare them for post-hospital care."

Findings included:

1. Document review of the hospital's policy and procedure titled "Discharge Planning Policy, 922.00," PolicyStatID: 6922577, Effective date 10/2019, showed the following:

a. Needs are addressed to the degree that there is a safe plan in place for the patient's discharge based on the patient and/or surrogate decision maker's agreement with the purposed plan and payer benefits and eligibility.

b. The Care Management team will work in conjunction with the Interdisciplinary Team to facilitate patient/caregiver education, ordering and delivery of needed discharge supplies and services, and transfer to the post-acute environment.

c. The hospital will consider a facility's acceptance of a patient as proof that the facility is able to meet the needs of the patient.

2. On 10/12/23 from 3:45 PM to 5:00 PM and on 10/16/23 from 3:00 PM to 5 PM, Investigator #1, Investigator #2, the Regulatory Compliance Program Manager (Staff #201), and the Clinical Nurse Manager (Staff #203) reviewed the medical records of 10 discharged patients. The review showed the following:

a. On 01/12/22 at 5:45 PM, Patient #105, a 53-year-old female with chronic disease processes declined to be placed at an adult family home (AFH). The medical record showed that an inquiry regarding support at home for a safe discharge was pending, but that the patient could not stay at her friend's house due to rules against extra residents in the house. The hospital discharged the patient to the patient's friend's house and the patient was subsequently returned to the hospital via ambulance. The patient was readmitted to the hospital. Evidence that the patient's friend's home was verified as an available option could not be found.

b. On 01/21/22 at 1:26 PM, Patient #103, a 55-year-old with dementia and diabetes was discharged from the hospital by taxi to an unknown location. The medical record showed that the discharge was not coordinated with the patient's adult living facility (ALF), memory care unit. On 01/22/22, the ALF called the hospital for an update on the patient's status. At the time of the inquiry, the patient's location and physical safety were unknown. Evidence that the discharge plan was coordinated with the ALF before discharge could not be found.

c. On 02/16/22 at 2:08 PM, Patient #106, a 36-year-old female with downs syndrome and respiratory illness was discharged to her sister's house by taxi. The patient's sister reported that she found the patient standing on her porch in the cold. The patient's sister stated that she was not notified of the patient's discharge from the hospital. The medical record did not indicate if a call was made to the patient's sister regarding discharge.

d. On 03/24/22 at 6:29 PM, Patient #107, a 62-year-old female with a primary diagnosis of pneumonia was discharged to an adult family home (AFH). The patient was on 2 liters of oxygen at the time of discharge but no orders for continued oxygen could be found. The patient was brought back to the hospital the same day and admitted for an additional 5 days. The patient was discharged home again on 03/29/22 with oxygen provided. Evidence that the discharge plan was coordinated to provide home oxygen before discharge on 03/24/22 could not be found.

e. On 05/18/22 at 7:30 PM, Patient #108, a 65-year-old female with weakness and chronic obstructive pulmonary disease (COPD) was discharged to an AFH via ambulance. The patient had an order for home oxygen, but none was provided. The patient was readmitted later the same day and stayed for an additional 3 days in the hospital. The patient was discharged home again on 05/21/22 with oxygen for transportation and home oxygen verified. Evidence that the discharge plan was coordinated and confirmed before the initial discharge could not be found.

f. On 7/21/22 at 2:35 PM, Patient #109, 54-year-old female with multiple chronic illnesses and substance use disorder was discharged via cabulance to a shelter. The patient was returned to the hospital by the cabulance when they discovered that the shelter was closed. The shelter had been closed for over 2 years but was never verified by the hospital. The patient was subsequently readmitted to the hospital until discharge on 07/23/22.

g. On 12/18/22 at 4:56 PM, Patient #101, a 71-year-old non-ambulatory female with an inpatient admission diagnosis of cellulitis was discharged by ambulance to a skilled nursing facility (SNF). On 12/18/22 at 5:29 PM, the patient was returned to the hospital by ambulance. The hospital documentation showed no evidence of a discharge evaluation, coordination with the SNF, the SNF accepting the patient, insurance authorization for SNF placement, or report to the receiving facility. The patient's discharge order was cancelled, and the patient remained an inpatient at the hospital until she was discharged home with home health services and durable medical equipment on 02/12/23.

On 02/18/23, Patient #101 called the hospital to inquire about her home health services. The medical record showed that the hospital failed to coordinate home health services for the patient. The patient remained at home without home health services until she was taken by ambulance to another hospital on 02/19/23 for related medical complaints.

h. On 01/19/23 at 7:17 PM, Patient #104, an 83-year-old male with a primary complaint of an unwitnessed fall was discharged back to his adult family home (AFH) residence via cabulance. The patient had a history of dementia, and his daughter was documented as his legal medical decision maker. The AFH staff reported that they were not notified that Patient #104 was ready for discharge. Documentation of communication with the patient's daughter or AFH could not be found.

i. On 5/18/23 at 2:00 PM, Patient #1010, a 73-year-old female with the primary diagnosis of acute pulmonary emboli and cancer of unknown origin was discharged home from the hospital via cabulance. Due to the timing of the patient's follow-up appointment, the patient's cabulance was dispatched to the outpatient gynecological cancer clinic located in another hospital instead of her residence. The outpatient oncologist documented that the patient arrived at the outpatient clinic in severe pain, vomiting and unable to walk. After reviewing the patient's medical record, the outpatient oncologist determined that the patient had not received adequate testing at the hospital to determine if the patient's cancer was gynecological. The patient was subsequently sent to the emergency department and admitted to the hospital for further diagnostic testing and treatement for her symptoms. Evidence of coordination with post-hospital services could not be found.

j. On 05/19/23 at 2:22 PM, Patient #1011, a 62-year-old male with Parkinson's disease and an acute ankle fracture secondary to a fall, was discharged to a skilled nursing facility (SNF). The patient's primary nurse called the SNF to give report. The SNF reported to the hospital that they were unaware that the patient was discharged, and that insurance had not authorized the SNF stay. The patient's discharge was cancelled, and the patient remained for an additional 3 days. The patient was discharged on 05/22/23 at 11:27 AM to the SNF.

3. At the time of the review, Staff #201 and Staff #203 confirmed that fully implemented discharge plans were not documented in the 10 medical records reviewed.

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ITEM #3 - Reassessment

The hospital failed to aggregate and review readmission data for 5 of 10 patients reviewed (Patients #105, #107, #108, #109, #1010).

Failure to ensure readmission data was accurately aggregated and reviewed limits the hospital's ability to enact measures that prevent or mitigate patient harm from uncoordinated discharges and unscheduled readmissions.

Reference: A-0843. CFR: 482.43(e) Reassessment. "The hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs."

Findings included:

1. Document review of the hospital's policy titled, "Incident Reporting Information System (IRIS) Guidelines and Management, 418.00," revised 06/2020, showed that readmission data and review is performed under the auspices of the Quality and Clinical Effectiveness department. Reporting of all incidents is encouraged as a means to improve processes and systems to enhance patient safety.

Document review of the hospital's policy titled, "Care Coordination Discharge Planning," effective 11/21/22, showed that the hospital defined "discharge" as documentation that the patient was no longer receiving acute care treatment in the hospital, or the patient had left the hospital.

2. Review of medical records and internal hospital documentation showed the following:

a. On 01/12/22 at 5:45 PM, Patient #105, a 53-year-old female with chronic disease processes declined to be placed at an adult family home (AFH). The medical record showed that an inquiry regarding support at home for a safe discharge was pending, but that the patient could not stay at her friend's house due to rules against extra residents in the house. The hospital discharged the patient to the patient's friend's house and was subsequently returned to the hospital via ambulance. The patient was readmitted to the hospital. An incident report was filed.

b. On 03/24/22 at 6:29 PM, Patient #107, a 62-year-old female with a primary diagnosis of pneumonia was discharged to an adult family home (AFH). The patient was on 2 liters of oxygen at the time of discharge but no orders for continued oxygen could be found. The patient was brought back to the hospital the same day and admitted for an additional 5 days. The patient was discharged home again on 03/29/22. An incident report was filed.

c. On 05/18/22 at 7:30 PM, Patient #108, a 65-year-old female with weakness and chronic obstructive pulmonary disease (COPD) was discharged to an AFH via ambulance. The patient had an order for home oxygen, but none was provided. The patient was readmitted later the same day and stayed for an additional 3 days in the hospital. An incident report was filed.

d. On 5/18/23 at 2:00 PM, Patient #1010, a 73-year-old female with the primary diagnosis of acute pulmonary emboli and cancer of unknown origin was discharged from the hospital via cabulance to an outpatient gynecological cancer clinic located in another hospital. The patient arrived at the clinic in severe pain, vomiting and unable to walk. The patient was subsequently sent to the emergency department and admitted to the hospital for further treatment. An incident report was filed.

e. On 7/21/22 at 2:35 PM, Patient #109, 54-year-old female with multiple chronic illnesses and substance use disorder was discharged via cabulance to a shelter. The patient was returned to the hospital by the cabulance when they discovered that the shelter was closed. The shelter had been closed for over 2 years but was never verified by the hospital. The patient was subsequently readmitted to the hospital until discharge on 07/23/22. An incident report was filed.

3. On 10/17/23 at 12:30 PM, Investigator #1 and Investigator #2 interviewed the Quality Program Manager (Staff #226) and the Vice President of Quality and Population Health (Staff #227) regarding the hospital's process of measuring and assessing readmission data. Staff #226 stated that the readmission data was collected directly from the electronic medical records and separated by types of hospital stays for analysis. Investigator #1 inquired about the process for capturing readmissions that occur within 24 hours, specifically the readmissions reported through the incident reporting system. Staff #227 stated that readmissions that occur in less than 24 hours were not included in their readmission data.
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