HospitalInspections.org

Based on record review and interview, the facility failed to implement an effective discharge plan for substance abuse addiction for one (#4) of 3 patients whose records were reviewed for discharge planning, resulting in the potential for less than optimal outcomes for patient #4.
Findings include:

Review of the medical record on 6/14/2021 at 1300 revealed the patient of concern (#4) was a 43-year-old female who presented to the Emergency Department (ED) on 2/24/2021 at 2322. The patient was discharged home to self care on 2/26/2021 at 1853.

Review of the patient's History and Physical (H&P) dated 2/24/2021 revealed the following:
Chief Complaint: Drug Overdose
Patient presents to the ED after accidental overdose on fentanyl. Patient states she uses fentanyl regularly nearly daily. States she regularly snorts fentanyl and heroin. Denies any IV drug use. Patient presents to the ED today after accidental overdose, found apneic, cyanotic, required 4 mg of intranasal Narcan, followed by 4 mg of IV Narcan. Patient then regained consciousness, awake, alert and oriented x 3. Very agitated. She has no other complaints at this time. Denies any homicidal or suicidal ideation. States she was "just trying to have fun." Denies any chest pain or shortness of breath. Denies any nausea or vomiting at this time. No abdominal pain.
Review of systems: " ...Psychiatric/Behavioral: Negative for agitation, confusion, self-injury and suicidal ideas. The patient is nervous/anxious."
Medical Decision Making:
Accidental fentanyl overdose: new and requires workup
Hypoxia: new and requires worker
Pulmonary edema (PE): new and requires workup
Diagnosis management comments: "Patient presents to the ED after accidental fentanyl overdose, once again. Recently seen for the same ...Concern for pulmonary edema secondary to Narcan version possible pulmonary embolism, as mother states does have history of saddle pulmonary emboli, unprovoked. No evidence of PE on CTA however opacities concerning for pulmonary edema were found. Patient will be admitted, continue oxygen therapy. Case was discussed with PCP who requested pulmonary consult. Social worker was consulted for substance abuse. Patient progress: stable."
Provider notes reviewed as follows:
On 2/24/2021 at 2357: Case discussed with mother; patient previously seen here for the same. Adamantly denies any homicidal or suicidal ideation. Patient does admit to problems with substance abuse. States that she wants to follow up on an outpatient basis for outpatient substance abuse treatment.
On 2/25/2021 at 0006: Patient reevaluated again secondary to low pulse oxygenation saturation. Satting 82%...Concern for possible pulmonary edema from Narcan-has gotten several doses, questionable pulmonary embolism. Chest x-ray are rather unremarkable.
Per H& P; On 2/25/2021 at 1340, this is 43-year-old female with PMH of drug overdose on fentanyl. Patient states she uses fentanyl regularly nearly daily. States she regularly snorts fentanyl and heroin. Denies having any other medical problems. In the ED she was found to be apneic, cyanotic, required 4 mg of intranasal Narcan, followed by 4 mg of IV Narcan. Patient then regained consciousness, awake, alert and oriented x 3. Patient was admitted for further evaluation and management. Psych was consulted.
Assessment/Plan:
Acute hypoxia
Accidental fentanyl overdose
Bilateral ground glass parenchymal changes may reflect underlying noncardiogenic pulmonary edema.
Hypotension
Elevated Troponin ...
Plan: " ...Psych consult. Supportive care. Counseling on Polysubstance abuse.
Provider Discharge Summary dated 2/26/2021; On day of DC, patient is stable for discharge home. Patient is feeling better, denies CP, SOB, HA, dizziness. I have spent greater than 35 minutes on DC patient, coordinating care with patient/family, staff consultants, and SW. Patient was cleared for DC by all consultants.
Follow-up Information:
(name of family medicine provider), (name of pulmonary medicine provider) (name of cardiology medicine provider).
After Visit Summary (discharge instructions) dated 2/26/2021:
Why you were hospitalized: Diagnosis: Your primary diagnosis was Hypoxia
There were no discharge instructions for Substance Abuse follow up documented on the provider's discharge summary.

Review of Care Management Initial Discharge Assessment Needs documented the following:
Per Registered Nurse: On 2/25/2021 at 1426: "Discharge Assessment completed? Yes.
Patient Assessment and in person interview with patient. Patient Mental Status: Alert and oriented.
Decision Maker: His/Herself. Plan for discharge: Patient to return to prior residential situation at discharge? Yes
Anticipated DC Plan A & B: IP Psych ..." Writer to patient's bedside. Patient alert conversing appropriately, pt's mother at bedside. Pt is independent with ADL's, uses no DME. Pt is hopeful she can go to inpatient for substance abuse treatment. MSW following."

Review of Social Worker progress notes: On 2/26/2021 at 1046: "SW following for substance abuse referral. Met with patient who was alert and orientated. She reports feeling much better than yesterday. Patient plans to go to substance abuse rehab (she is hoping for name of facility). Patient has already completed screening with DWIHN (name of county mental health network) and is aware that she needs to call back when ready for discharge. DWIHN will assist with coordination of placement. She states that she has not yet been placed on wait list for (name of treatment center that provides 5 levels of treatment options: withdrawal management, short term residential, day treatment, intensive outpatient and intensive outpatient treatment). SW will continue to follow and assist patient as needed. Patient requesting that SW visit her again when closer to discharge in case she needs any further assistance.
However, the patient was discharged later that evening. There were no further SW notes in the medical record.

An interview and record review of patient #4's medical record was conducted with the Director of Case management Staff P. Staff P was queried regarding the patient's discharge. Staff P explained the physician said she (#4) was stable for discharge. Staff P was asked to explain and provide evidence that confirmed the social worker had initiated a referral for placement or assistance to a substance abuse facility. Staff P replied, "most substance abuse places are walk-in and entered on a voluntary basis."

However, Staff P offered no further explanation when asked to provide further evidence that reflected the patient was discharged to a safe setting.

A review of the facility's "Acute Care Discharge Planning and Patient Choice" PolicyStat ID: 7620753, dated last revised on 2/25/2020 documented:
Procedure
I. Purpose and Objective:
In supporting patient and family-centered care, (name of facility) partners with patients and families to offer options acknowledging their choice with post hospital care services in preparation for the next level of care ...
II. Procedure:
A. (name of facility) compliance with patient choice laws includes:
1. Informing patients they have freedom to choose.
2. Presenting a list of post-acute care providers to patients including notation of any financial and ownership disclosures to the best of (name of facility) knowledge.
3. Supporting patients in making their choice adhering to insurance parameters.
4. Providing patients (or family/caregiver) information related to their specific care needs and acknowledging what their priorities are.
5. Proactively discussing guidelines about anticipated discharge date and rationale of securing next level of care when medically stable.

A review of the facility's "Discharge Preparation to Next Site of Care" PolicyStat ID: 6943177 dated last revised on 11/26/2019 documented:
Procedure
III. Purpose and Objective:
Care Management staff is responsible to assess and respond to referral related to next site of care (NSOC) or facility placement, assist patient/significant other(s) with arrangements, and to provide adequate information to the ambulance provider and facility.
Indications for next site of care occur when:
A. Patient/primary support person(s) request assistance with NSOC transitions (or return to NSOC).
B. Members of the health care team determine the patient needs NSOC transitions and may make recommendation to the patient/significant other(s).
C. Patient is unable to resume previous living arrangement including the inability to care for self in an independent living situation or inability for current assisted living arrangements for patients' needs at discharge, e.g. behavior issues, changes in physical or mental status or the care givers inability to manage the patient's condition.
IV. Procedure:
A. Care Management acknowledges referral.
1. Open the case and document in the electronic health record providing a brief synopsis and documenting patient choices for next site of care.
B. Care Management case finding:
1. Review the medical record.
2. Upon identification of potential need regarding NSOC transitions, explore the following:
a. Is the patient/primary support person(s) aware of the need for next site of care transitions?
b. Is temporary or permanent placement anticipated?
c. Is the patient discharged from an extended care facility?...
d. Any special needs ....f. Determine the primary payer ...
C. Care Management data gathering
...2. Discuss with the health care team
a. Diagnosis and planned treatment
b. Prognosis
c. Potential for rehab.
D. Care Management staff procedure
1. Confirm with the attending the discharge plan, anticipated discharge date and bed availability at the selected next site of care
2. Contact the facility to arrange a transfer time
3. Complete the Mental Illness/Developmental Disability Screening DCH 3877, as needed ...7. Notify the patient/family and (name of facility) care team of transfer detail. 8. Complete the discharge documentation to include next site of care and to close the case in the electronic medical record and in electronic Care Management system.
However, there was no evidence that this was done.