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Based on interviews and record review, the facility failed to ensure patient's discharge plans were re-evaluated and updated by the multi-disciplinary team to reflect occurrences/updated information and recommended care provided at the facility in preparation for discharge. (Patient ID # 1 and 2). Therefore, patients and/or families failed to receive:
1) safe discharge plan after staff filed an adult protective service complaint for concern for "safety at home" prior to patient's discharge home from the facility. The facility failed to engage adult protective services to ensure safe discharge plan prior to discharge home, despite their concerns and failed to demonstrate safe discharge plan which considered multi-disciplinary team recommendations (Patient ID #1)
2) thorough comprehensive discharge orders which included the recommended modified full liquid diet with nectar thickened liquids and necessary follow-up and care for this limitation/restriction (Patient ID #2)
3) failure to communicate and provide written notification/communication of patient's difficulty airway status prior to discharge (Patient ID #2).

Findings included:

Record review of facility policy titled "Discharge Planning", last reviewed 01/2025 stated "C. During the hospital stay. The discharge planning needs of the patient are identified, assessed and planned for in many ways during the hospital stay. An interdisciplinary team meets routinely on each unti to discuss high risk patients. Case managers/social workers will reassess patient needs based on changes in care and discharge plan. All discharge planning activities will be documented in the medical record. D. On discharge... Discharge documentation will accurately reflect the final discharge plan and include the actual final disposition."

Record review of facility policy titled "Abuse and Neglect", last reviewed 06/2024, stated "Neglect: the failure to provide for one's self the goods or services, inclduing medical services that are necessary to avoid physical harm, mental anguish, mental illness, or the failure of the caretaker to do so." It further defines "E. Neglect of exploitation 1. Family members are indifferent, angry or violent." The procedure listed in the policy stated "D. Case management will assist staff with coordinating all information/activities involving protective agencies and coordinate appropriate discharge of the patient as deemed appropriate by protective agencies."

Record review of Patient ID #2 medical record with Nurse Informaticist on 3/27/2025 at 11:45 am. Patient ID #2 Anestheisa record on 8/23/24 stated "(Difficult Intubation notes): Grade IV view with DL. Attempt with Glidescope (4 Blade). Grade II view. Pt extremely anterior. Difficulty advancing tube and/or bougie. Successful attempt with glidescope + bougie." Anesthesia record stated "Attempts 4". This was recorded by CRNA Staff ID # 69. Speech therapy Staff ID # 72 note dated 8/29/24 at 11:15 am stated "Full liquid with Dysphagia 2 - Nectar thickened liquids" as a recommendation. Hospitalist Staff ID # 66 entry on 8/30/24 at 1:01 pm stated "Discharge home. Diet: Resume home diet and feeds." There was no mention of the Difficult Airway or Difficult airway instructions/safety precautions. There was no case management or discharge planning note which addressed Patient ID #2 modified diet with need for thickener agentand how to obtain this once discharged.

Interview with Director of Case Management Staff ID # 63 on 3/27/2025. She confirmed that discharge planning is documented by clinical staff and case managers in the medical record. She confirmed that clinical changes or modifications to the patients care should be documented by clinical staff and followed up with case management. She confirmed that Patient ID # 1 had an entry placed by Case Manager staff ID # 73 on 11/26/24 at 2:51 pm which stated "SW submitted APS (Adult Protective Services) report due to safety concerns at home. E-Report Confirmation # (redacted)." She confirmed that the patient was discharged home on 11/26/24 at 09:18 pm. She confirmed there was no documentation of which transportation service discharged patient home in the clinical record. She confirmed there was no documentation why the APS report was filed by the social worker, no social work consult and no documentation by social worker/case manager as to what the safety concerns in the home were. She confirmed that APS needed to engage with patient and staff, prior to discharge home, if an APS report had been filed related to safety with discharge plan. She stated Case Manager Staff ID #73 no longer was employed at the facility so was not available to interview related to this case.

Interview with Anesthesia Medical Director Staff ID # 61 on 3/28/25 at 10:25 am. He confirmed that Patient ID #2 qualified to recieve a "Difficult Airway" letter after his surgery on 8/23/24 per the practice guidelines for the anesthesia group. He provided a blank form letter for review. This letter is printed on anesthesia group letterhead and is titled "Subject: Difficult Airway." The letter stated "In the course of your recent anesthetic, your Anesthesiologist identified that you have a Difficult Airway. This is a serious condition that could be life-threatening." He confirmed that he was unable to locate the duplicate copy in Patient ID #2 medical record and could find no documentation that this had been provided prior to discharge from the facility.

Based on document review and interview, the facility failed to properly consent 2 of 13 patients for anesthesia services (Patient ID #2 and 6). The facility was not following the established policy that required the anesthesiologist to obtain a separate completed consent for anesthesia services.

Findings Included:

Review of the medical records for patient ID #2 date of service 08/23/24 revealed "Disclosure and Consent - Anesthesia and/or Perioperative Pain Management" forms with Nurse Informaticist Staff ID # 68 on 3/27/25 at 11:40 am. She confirmed that the lines were left blank next to boxes checked "Physician Anesthesiologist Dr. ____________ (Name) and "Certified Registered Nurse Anesthetist: _______________ (Name). She confirmed both lines had been checked but there was no name of responsible anesthesiologist/nurse anesthetist listed.

Review of the medical records for patient ID #6 date of service 03/27/25 with PACU Director Staff ID #75. She confirmed that "Disclosure and Consent - Anesthesia and/or Perioperative Pain Management" form was present. However, the lines were left blank next to boxes checked "Physician Anesthesiologist Dr. ____________ (Name) and "Certified Registered Nurse Anesthetist: _______________ (Name). She confirmed both lines had been checked but there was no name of responsible anesthesiologist/nurse anesthetist listed. She confirmed the patient had already undergone a procedure 3/27/25 and been discharged home from the facility.

Record review of facility policy titled "Disclosure and Consent (Informed Consent), last reviewed 04/2024, stated "b. Anesthesia Consent 1. Prior to elective surgery, invasive procedure or treatment, the anesthesiologist has a duty to obtain informed consent regarding type of anesthetic, risks and benefits, side effects, significant alternatives and results of non-treatment."

Interview with Anesthesia Medical Director Staff ID # 61 on 3/28/25 at 10:10 am. He confirmed that the anesthesia consent form should be completed in entirety per facility policy and anesthesia practice guidelines.

Based on interview, and record review, the facility failed to perform/accurately document pre-anesthesia evaluations in 1 of 13 patients reviewed. (Patient ID# 6).

Findings Included:

Record review with Informatics Nurse Staff ID # 68 on 3/27/25 at 11:45 am. She confirmed the following findings:

Patient ID #2 on date of service 08/23/2024 had "Anesthesia Assessment" form had "Anesthesia Planned" box checked "Gen." The box which stated "Risks and benefits of sedation/anesthesia have been explained" was not checked/marked. NPO stated ">8 hrs". The signature line housed an illegible signature. The anesthesiologist last name was [printed]. The date and time were left blank. The section which stated "Update" was completely blank. "Date, Time, Anesthesia Planned. ASA Classification. Signature. Printed Name. Date and Time" were all blank.

Informatics Nurse Staff ID # 68 confirmed the anesthesia plan and pre-anesthesia evaluation was incomplete for Patient ID #2.

Record Review of facility policy titled "Guidelines for Anesthesia Care", last reviewed 04/2024 stated "Pre-anesthesia evaluation shall be done by a licensed independent practitioner for each patient for whom anesthesia is contemplated." It further stated "the pre-anesthetic evaluation should be recorded prior to the transfer of the patient to the operating room. Entry in the medical record shall be dated and timed."

Interview with Anesthesia Medical Director Staff ID # 61 on 3/28/25 at 10:15 am. He confirmed that the pre-anesthesia evaluation/assessment should be completed per facility policy and anesthesia practice guidelines prior to the patient leaving the pre-op area to go to the operating room. He confirmed that the evaluation should include a physician signature, date and time when the assessment was completed.

Based on observation, interview, and record review, the facility failed to perform/ accurately document post-anesthesia evaluations in 8 of 13 patients reviewed. (Patient ID#s 7, 8, 9, 11, 12, 15, 16, 17).

Findings Included:

Observation on 3/27/25 at 2:25 pm in Phase 2 Post-Anesthesia Care Unit (PACU). Medical Record storage drawer held paper chart records for patients who had undergone surgeries today as identified by Staff Nurse RN # 76. Patient ID # 6, 7 and 8 medical records were located. Staff RN #76 confirmed the patients had surgical procedures today (3/27/2025) and were already discharged from the PACU.

Record review of Patient ID # 7 and 8 anesthesia records revealed there was no date and time for post-anesthesia evaluation on 3/27/2025.

Interview with PACU Director Staff ID # 75 om 3/27/25 at 2:45 pm. She confirmed that all patients should receive a post-anesthesia evaluation prior to discharge from Phase I PACU per facility policy. She confirmed this should be documented on Page 2 of the "Anesthesia Intraoperative Form" in the space labeled "Post Anesthesia Evaluation."

Record review with Informatics Nurse Staff ID # 68 on 3/27/25 at 11:45 am. She confirmed the following findings:
Patient ID # 9 - there was no date and time for post-anesthesia assessment on 10/25/2024.
Patient ID #11 - there was no date and time for post-anesthesia assessment on 12/9/2024.
Patient ID # 12 - there was no anesthesia provider signature and no date and time that post-anesthesia assessment was performed on 12/9/2024.
Patient ID # 15 - there was no post-anesthesia evaluation for the patient who went to ICU post-operatively on 12/9/2024 within 48 hours.
Patient ID # 16 - there was no time for post-anesthesia evaluation on 2/14/2024.
Patient ID # 17 - there was no time for post-anesthesia evaluation on 2/14/2024.

Record review of facility policy titled "Guidelines for Anesthesia Care", last reviewed 04/2024 stated "8. Post-operative care. The post-operative status of the patient is evaluated on admission to and discharge from post-anesthesia recovery ...12. The anesthesiologist must release the patient from PACU ...15. The post-anesthesia visit will be documented on the medical record and will include date and time."

Record review of facility policy titled "Pre-Anesthesia and Post-Operative Anesthetic Evaluation and Assessment", last reviewed 12/2024 stated "Post Operative Anesthesia Evaluation"1. The anesthesia department will date and time their post-op visits in the medical record. 2. Outpatients will be discharged from the Same Day Surgery unit by a member of the anesthesia department and the Surgeon."

Interview with Anesthesia Medical Director Staff ID # 61 on 3/28/25 at 10:25 am. He confirmed that the anesthesia post-evaluation assessment should be completed per facility policy and anesthesia practice guidelines prior to the patient leaving post-anesthesia care unit. He confirmed that the evaluation should include a physician signature, date and time that the assessment was completed.