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Based on medical record review and interviews the hospital failed to provide an effective, safe discharge plan for 1 of 10 patients (Patient #1). Patient #1 presented to the emergency department from detox with chest pain. Documentation received from detox noted Patient #1 was on a hold for commitment. Patient #1 was admitted to an inpatient floor and discharged to home versus detox. He was found deceased eight days later. This failure places the Condition of Participation of Discharge Planning out of compliance. See documentation at tags A800, A806, A807 and A837.
Findings include:

Based on medical record reviews and interviews, the hospital failed to identify at an early stage of hospitalization, a patient's discharge needs for 1 of 10 Patients (#1) who was likely to suffer adverse consequences upon discharge. When Patient #1 was admitted to the hospital from detox he had paperwork identifying he was on a hold for commitment. The hospital failed to follow a commitment hold for Patient (#1) and he was discharged home. He was found eight days later deceased. Findings include:

Patient #1's medical record was reviewed and revealed that on June 26, 2010, Patient #1 presented with chest pain to the emergency department from detox via ambulance. Paperwork that accompanied Patient #1 included a medical report that noted Patient #1 was on hold for commitment for Dakota County. Emergency department (ED) visit note dated June 26, 2010, noted Patient #1's diagnoses included abdominal aortic aneurysm, ischemic cardiomyopathy and alcoholism. He was evaluated in the ED for his chest pain by Physician (D). The ED visit note indicates Patient #1 is positive for alcohol use and currently on commitment due to chemical dependence. Patient #1 had a medical evaluation in the ED and it was determined he needed to be admitted to the hospital for further evaluation of his chest pain. He was transferred to an inpatient floor. Then his care was turned over to Physician (E).

There is no further documentation in the medical record regarding commitment. His discharge summary of June 30, 2010, notes Patient #1 was discharged to home with family on June 27, 2010.

An interview with the Physician (D) was conducted on August 24, 2011, at 10:52 a.m. and she verified her documentation of June 26, 2010, noted Patient #1 was on a commitment. She also stated her standard practice would have been to pass the information on to the receiving physician. Physician (D) verified she did not document information given to the receiving physician and does not remember any of the specifics. She also verified she did not contact the social worker to follow up as she is now aware would be part of the standard practice.

A review of the hospital policy and procedure titled Transport Holds & 72 Hour Holds
was conducted. It states "A social worker will be notified when a hold is placed." This was not done by the hospital staff.

Additional documentation received from the hospital internal investigation dated July 11, 2011, noted "being a weekend the longstanding expectation is that if this is a situation that involves commitment or returning to detox the on-call SW (sic) should have been paged". This was not done by the hospital staff.

Based on medical record review and interviews, the hospital failed to provide a discharge planning evaluation for 1 of 10 Patients (#1) assessing the patient's active commitment status and his need to return to detox. Documentation received by the hospital noted Patient #1 was on a hold for commitment. The discharge evaluation did not include the hold for commitment and the need to return to detox. Patient #1 was discharged to home and was found eight days later deceased. Findings include:

Medical record review indicated Patient #1 was admitted to an inpatient unit from the Emergency Department (ED) on June 26, 2010 at 7:00 p.m. His diagnoses included coronary artery disease, ischemic cardiomyopathy and alcoholism. The Nursing Initial Assessment note, date June 26, 2010, at 7:59 p.m. was reviewed and included the following: under history of alcohol use, it is documented as "not on file". Under Social screening documentation noted, "no discharge planning screening criteria applicable". Under chemical use screening, documentation noted "no chemical use screening applicable".

An interview was conducted with Employee (A)/Administration on August 22, 2011, at 5:30 p.m. and she verified the medical record for Patient #1 did not include discharge planning related to his chemical dependency needs and his hold for commitment.

An interview was conducted on August 29, 2011, at 12:07 p.m. with Physician (F). During this interview he verified Patient #1 would be likely to have adverse health consequences if he continued drinking after his discharge from the hospital with his cardiac conditions and alcoholism. He also stated the admitting physician would review documents that would come with the patient to the hospital and put that information into notes the following physician would review. This information would play a part in discharge planning and would be reviewed at daily rounds Monday through Friday. On the weekend, the physician would follow up with the patient and contact the social worker as needed. Physician (F) stated he was not aware of the commitment hold for Patient #1 and saw no documentation regarding a commitment. Patient #1 was discharged to home with a family member.

Based on medical record review and interview, the hospital failed to involve appropriate qualified personnel to develop and supervise the discharge evaluation for 1 of 10 Patients (#1) who was discharged to home instead of to detox where he was on a hold for commitment. Patient #1 was found eight days later deceased. Findings include:

Patient #1's medical record was reviewed and noted Patient #1 arrived to the Emergency Department (ED) from detox with paperwork indicating he was on a hold for commitment for Dakota County. He was admitted to the hospital from the ED for an evaluation of chest pain. The admitting physician, Physician (E), ordered a routine social worker evaluation for chemical misuse on June 26, 2011, at 8:34 p.m. The order was discontinued on June 27, 2011 at 9:23 p.m. as Patient #1 had been discharged from the hospital. There was no documentation from a social worker that Patient #1 was seen or evaluated.

Additional documentation received from the hospital internal investigation dated July 11, 2011, noted "being a weekend the longstanding expectation is that if this is a situation that involves commitment or returning to detox the on-call SW (sic) should have been paged". This was not done by the hospital staff.

An interview was conducted with Employee (K)/ Administration on August 23, 2011, at 1:22 p.m. and she stated that when a patient is on a hold for commitment, a nurse or physician should call or page the crisis social worker in the ED and upon review of Patient #1's medical record, this was not done.

Review of the Patient Discharge/Transfer policy and procedure revealed "the discharge plan will address the transition between the acute hospital setting and the next level of care required by the patient. Attention will be paid to the patient's ongoing medical and nursing care as well as psychosocial, housing and financial issues". It also indicates "social work responsibilities include to identify and coordinate appropriate level of care/resources needed after discharge..." and "to serve as a communication link between hospital staff, community, patient and family". There was no discharge evaluation for Patient #1 addressing the hold for commitment. There was no social worker involved in Patient #1's discharge evaluation.

Based on medical record review and interviews, the hospital failed to transfer a patient to the appropriate agency, (detox), for follow-up care when 1 of 1 patients (#1) who presented to the hospital from detox while on a hold for commitment. Patient #1 was to be discharged back to the detox facility, instead the hospital discharged the patient to home. Findings include:

Review of the medical record revealed Patient #1 presented to the emergency room from detox on June 26, 2010, with chest pain. Paperwork, dated June 26, 2010, from detox to the emergency department noted Patient #1 was on a hold for commitment. Emergency room physician note dated June 26,, 2010, noted Patient #1 was admitted to a telemetry unit later that afternoon after being treated in the emergency department. The physician on duty in the emergency department noted Patient #1 was on commitment. No further staff documentation related to a commitment hold was found in the medical record. The discharge summary dated June 30, 2010, noted Patient #1 was to be discharged home with family.

An interview was conducted with Employee (A)/Administration on August 23, 2010, at 1:08 p.m. and she verified the hospital staff did not follow the hospital practice relating to a commitment hold.

Employee B/Administration was interviewed on August 23, 2011, at 1:24 p.m. and he verified the standard practice for patients who are admitted to the hospital with a commitment hold was not followed through Patient #1's hospital stay when he was discharged to home. Patient #1 was to be taken back to detox and held until treatment after discharge from the hospital and this was not followed by hospital staff. Patient #1 discharged to home and was found several days later deceased.

Physician (F) was interviewed on August 29, 2011, at 12:07 p.m. During this interview he verified Patient #1 would be likely to have adverse health consequences if he continued drinking after his discharge from the hospital with his cardiac conditions and alcoholism. He also stated the admitting physician would review documents that would come with the patient to the hospital and put that information into notes the following physician would review. This information would play a part in discharge planning and would be reviewed at daily rounds Monday through Friday. On the weekend, the physician would follow up with the patient and contact the social worker as needed. Physician (F) states he did not see any documentation regarding commitment hold. Unaware of the commitment hold for Patient #1, Physician (F) discharged Patient #1 to home with a family member.

Based on medical record review and interview, the hospital failed to involve appropriate qualified personnel to develop and supervise the discharge evaluation for 1 of 10 Patients (#1) who was discharged to home instead of to detox where he was on a hold for commitment. Patient #1 was found eight days later deceased. Findings include:

Patient #1's medical record was reviewed and noted Patient #1 arrived to the Emergency Department (ED) from detox with paperwork indicating he was on a hold for commitment for Dakota County. He was admitted to the hospital from the ED for an evaluation of chest pain. The admitting physician, Physician (E), ordered a routine social worker evaluation for chemical misuse on June 26, 2011, at 8:34 p.m. The order was discontinued on June 27, 2011 at 9:23 p.m. as Patient #1 had been discharged from the hospital. There was no documentation from a social worker that Patient #1 was seen or evaluated.

Additional documentation received from the hospital internal investigation dated July 11, 2011, noted "being a weekend the longstanding expectation is that if this is a situation that involves commitment or returning to detox the on-call SW (sic) should have been paged". This was not done by the hospital staff.

An interview was conducted with Employee (K)/ Administration on August 23, 2011, at 1:22 p.m. and she stated that when a patient is on a hold for commitment, a nurse or physician should call or page the crisis social worker in the ED and upon review of Patient #1's medical record, this was not done.

Review of the Patient Discharge/Transfer policy and procedure revealed "the discharge plan will address the transition between the acute hospital setting and the next level of care required by the patient. Attention will be paid to the patient's ongoing medical and nursing care as well as psychosocial, housing and financial issues". It also indicates "social work responsibilities include to identify and coordinate appropriate level of care/resources needed after discharge..." and "to serve as a communication link between hospital staff, community, patient and family". There was no discharge evaluation for Patient #1 addressing the hold for commitment. There was no social worker involved in Patient #1's discharge evaluation.