HospitalInspections.org

Based on document review and interview, it was determined for 1 of 10 (Pt #1) patient records reviewed, the hospital failed to provide care in a safe environment. This has the potential to affect all patients who are discharged by the hospital.

Findings include:

1. Pt #1 was admitted to the hospital on 10/22/22 with the diagnosis of Myocardial Infarction (heart attack), new onset insulin dependent diabetic, heart failure, schizophrenia, multiple sclerosis, and continuously monitored cardiac telemetry was ordered. The IDG note dated 10/26/22 at 1:30 PM noted "Notified Charge RN that pt will not stay in his room, and is yelling and screaming at RN. Asked Charge RN if we should call security. Charge RN said he is "decisional" so we cannot hold him in his room. Pt left the unit to "get some fresh air." Charge RN told pt to keep his phone on him and she would call him when his ride to the SNF was set up." The IDG note dated 10/27/22 at 4:01 AM noted "Pt not in room RN aware." The Discharge Summary dated 10/27/22 at 8:06 PM noted "During... stay... one night left... room and camped in the relative's room waiting area."

2. During an interview on 4/12/23 at approximately 12:00 PM, E#7 (Charge Nurse) stated "We usually do not let people walk around because we can't pick up the tele monitor (cardiac monitor)."

Based on document review and interview, it was determined for 1 of 2 Physician files reviewed, the hospital failed to ensure the Physician's ordering non-violent and violent restraints had a working knowledge of the hospital's policy. This has the potential to affect all patients who may require the use of violent and/or non-violent restraints.

Findings include:

1. The policy titled "Restraint and Seclusion Management" (approved 12/19/2022) was reviewed on 4/11/23. The policy noted "9. Training: a. Physicians... that order and or evaluate for restraints, have working knowledge about the hospital policy for restraint use. Training occurs during orientation, every 2 years and if significant policy revisions occur..."

2. The Physician file for MD#2 (reappointment 2/28/23) was reviewed on 4/12/23 at approximately 12:30 PM. The file lacked documentation MD#2 had working knowledge of the hospital's restraint/seclusion policy and competence in ordering restraints.

3. During an interview on 4/12/23 at approximately 1:00 PM, the Quality and Safety Regulatory Coordinator (E#1) verbally agreed MD#2's personnel file lacked documentation of violent and/or non violent restraint training and competence.

A. Based on document review and interview, it was determined for 1 of 10 (Pt #1) patient records reviewed,the hospital failed to conduct an accurate discharge evaluation plan. This has the potential to affect all patients who are discharged by the hospital.

Findings include:

1. The policy titled "Discharge Planning" (originated 12/17/2019, approved 2/28/2023) was reviewed on 4/11/23. The policy noted "Discharge Plan 1. Once the need for discharge planning is identified, a discharge evaluation is performed. Evaluation includes:
a. Patient's capacity for self-care or likelihood of the patient returning to pre-hospital environment b. Likelihood of a patient needing post-hospital services and availability of the services, and the patient accessibility to those services c. Patient's and/or legal decision maker(s) preferences regarding discharge plan d. When a patient is identified as a re-hospitalization within the past 30 days, the evaluation records information from the prior hospitalization, including the discharge plan and the patient and family's account from prior hospital discharge to current hospitalization."

2. Pt #1 was admitted to the hospital on 10/22/22 with the diagnosis of Myocardial Infarction (heart attack), new onset of insulin dependent diabetes, heart failure, schizophrenia, and multiple sclerosis. The initial Case Management Comprehensive Assessment was conducted on 10/23/22 at 10:56 AM while Pt #1 was in the Intensive Care Unit on an insulin infusion, nitroglycerin drip, and was closely monitored for acute kidney injury, heart failure, was anticoagulated for a thrombus (blood clot) observed in the heart, and was to be considered a 2-Medium Low readmission risk. The following Case Management notes, Nurses notes and Physician Progress notes noted the anticipated discharge plan was a Skilled Nurse Facility (SNF) and the readmission risk remained a 2-Medium Low risk level: 10/25/22, 10/26/22 and 10/27/22. The record noted Pt #1 was discharge home on 10/27/22 without any home services.

3. During an interview on 4/11/23 at approximately 1:30 PM, E#4 (Director of Case Management) stated "The risk level score are generated by EPIC (electronic health record) to tell us the risk of rehospitalization within 30 days. There are like 2000 elements built into it. zip codes, Primary Care Physician, diagnosis, overall score for rehospitalization. Increased risk patient are medium high or high risk or congestive heart failure patients. We would follow up with these patient 24 hours after discharge." E#4 reviewed Pt #1's record and stated, "Pt #1 should have scored at a higher level for readmission risk."

4. During an interview on 4/12/23 at approximately 11:00 AM, E#1 (Quality and Safety Regulatory Coordinator) stated " The data based gels a lot of information based on historical data. It doesn't look at the patient in their current health state. It's not an accurate reflection of the patients re-admission risk. For example, it may not consider a change in a diabetes diagnosis but now the patient is insulin dependent. That's a big difference that is not calculated." E#1 verbally agreed Pt #1 should have scored at a higher level for readmission risk.

B. Based on document review and interview, it was determined for 1 of 10 (Pt #1) patient records reviewed, the hospital failed to provide a safe discharge. This has the potential to affect all patients who are discharged by the hospital.

Findings include:

1. The policy titled "Discharge Planning" (originated 12/17/2019, approved 2/28/2023) was reviewed on 4/11/23. The policy noted "Discharge Plan 1. Once the need for discharge planning is identified, a discharge evaluation is performed. Evaluation includes: a. Patient's capacity for self-care or likelihood of the patient returning to pre-hospital environment."

2. Pt #1 was admitted to the hospital on 10/22/22 with the diagnosis of Myocardial Infarction (heart attack), new onset of insulin dependent diabetes, heart failure, schizophrenia, and multiple sclerosis. The record noted Pt #1 was discharged with home insulin and blood glucose monitoring. The record lacked documentation Pt #1 was taught how to obtain a blood sample, conduct blood glucose monitoring with the meter, care of the meter, drawing up the medication, how to store the medication or how to administer insulin and discard of needles post discharge. The record lacked documentation medications were thoroughly discussed and education provided to the Patient or Patient's representative, as well as ensure medications were affordable and able to be picked-up or delivered. The record noted Pt #1 and patient's representative were offered to be referred to a Home Health Agency although "they won't come daily."

3. During an interview on 4/11/23 at approximately at 2:00 PM and 4/12/23 at 11:45 AM, E#5 (Case Manager-Social Worker) stated "Home Health Care would only come like three times a week and that's not what... wanted."

4. During an interview on 4/12/23 at approximately 2:00 PM, E#8 (Vice President of Quality and Safety) stated "There is an opportunity for improvement right there when (E#5) said home health would only come in 3 days a week. They would have come in the first day home and ensured Pt #1 had the medications needed and was instructed on proper administration. They will come daily if the patient needs it. This patient (Pt #1) should have had a psych evaluation prior to discharge to ensure competence and safe discharge planning."

C. Based on document review and interview, it was determined for 1 of 10 (Pt #1) patients records reviewed, the hospital failed to provide a discharge plan with complete and accurate assessment of patient needs . This has the potential to affect all patients who are discharged by the hospital.

Findings include:

1. Pt #1 was admitted to the hospital on 10/22/22 with the diagnosis of Myocardial Infarction (heart attack), new onset of insulin dependent diabetic, heart failure, schizophrenia, and multiple sclerosis. An IDG Addendum note dated 10/26/22 at 9:05 AM noted "Expressed concern to (MD#1) that this RN spoke with pt's POA and per her and this RN's assessment, pt will not be able to care for himself at home. He is new start insulin pt, and per POA, pt does not even take his PO (oral) medications correctly or at all. He also does not understand a diabetic diet, or that he needs to eat three meals a day. Per POA, she can no longer care for him, he will not let her ... ". RN expressed concern that pt is not decisional,and suggested a Neuropsychology assessment. RN also notified MD#1 that pt does not take medications to manage his schizophrenia and that today, he was having agitation, yelling obscenities at nurses and staff, and just all around having behaviors to demonstrate his lack of touch with reality. Pt refused compliance with hospital rules and protocols. RN notified MD#1 that he did wet his pants and refused to change them. On 10/26/22 at 11:55 AM, the IDG note noted "Notified Charge RN and (MD#3) that pt is trying to leave without his medications and without being discharged. He pulled out his IV's (Intravenous Lines), pulled off his telemetry pack and said he is "being called to church." The IDG Note dated 10/26/22 at 9:45 PM noted "Paged on-call hospitalist. Discussed pt's known medical history of schizophrenia with no psych consult ... MD agreed that patient and staff safety was a concern. Stated that he would place consult for psych and an order for prn (as needed) medication for agitation." The record noted Haldol was ordered although no order for a psych consult was ordered.

2. During an interview on 4/12/23 at approximately 11:00 AM, E#8 verbally agreed Pt #1 should have had a psychiatric evaluation prior to discharge to ensure Pt #1's safety. E#8 stated the cardiologist should have made that referral.