HospitalInspections.org

42477

A. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure staff had a policy and process in place to monitor weight gains or losses on four of four sampled patients (2, 3, 4, and 5). Findings include:

1. Observation and interview on 8/23/22 at 9:50 a.m. with rehabilitation nursing technician (RNT) P and patient 2 revealed:
*She informed patient 2 he could not have any more water as he was on a fluid restriction.
-The patient seemed confused by this statement.
*RNT P stated the nurse had just informed her that he was to be on a fluid restriction because he had gained 14 pounds (lbs.).
*The fluid restriction had started that day, on 8/23/22.
*He received outpatient hemodialysis treatments.
*He had no signs up regarding fluid restrictions, or fluid intake sheets on his door.

Interview and review on 8/23/22 at 1:41 p.m. with registered nurse (RN) M regarding patient 2 revealed:
*They communicated with the dialysis unit via dialysis communication sheets.
-The communication sheets traveled with the patient to and from dialysis.
*A review of his dialysis communication sheets located in his paper chart documented:
-The provider should have been monitoring patient 2's fluid intakes.
*When asked why he was not put on a fluid restriction sooner she stated, "I guess that got missed and didn't get communicated."
*Physician assistant (PA) G had placed patient 2 on a 2000 cubic centimeter (cc) fluid restriction.
*She was unsure why PA G had placed patient 2 on a 2000cc fluid restriction rather than a 1200cc dialysis fluid restriction.
-They had not contacted the dialysis unit to clarify this.
*She pulled up an example of a dialysis patient's care plan and the note stated: "Notify Nephrologist if 0.5 kg [kilogram] weight increase."
-She was not sure who the nephrologist was and unsure how to notify a nephrologist.

Review of patient 2's electronic medical record (EMR) revealed:
*He had been admitted to the facility on 8/9/22.
*He had the following diagnoses:
-Chronic kidney disease (CKD).
-Chronic diastolic congestive heart failure.
-Hypertension.
-Uncontrolled type II diabetes.

Review of patient 2's undated nurse to nurse transfer report from the acute care hospital revealed:
*He was receiving dialysis three times per week.
*His dialysis access was a right central catheter.
*He was to be on a 1200cc fluid restriction.
*He had pitting edema on admission to the provider.

Review of patient 2's dialysis communication sheets revealed:
*On 8/10/22 his pre dialysis weight was 166.98 lbs.
*On 8/12/22 his pre dialysis weight was 175.78 lbs.
*On 8/15/22 his pre dialysis weight was 188.98 lbs.
*On 8/17/22 the communication note stated:
-"Fluid gain of more than 5.3 kg watch fluid intake that[']s more than we can remove in one trx [treatment] thank you."
-His pre dialysis weight was 190.96 lbs.
*On 8/19/22 his communication note stated:
-"...watch fluid gain of more than 5 kg!"
--His pre dialysis weight was 193.6 lbs.
*On 8/22/22 his communication note stated:
-"Pt [patient] gained 14.3 pounds since Friday. He says he's on a fluid restriction. Is he able to 'sneak' any being in w/c [wheelchair] and blind?"
-His pre dialysis weight was 197.56 lbs.
*On 8/24/22 his communication note stated:
-"gain of 5.2 kg from last trx. still over tw [total weight] by 6.0 kg watch fluid intake restrict fluid phosphorous 10.9 H [high] Potassium 6.5 H watch diet! please."
-His pre dialysis weight was 90.7 kg (199.54 lbs.).

Review of patient 2's intake and output documentation revealed:
*From 8/9/22 through 8/25/22 revealed:
-There had been no documented outputs.
*His fluid intakes had not matched the 33 pounds he had gained in the 15 days he had been in the facility.
*On 8/23/22 he had been documented to have taken in 2970cc of fluids.

Further review of patient 2's EMR revealed there had been no documentation to inform the provider that patient 2 had went over his physician ordered fluid intake.

2. Review of patient 3's dialysis communication sheets revealed:
*On 8/22/22 he had gained 11.88 lbs. and dialysis staff had been unable to remove more than 3.3 lbs during his treatment.
*On 8/21/22 they dialysis staff had asked the provider to "watch fluid intake please."
*His dialysis access was located on his right upper arm.

Review of patient 3's physician orders revealed:
*On 7/9/22 he had a physician's order which stated:
-"Notify Physician (For weight gain greater than 2 pounds from prior weight, or greater than 5 pounds for prior seven day period)."
*On 7/9/22 he had a physician's order for continuous assessment and monitoring of dialysis access.
*On 7/19/22 he had a physician order for weights every Wednesday.

Review of patient 3's EMR revealed:
*His pre admission discharge orders stated:
-He should have been weighed daily.
-He was on antibiotics for osteomyelitis (inflammation of the bone due to infection).
-He had ascites (fluid accumulating in the abdomen).
*RN I had entered for staff to monitor his dialysis access on his right lower arm.
-His dialysis access was on his right upper arm.
*From 8/15/22 through 8/25/22 he had weight fluctuations greater than 2 lbs.:
-8/25/22, there was a 4 lbs. weight variation.
-8/23/22, there was a 4.2 lbs. weight variation.
-8/18/22, there was a 6.3 lbs. weight variation.
-8/16/22, there was a 5.7 lbs. weight variation.
*There had been no documentation that the physician or nephrologist had been notified or re-weights had been obtained.

Review of patient 3's interdisciplinary plan of care (IPOC) revealed:
*He was "at risk for fluid volume deficit rehab"
-Outcome was to maintain adequate fluid volume.
-The expectation had been marked as "met."
*He also had the following interventions for "maintaining adequate fluid volume."
-Encourage fluid intake as ordered by medical doctor.
-Encourage adequate hydration.
-Monitor weight.

3. Review of patient 4's EMR revealed:
*He had been admitted to the facility on 8/10/22.
*His admission orders were for him to have daily weights taken and his intakes and outputs monitored.
*He had various weights documented:
-On 8/10/22 he had a weight of 160.4 lbs.
-On 8/11/22 he had a weight of 240 lbs.
--He had not been re weighed.
-On 8/12/22 he had a weight of 195.6 lbs.
-There was no documentation or explanation why he had gained 30 lbs. or greater since admission.
*He was not on a fluid restriction.
*Dialysis communication forms had mentioned watching his fluid intake.

Review of patient 4's intake and output forms revealed:
*There were many discrepancies in the intakes and outputs.
*For a period of 15 days he had a total of 10,800 milliliters (mL) of fluid intake.
*Over 15 days he had an output of 6025 mL.
-Resulting in 4775 mL of a fluid imbalance.
-He had averaged approximately 720cc of total fluid intake for each day.
*Some days he had received 1400cc of fluid, other days he had received 300cc of fluid.

Review of patient 4's IPOC revealed, he was to have adequate fluid volume maintained.
*There was no documentation to support how that fluid volume should have been maintained.
*There was no information as to what was considered "adequate."

Observation on 8/25/22 at 10:20 a.m. of the IDT team conference meeting regarding patient 4 revealed:
*They stated he had been very tired and had declined in therapy.
*The physician had recently put him on non steroidal anti inflammatory drugs (Ibuprofen), due to his swelling.
*The registered dietitian (RD) N stated they removed nine lbs. of fluid during dialysis the other day.
*Director of case management F asked if he was tired all the time or just after dialysis.
-Therapy stated he was tired all the time lately.
*RN I had not mentioned his recent fluid gains and how that could have affected the outcome of his therapy sessions.
-No other IDT staff had mentioned his weight or fluid issues and how that could affect his therapy progress.

4. Observation and interview on 8/23/22 at 9:25 a.m. of patient 5 revealed:
*Outside of his room door there was a sign that stated, fluid restriction 2000cc per day.
*He was laying in his bed, wearing oxygen tubing and a nasal cannula.
*He appeared to be short of breath when talking.
-He appeared to have trouble talking and kept taking deep breaths.
*His lower legs appeared to have some swelling and were red.
*His oxygen had been set to six liters (L) per minute.

Observation and review on 8/23/22 at 10:00 p.m. of patient 5's intake and output sheet hanging on his door revealed:
*On 8/22/22 he had two entries:
-500cc at 7:00 a.m.
-500cc at 11:00 a.m.
-He had no other entries for dinner or after 11:00 a.m.
*On 8/23/22 he had one entry for 500cc at 7:30 a.m.

Observation on 8/23/22 at 10:25 p.m. of the provider's interdisciplinary team (IDT) conference revealed:
*They were discussing patient 5.
*He had been admitted to the facility on 8/18/22.
*His diagnoses included:
-CKD, obesity, congestive heart failure (CHF), and diabetes.

Review of patient 5's physician orders revealed:
*On 8/22/22 he had an order for a daily weight.
*On 8/18/22 he had an order for:
-Staff to monitor his intake and output.
-A 2000 cc per day fluid restriction.
-A daily weight.

Review of patient 5's EMR revealed:
*His 8/18/22 pre admission information included:
-He had many weight fluctuations:
-On 8/18/22 his admission weight was 263 lbs.
-On 8/23/22 he had a 2.6 lb. weight increase and had not been re-weighed.
-On 8/24/22 it was documented that he weighed 167 lbs.
-He was re weighed 6 hours later and weighed 269.1 lbs., which was a 3.8 lb. increase from the previous day.*During his seven days stay he had gained 6.6 lbs.

Observation and interview on 8/24/22 at 8:07 with patient 5 in his room revealed:
*He had received his breakfast and he had the following liquids in his room:
-Orange juice.
-Milk.
-Water.
-Oatmeal.

5. Review and interview on 8/23/22 at 2:00 p.m. with RN M and patients' weight audit sheets revealed:
*The book was started to help them monitor weight increases or decreases.
*From 8/21/22 to 8/23/22 patient 2 went from 148.1 pounds (lbs.) to 188.1 lbs. and was not re-weighed.
*There were many other inconsistencies on the weight audit forms such as weights that showed an abnormal increase/decrease for a patient without being re-weighing the patient and missing patients.

Interview on [date and time withheld due to anonymity] with anonymous staff member J revealed:
*They were very inconsistent with monitoring patients's fluid levels.
*Some patients had been put on fluid restrictions, and some had not.
-They lacked consistency with implementing and following through on fluid restrictions.
*Stated there seemed to be some kind of disconnect with nursing staff, physicians, and fluid restrictions.

Phone interview on 8/24/22 at 8:35 a.m. with dialysis unit charge nurse RN at [Name of dialysis center] revealed:
*Patients 2, 3, and 4 go to their facility to receive outpatient dialysis services.
*She had expected the provider's staff to be monitoring the patients' fluid intakes.
*They had been seeing weight increases in patient's 2 and 3.
*Patient 3 had complained to the dialysis unit the provider was not helping them to monitor their fluid intakes.
*They had been writing on their dialysis communication sheets to ensure they monitored the patients' fluid intakes.

On 8/24/22 at 8:45 a.m. chief executive officer (CEO) A delivered a dialysis/renal services policy and stated it was her understanding that the policy was only in effect if they were performing hemodialysis treatments in their facility.

Interview on 8/25/22 at 1:33 p.m. with PA G revealed:
*She has been the PA for the facility for about three weeks.
-She had received a recommendation from the charge nurse after there was communication with the dialysis unit.
*They do not usually implement a fluid restriction on dialysis patients upon admission.
*Surveyors had asked why patient 2 was put on a 2000cc fluid restriction since his admission paperwork stated he should be have been on 1200cc.
*The newly ordered fluid restriction for patient 2 stemmed from his weight increase on 8/23/22
-She stated they generally start everyone on a 2000cc fluid restriction.
-She had not talked to patient 2's nephrologist regarding their expectation.
*They generally do not consult the patient's nephrologist.
-She was unsure what the protocol was for contacting their nephrologist.
*She would have expected to be informed when any patients exceeded their fluid restrictions.

Interview on [date and time withheld due to anonymity] with anonymous staff member O revealed:
*Staff should be re-weighing patients when there was a weight variation.
*The staff were not:
-Consistent on how they document patient's intakes and outputs.
-Consistent on how they weigh and/or re weigh those patients with weight variations.
*The staff document when fluid is given to the patient on the sheet in their room.
-Not the amount the patient consumes.
*They are not always able to see the patient's plan of cares.
-They must be loaded on the IPADs and they were not sure who was responsible for doing that.

Interview on 8/25/22 at 1:50 p.m. with registered dietician (RD) N revealed:
*Fluid intakes and outputs should be have been documented on the intake and output sheet and in the medical record.
*Any outlier weights for patients should have been verified with a re-weigh.
*He was:
-Aware they were doing audits on weights and of the audit book at the nurses' station.
-Not aware there was no weight policy or process for the staff to refer to and follow.
*He:
-Agreed there should have been a weight policy in place.
-Was not aware the dialysis policy was only used when they were treating dialysis patients in the facility.
*The fluid restriction was a physician's order, and the patients should not be exceeding it.
*The staff should have been documenting the fluid patients are consuming and not what they were being given.
*He agreed there was confusion among staff regarding documentation of intakes and outputs.

Interview on 8/24/22 at 2:30 p.m. with medical director D revealed:
*He agreed Staff should have been monitoring the fluid restrictions and weights of patients closely.
*He expected staff to follow the dialysis unit's recommendations regarding fluid monitoring.
*All intravenous (IV) fluids should be calculated into the patient's fluid intake.
*Dialysis patients were typically on a fluid restriction that ranges from 1200cc to 1800cc.
-This would depend on the patient, and other factors such as kidney function and urine output.
*He expected the physicians to contact the nephrologists to see what fluid restrictions patients should be following.
*If a patient was on a fluid restriction, he expected staff to be following that fluid restriction.
*Fistulas and dialysis accesses should be monitored daily, as with any IVs and lines.

6. Review of the providers undated Readmission Prevention Playbook revealed:
*"Facilitate Team Conference and ensure it includes detailed discussion and problem solving related to specific model features or risk factors contributing to high readmission risk. Examples of some key features that would be discussed include the following:"
-"Management of chronic conditions in rehab and at home."
-"Utilization surveillance protocols in place (CHF, COPD [chronic obstructive pulmonary disease]).
-"Education plan for self-management of chronic condition to ensure continued management at home."
-"Home equipment or device needs related to conditions (scales, glucometer, nebulizer, etc.)"
*"Focus on instrumental ADLs [activities of daily living] plan for medication management, hydration, nutrition."

Review of the provider's March 2020 Fluid Restriction policy revealed:
*"To provide a system for limiting fluid consumption for patients with physician ordered restrictions."
*"It is the responsibility of the Nutritional Manager/Director to disseminate information concerning to this policy to affected personnel and departments. It is the responsibility of the physician to place fluid restriction orders as medically necessary."
*"It is the policy of the Nutrition Department that Fluid Restriction Orders will be implemented with the cooperation of the Department of Nursing."
*"1. Fluid intake restriction will be instituted following the attending physician's order for a specific level of fluid intake."
*"2. Nursing and the Registered Dietician will consult on how the division of total fluids will be allocated."
*"3. The meal pattern will be modified to meet the allocation for each individual meal. The tray menu slips will be marked 'FLUID RESTRICTION' and adjustments made on selections."
*"4. Nursing will monitor and record the fluid intake on the I & O [intake and output] documentation flow."

Review of the provider's November 2021 Dialysis/Renal Services policy revealed:
*"The need for dialysis staff should not be a deterrent to receiving inpatient rehabilitation. Maintaining a safe environment, competent staff, and regulatory compliant service is expected whether the service is via contract or provided in house."
*"The CNO is responsible for providing a safe dialysis service regardless of location."
*"Dialysis services may include hemodialysis, ultrafiltration, and peritoneal dialysis. The hospital will define which services they provide in the Plan for the Provision of Patient Care."
*The policy went through the protocol for hemodialysis and peritoneal dialysis.
-This did not apply to the fluid and weight monitoring of their inpatients, per CEO A's statement on 8/24/22 at 8:45 a.m.

B. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure one of one sampled patient (5) had his oxygen needs met. Findings include:

1. Observation and interview on 8/23/22 at 9:25 a.m. of patient 5 revealed:
*Outside of his room door there was a sign that stated, fluid restriction 2000cc per day.
*He was laying in his bed, wearing oxygen tubing and a nasal cannula.
*He appeared to be short of breath when talking.
-He appeared to have trouble talking and kept taking deep breaths.
*His lower legs appeared to have some swelling and were red.
*His oxygen had been set to six liters (L) per minute.

Review of patient 5's physician orders revealed:
*On 8/20/22 he had an order for five L of oxygen.
-"Maintain O2 [oxygen] sat [saturations] at > [greater than] 88, 1 L/min q [every] 15 30 minutes."

Review of patient 5's EMR revealed:
*His 8/18/22 pre admission information included:
He had sleep apnea.
"...At that time he required 10L Oxygen to maintain saturations..."
"...The patient was diuresed [removed fluid] with Lasix [fluid removal pill] and was on a 2500 ml [milliliter] fluid restriction. He continued to have significant leg edema and remained hypoxic [low oxygen levels in blood stream] and continued to need BIPAP Hs [at night] and was sent to [a hospital's name] for ongoing pulmonary weaning, since. Since he is on 1-2 L and 2000 ml fluid restriction..."
*He had various documented oxygen saturation levels.
-On 8/23/22 at 6:43 p.m. he had an O2 saturation level of 86%.
-The next time his oxygen saturation was documented was about 13 hours later.
-On 8/22/22 at 7:20 a.m. he had an oxygen saturation level of 83%, it was not re checked until 12 hours later.

Review of patient 5's nursing and physician progress notes revealed:
*On 8/22/22 respiratory therapist (RT) had documented the patient had been found to be on room air and had an oxygen saturation of 43%.
-Oxygen was placed on patient 5 at 5L and his saturation levels rose to 90%.
-When he fell asleep his saturation level dropped to 84% on 6 L.
-RT documented she had let the nurse and physician's assistant (PA) know about the situation.
*On 8/23/22 RT documented:
-"Patient was resting in bed, awake, on 2L via NC[nasal cannula] with [an] oxygen sat [saturation] of 68% [percent].
-Oxygen increased to 4L with a sat of 88%. Patient not in any distress and denies SOB [shortness of breath]. RN and physician aware. Will continue to monitor."
*On 8/22/22 PA G documented:
-There had been ongoing concern from nursing and respiratory staff regarding his oxygen requirements.
-He was consistently requiring 5L of oxygen.
-He likely required some type of CPAP/BIPAP that he was receiving prior to arriving at the facility.
-RT had informed the PA that they had been unable to do a CPAP/BIPAP in the facility.

Observation on 8/23/22 at 10:25 p.m. of the provider's interdisciplinary team (IDT) conference revealed:
*The physician stated he was on one liter (L) of oxygen at bedtime.
-Respiratory stated he had been sating [oxygen in blood] at 94% on five or six L of oxygen.
*The IDT was unsure why he was not on a continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) machine.

Observation and interview on 8/24/22 at 8:07 a.m. with patient 5 in his room revealed:
*Surveyor asked about his CPAP/BIPAP:
-He stated he usually used one.
*He was not sure why he did not have one while he was staying in the facility.

Interview on 8/25/22 at 1:33 p.m. with PA G revealed:
*She has been the PA for the facility for about three weeks.
*She was unsure why patient 5 was not on a CPAP or BIPAP, agreed he was on one in the hospital.
-She stated she would investigate this and let the surveyor know the outcome.
--She did not let the surveyor know the outcome of her investigation.

Review of the providers June 2022 Supplemental Oxygen policy revealed:
*"Supplemental oxygen is provided pursuant to a prescribed order and may be initiated by registered nurse or respiratory therapist. An assessment shall be completed to determine the need for oxygen therapy, assessment criteria include clinical and physical findings..."
*"In emergent situations, supplemental oxygen may be started prior to a prescriber order. The prescribed order will be obtained following the emergency if the supplemental oxygen will be continued."
*"Oxygen orders written for a specific flow rate and delivery device without titration or weaning parameters cannot be changed by clinical staff members without a new oxygen order from the prescribed..."
*"Therapy staff may adjust the patient's oxygen flow rate during therapy when prescribed by a physician with defined parameters of the order, unless stated in specific practice standards for OTs [occupational therapists], OTAs [occupational therapy assistants], PT [physical therapists], PTAs [physical therapy assistants], or SLPs [speech and language pathologists] specify other requirements or limitations."

Interview on 8/25/22 at 5:00 p.m. with CEO A, chief nursing officer (CNO) B, and director of quality and risk (C) C revealed:
*When asked how direct care staff received current and changed information on a patient's status.
-They stated the direct care staff had the ability to look in the chart.
*When asked how direct care staff are kept informed of a patient's discharge status
-CEO A stated, So non-licensed staff know more than licensed staff?
-She then refused to give surveyors an answer to their question.
*When surveyors inquired about patients' profiles and the IPOCs had not been loaded into the care techs' IPADs:
-They stated the staff can go to a computer at any time to see that information.
*The purpose of the team conference meetings was to discuss the patient's barriers to discharge.
-Surveyors brought up patients who are fluid overloaded could be tired and not able to participate as well in therapy.
-CEO A, "well, did they miss any minutes?" refusing to answer the surveyors questions regarding barriers to discharge.
*They would have expected the staff to document any patient noncompliance and had not followed physician orders.
*CNO B stated there was not a hard answer on how staff were expected to follow the plan of care.
*She stated:
"They have access to the patient's charts and can check on any computer."
"We would use our critical thinking skills."
*When asked if the physicians should contact the patient's nephrologists regarding fluid restrictions or other issues, CNO B have expected them to use their clinical judgement.
*There was no weight policy, and they would have followed the physician's preference.
CEO A asked: "Did they look in the computer on the policy? Because that is where I am at right now and I can't find one. Because we don't have one."
*Care techs put the weights in the computer, and it is up to the nurse to let the physician know and follow up.
*CNO B had not been aware of the weight audit book that the nurses had been using.
-She stated: "That is for their own personal use. All the patient's information can be found in the electronic record."
*CNO B expected dialysis communication to be handed off to the care team and physician.
*The public health surveyor advisor ended the interview to ensure professionalism was maintained and a hostile environment would not occur.
*CEO A and CNO B were argumentative, answered surveyors' questions with questions, and were defensive.
*All areas of concern identified with nursing services, oxygen services, and discharge planning could not be reviewed and addressed with the management staff due to the negative and argumentative nature of the interview.
*Director of quality and risk C:
-Offered no comment during the interview, kept her head down and took notes.

Review of the provider's undated Rehabilitation Nursing Technician job description revealed:
*"The Rehabilitation Nursing Technician I assists rehabilitation nurses with rehabilitation treatment and patient care according to hospital, state, professional, and federal regulations and guidelines. In addition, the position:"
-"Requires effective communication skills for working with patients, families, and caregivers."
-"Requires competency in assisting with delegated rehabilitation treatment and patient care."
-"Performs tasks as delegated by and supervised by rehabilitation nurses."
-"Maintains open and an on going communication with coworkers and supervisors."
*"The Rehabilitation Nursing Technician I supports an environment and culture that enables the hospital to fulfill its mission by helping to provide patient safety and patient centered treatment."

Review of the provider's undated Chief Nursing Officer's job description revealed:
*"The Chief Nursing Officer (CNO) is responsible for the development and implementation of the plans for providing nursing care, treatment, and services including determination of the types and numbers of nursing personnel necessary to provide nursing care and the development of a patient focused, team oriented culture, working in conjunction with all other medical, clinical and therapeutic disciplines to ensure optimal service and superior outcomes. The CNO holds full responsibility for the quality of nursing care provided and represents nursing on the Governing Body and other hospital committees. This position creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient centered treatment."
*"Develops patient care programs, policies, and procedures."
-"Describes how patients' needs for nursing care, treatment, and services are assessed, evaluated, and met for the programs, policies, and procedures developed."

Review of the provider's undated Nurse Supervisor Job description revealed:
*"The Nurse Supervisor is responsible for assisting in the development and implementation of patient care programs, policies, and procedures that describe how patients' needs for nursing care, treatment, and services are addressed, evaluated, and met."
*"Supervisors the provision of nursing care, treatment, and services on assigned shift or unit."
-"Insure [sp] all patient care activities are completed as required."
-"Directs administrative and clinical (nursing/interdisciplinary) activities for optimum patient care."
-"Assumes responsibility for nursing staff during assigned shift."

Review of the provider's undated Quality/Risk Director's job description revealed:
*"The Quality/Risk Director is responsible for an environment and culture that enables the hospital to fulfill its mission by meeting or exceeding goals, conveying the mission to all staff, facilitating staff accountability for performance, and motivating staff to improve performance."
*"This position managed, directs, and plans all aspects of Quality and Risk Management. The Director is responsible for hospital wide quality management program and works with hospital administration, departments, and the medical staff to monitor and evaluate the quality of the delivery of patient care services within the hospital. They will have access to all medical records for the hospital; will ensure proper compliance with regulatory agencies, accrediting bodies, and Home Office and hospital policies and procedures; and will work to develop, implement, and maintain quality assessment and improvement programs within the hospital."

Review of the provider's undated Chief Executive Officer's job description revealed:
*"The Chief Executive Officer is responsible for all day to day operations of the hospital. This position is accountable for planning, organizing, and directing the hospital to ensure quality patient care is provided and the financial integrity of the hospital is maintained. The CEO ensures compliance with applicable laws, regulations, policies, and procedures set forth by the Governing Board and Medical Staff, as well as Joint Commission standards."
*"The CEO is responsible for creating an environment and culture that enables the hospital to fulfill its mission by meeting or exceeding its goals, conveying the hospital mission to all staff, holding staff accountable for performance, motivating staff to improve performance, recognize and reward performance, and being responsible for the operations behind measurement, assessment, and improvement of hospital performance."

Based on observation, interview, record review, policy review, and review of complaint received by the South Dakota Department of Health (SD DOH) revealed the provider failed to ensure:
*Ongoing communication with all direct care staff had been completed to ensure treatment and care continued for a safe and effective discharge for two of two sampled patients (1 and 6).
*Follow-up and review had been completed for one of one sampled patient (1) after they had been discharged from the provider's care.
*Timely education had been completed for one of one sampled patient (6) and their representative to ensure her needs would have been met post discharge.
*The communication board in two of two sampled patient's (3 and 6) rooms had been kept up to date to ensure continuity of care occurred.
Findings include:

1. Review of the 8/18/22 complaint from Adult Protective Services (APS) received by the SD DOH revealed:
*Patient 1 had been receiving in-patient rehabilitation (rehab) services with the provider.
*She had been:
-Discharged from the provider and had been unable to care for herself or ambulate.
-Determined to be unsafe at home.
-Determined to be unable to perform household tasks such as toileting and cooking.

Review of patient 1's electronic medical record revealed she had:
*Been admitted to the facility for rehab on 8/6/22.
*Been discharged to home with home health services on 8/17/22.
*The following medical history:
-Left femur fracture with nail fixation.
-Lumbar stenosis and interbody fusion [an implanted device to prevent compression of spinal canal].
-Lumbar stenosis with neurogenic claudication [narrowing of the spinal canal of the lower back].
-Lymphedema secondary to breast carcinoma [fluid retention].
-Narcolepsy.
-Osteoporosis.
-Osteoarthritis in both knees.
-Hypertension.

Review of patients 1's 8/6/22 history and physical (H & P) documentation revealed she had been:
*Admitted for bilateral leg weakness.
*Unable to walk or transfer without assistance for the past two weeks.
*Receiving home health services prior to her admission.
*Noticeably weaker for the past two weeks and was unable to stand up or walk on her own.
*Wheelchair (w/c) bound for the two weeks prior to admission.

Review of patient 1's home health notes revealed:
*A registered nurse (RN) had arrived at her home on 8/18/22 to complete a home evaluation for home health care services.
*The RN had found the patient to:
-Take 25 minutes to ambulate to the restroom.
-Be unable to lift her lower legs/feet off the floor.
-Not have family around to help her twenty-four hours a day, seven days per week.
*The patient voiced a concern that she was not safe to be at home by herself.
*Home health services was unable to admit the patient because their assessment determined she was unsafe to be home alone.

Review of patient 1's 8/6/22 through 8/16/22 occupational therapy (OT) and physical therapy (PT) notes revealed:
*The patient's capabilities to perform activities of daily living tasks without assistance fluctuated from day-to-day and time of day.
*On 8/9/22:
-OT documented she needed partial assistance for performing after toilet hygiene.
-Toileting hygiene had been marked as partial/moderate assistance.
*On 8/10/22 she had been marked as "independent" with toileting hygiene.
*On 8/16/22:
-PT had documented all of her mobility goals to be "Supervision or touching assistance."
-Patient 1 had been determined to need partial assistance with putting on supportive shoe.
*On 8/16/22 at 9:30 a.m. she had been determined to need supervision or touch assistance for the following tasks:
-Car transfers.
-Transitioning from sitting to lying.
-Lying to sitting on side of the bed.
-Sitting to standing.
-Chair to bed transferring.
-Walking 10 feet.
-Walking 10 feet on an uneven surface.
-Barriers to safe discharge for PT were listed as "Time since onset, Unsafe home environment."
*On 8/16/22 at 11:43 PT had marked patient 1 independent (did not require supervision or touch assistance) for the following tasks on her discharge instructions:
-Transitioning from sitting to lying.
-Lying to sitting on side of the bed.
-Sitting to standing.
-Chair to bed transferring.
-Walking 10 feet.
-Walking 10 feet on an uneven surface.
-Walking 150 feet.
*She was discharged to home with home health services on 8/17/22.

Review of patient 1's 8/6/22 through 8/17/22 interdisciplinary plan of care (IPOC) revealed:
*She was at a high risk for falls.
*Her mobility status and goals had not been updated since the day of admission on 8/6/22.

Review of the provider's 8/10/22 and 8/17/22 team conference notes regarding patient 1 revealed:
*On 8/10/22 her team conference had been identified as an "initial" conference.
*Her risk factors had been identified as:
-Advanced Age.
-High fall risk.
-More than eight routine medications.
*On 8/17/22 her team conference had been identified as an "ongoing" conference.
-Rather than a pre-discharge conference.
-Physical therapy had not been documented to have attended this conference.

Review of 8/17/22 security camera footage of patient 1 revealed:
*Her daughter had pushed her outside in a w/c at 11:58 a.m.
*It took her approximately two minutes to walk five feet to get into the vehicle.
*She had been unable to lift her feet into the car.
*Staff had not been present to assist the patient and her daughter to ensure a safe transfer had occurred.

Phone interview on 8/22/22 at 9:53 a.m. with home health nurse V regarding patient 1 revealed:
*She had arrived at patient 1's home on 8/18/22 to complete the admission evaluation for the patient.
*When she arrived, she had found the patient to:
-Be unable to lift her legs off the ground.
-Take over 17 minutes to walk 100 ft.
-Not be able to care for herself.
-Be unsafe to be at home by herself.
*She did not have help at home to assist her with daily tasks.
-She was unable to complete the tasks without assistance.

Interview on 8/24/22 at 1:30 p.m. with patient 1's daughter revealed:
*She was disappointed with the lack of communication the provider had with her regarding her mother.
*When she came in to visit her mom, she was always sitting in her w/c with a seatbelt and seat alarms activated.
-She thought if her mom had to have those in place then why was she being sent home?
*She stated she had very little to no communication with the facility.
*Her mom was readmitted to the hospital the day after discharge due to not being able to care for herself at home.
*The provider had not reached out to her to check on her mom post-discharge.

2. Interview on 8/24/22 at 2:30 p.m. with medical director D revealed:
*They needed the interdisciplinary team (IDT)'s approval before discharging a patient.
*Regarding tracking readmission rates:
-Case managers complete a follow-up call to patients after discharge.
-He agreed they should have completed follow-up calls with physicians or primary care providers to ensure continuum of care.
-There should have been a better process in place to follow-up with patients after discharge.
*There should have been constant contact with patients' family members throughout their inpatient rehab stay.
*He expected staff to document their calls to patient's family members and include whether they answered or not.

Interview on 8/24/22 at 3:25 p.m. with OT L regarding patient 1 revealed:
*The patient was admitted at a supervision (eyes on) level for therapy.
*She walked out of the doors independently.
-He was unable to state whether she actually "walked" out of the doors.
*He had not specifically interacted with family.
*Care techs should be able to look in any patient's chart regarding the level of assistance they needed.
*They also used the white board in patient's rooms to write down:
-Type and how they transfer.
-Any specialized equipment they used.
-Toileting assistance.
*She was independent with toileting.
*The surveyor inquired why her initial evaluation appeared to be partially completed.
-He was not able to answer that question.
*She was unable to walk up or down steps.
-He was not aware the patient's laundry was in the basement.
-To his knowledge, that would not have been a barrier for her being discharged home.

Interview and record review on 8/24/22 at 3:50 p.m. with PT H revealed:
*The level of assistance and discharge plans were written on the white board in the patient's rooms.
*The direct care givers would have been expected to follow the directions provided on that board.
*Patients' discharge dates were determined at a case management level.
-It was not within her practice to determine whether a patient needed more days of therapy or not.
-She could have asked for more days of therapy for a patient.
*She recalled patient 1 required maximum assistance from staff when she arrived.
-At discharge, she was independent with everything.
*Case managers handle the follow-up process with discharge patients.
*Patient 1's laundry in the basement had not been brought to her attention.

Interview [date and time withheld due to anonymity] with anonymous staff member O revealed they:
*Had taken care of patient 1 frequently during her hospital stay.
*Were surprised to learn patient 1 had been discharged home with home health services.
-The RNTs were unaware what her discharge goal was but should have known it.
*Stated patient 1 was unable to reach behind and wipe herself after toileting.
*Confirmed patient 1 would have required a lot of assistance to go home on her own.
*Had not felt the management staff had communicated with the direct care givers regarding patient's current statuses and discharge goals and should have been.
*Found patient 1:
-Had a lot of trouble getting in and out of bed.
-Voiced to the staff members she would like to stay at the facility longer.
-Was scared to go home by herself.
*Thought patient 1 was discharging from the facility to an assisted living facility not home.
-At an assisted living facility, she would have received help. At home she would not have that type of assistance.
*Were not consistently informed of the discharge plans for the patients or follow-up from the IDT meetings and should have been for continuity of care.
*Confirmed communication was important to ensure quality of care and goals were maintained and/or met.

Interview on 8/24/22 at 4:26 p.m. with case manager (CM) K and director of case management F revealed they:
*Were unable to:
-Support how patient 1 was doing after being discharged to her home.
-Recall hearing from patient 1 after discharge.
*Had called the patient one time after she discharged, but no one answered.
-They did not try to call her emergency contact or the home health agency for further follow-up on her post-discharge status.
-There was no documentation to support when that call occurred.

Review of a patient 1's 8/18/22 case management note from CM K revealed:
*"Call from Center for Family Medicine [staff members name] stating that the home health nurse contacted them today for an appointment tomorrow for a Nursing Home referral. Per [staff member's name], per Home Health Nurse, '[patient's name] said she didn't feel safe at home. She didn't understand why she didn't stay longer in rehab.' Made aware team conference with goal objective met per patient and therapy/medical team. Voiced understanding."

Interview on 8/25/22 at 1:29 p.m. with director of case management F regarding the 8/18/22 case management K's note revealed:
*CM K was on vacation and was unable to be interviewed regarding the above note on patient 1.
*Case manager F stated, "She must have forgotten the note was in there."
*She confirmed the surveyors had asked specifically, about the status and update for patient 1 post discharge.

On 8/26/22 at 10:15 a.m. chief executive officer (CEO) A, chief nursing officer (CNO) B, and director of quality and risk C handed surveyors with an amended team conference form which stated PT was present and the "ongoing" conference had been changed to "predischarge."
*CEO A also handed surveyors a task sheet for patient 1 which stated she had been marked as "independent."
-However, this was three days before she had been discharged from the facility on 8/17/22.

3. Review of the provider's undated physical therapist job description revealed:
*"The Physical Therapist provides physical therapy treatment and patient care according to hospital, state, professional and federal regulations and guidelines. This position requires effective communication skills for working with patients, families, caregivers, and departmental and interdepartmental contacts; competency in physical therapy evaluation, assessment, care planning and treatment and task delegation and supervision of physical therapist assistants and technicians. The Physical Therapist creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient-centered treatment."

Review of the provider's undated occupational therapist job description revealed:
*"The Occupational Therapist provides occupational therapy treatment and patient care according to hospital, state, professional and federal regulations and guidelines. This position requires effective communication skills for working with patients, families, and caregivers, and departmental and interdepartmental contacts; competency in occupational therapy evaluation, assessment, care planning and treatment and task delegation and supervision of occupational therapist assistants and technicians. The Occupational Therapist creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient-centered treatment."



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4. Observation and interview on 8/23/22 at 9:35 a.m. with patient 6 revealed:
*Outside of her room there was a sign that stated what type of diet she had required.
-She was on a level 5 diet and her food should have been minced and moist.
-Her liquids were to have been mildly thick (level 2) and could have single ice chips.
*She was awake and sitting in a wheelchair (w/c) with a fall safety self-release belt around her waist.
-She had been at high risk for falls per the red sign attached to the entrance door frame.
*The over-the-bed table had been in front of her with a pitcher half full of thickened water.
*Both of her feet were off the floor and resting on foot pedals attached to the w/c.
*Her left arm was resting on a lap tray that had been attached to the w/c.
-She was not able to move left arm spontaneously and was moving it around with her right hand.
*She was alert and able to respond appropriately to questions.
-Her voice was soft and the responses were delayed.
*There was a white board on the wall with writing on it.
-A discharge date of 8/24/22 was written on it and her type of diet.
-No documentation to support where she was discharging to.
-No documentation on how much staff support she required for mobility, transfers, toileting, dressing, eating, and bathing.
*She recently had a stroke and was admitted for intensive therapy services to get stronger.
-Her discharge date was tomorrow, and she was going home with her boyfriend.

Review of patient 6's medical record revealed:
*On 6/25/22 she had an acute ischemic stroke resulting in left sided paralysis and neglect.
*From 6/25/22 through 7/30/22 she had been admitted to an acute care setting and then transferred to a specialty hospital for further therapy service, monitoring, and care.
-On 7/6/22 a feeding tube (tube placed in the stomach for nutritional support) was placed due to swallowing difficulties and the need for nutritional support.
*On 8/1/22 she was transferred to Encompass Health Rehab Hospital for intensive therapy services to further prepare her for discharge home with her significant other.
*Her admission diagnoses were: stroke, type 2 diabetes, hypertension, dysphagia with feeding tube, bilateral cataracts, acute kidney injury, bladder retention, and mood disorder.
*On admission she had orders for evaluations and treatments with physical therapy, occupational therapy, and speech therapy for three hours a day.
*On 8/2/22 she was ordered a level 5 dysphagia diet per speech therapy recommendations.
-Her food was to be minced, moist, and liquids mildly thick.
-She could have single ice chips for hydration and no straws.
*Speech therapy had attempted twice to upgrade her diet prior to discharging home.
-She was not able to upgrade to a higher level due to her reduced strength and tolerance for the amount of chewing it required.
*With her left sided paralysis, she had to be monitored for pocketing of pills and food on that side.
*All medications had to be crushed and placed in applesauce for safety from choking.
*On discharge she had remained on a dysphagia diet with her medications crushed and put in applesauce.
*Per the physician's progress notes dated 8/23/22:
-The tube feeding was to remain in place until she was seen by her physician post discharge.
-That appointment was scheduled for two days after her discharge on 8/26/22.
-At that appointment, the physician was to determine if there was a continued need for the feeding tube.
-The significant other would have been educated on how to flush the feeding tube with normal saline at that appointment.
*There was no documentation to support her significant other had been educated on how to:
-Prepare and administer her medications to ensure her safety from choking and pocketing.
-Flush the feeding tube to ensure it remained opened and unclogged until her physician appointment.
-Care for the feeding tube site to ensure it remained free from infection and patent.
*There was no documentation she had required her medications crushed prior to her stroke on 6/25/22.

Interview on 8/23/22 at 3:40 p.m. with patient 6 and her significant other revealed:
*She was discharging home on 8/24/22.
*He would be her primary care giver and was aware of her limitations from the stroke.
*The pharmacy department had just been there to review her medications with him.
-They had not provided any education on her medications prior to that day.
-The review consisted of the medication side effects, what they were taken for, how often she took them, and time of day.
*He was aware of the feeding tube and stated:
-"She's not using it, I think it's dormant."
-"We go to see her doctor in two days and they'll let us know if it's coming out or not."
-"No, no one has showed me how to take care of it."
-"Are they supposed to?"
*She stated: "They flush it with water."
*He had not been aware the feeding tube required:
-Flushing to ensure it remained patent and free from clogging.
-Monitoring and cleansing of the site to ensure it remained free from infection and irritation.

Observation on 8/23/22 at 4:00 p.m. of patient 6's significant other at the nurse's station revealed:
*He had asked the supervisor who he should talk to about taking care of her feeding tube.
*The supervisor directed him to talk to her case manager (CM) F.

Interview [date and time withheld due to anonymity] with anonymous staff member P revealed they:
*Took care of patient 6 and was surprised she was going home with her boyfriend.
*Stated: "She needs help with about everything."
*Would have used the white board in the patient's rooms to guide them with care for the patients.
*Stated: "The problem is, they are not always kept up-to-date or have all the information we need."
*Confirmed patient 6's white board should have had information on how much assistance she needed with transfers, toileting, eating, and bathing and it did not.
*Stated:
-"Sometimes she needs two of us to help her."
-"Would be nice to know what to do or how much we are supposed to help her since she's going home."
-"Most times we know nothing about their discharge, we really should. It can change how we work with them."

Interview [date and time withheld due to anonymity] with anonymous staff member Q revealed they:
*Did staff rounding on all the patients at 5:30 a.m. with the incoming and outgoing staff.
*Used the white board in the patient's rooms to help guide them with care for the patients.
-Those boards were not always kept up-to-date with the patient's current status.
*Had not felt there was cohesive communication amongst all the disciplines to make sure the care for the patients was consistent amongst them all.
*Had worked with patient 6 and was not aware of what education had been provided to the significant other or patient to ensure a safe transition with care occurred.
*Stated:
-"Her liquids are thickened, her meds [medication] have to be crushed, and she needs a lot of help."
-"We really should know where they are at with patient's discharges and education."
-"That way we can help educate the patient or care giver and try to meet their goals to."
-"Most of the time we really do not know these things and should."

Observation on 8/24/22 at 8:40 a.m. of patient 6's white board in her room revealed:
*It had been updated to support how to assist her with a transfer.
*How much assistance she required with transfers.
*She was discharging home today.

Interview on 8/24/22 at 8:30 a.m. with speech therapist (ST) U revealed:
*She would have worked with patient's memory capabilities with medication administration.
*That education involved:
-Capability of reading medication labels properly.
-Understanding doctors orders for the meds.
*Nursing would work with the patients on knowing the meds, timeliness of taking the meds, and how to prepare them.

Interview on 8/24/22 at 8:50 a.m. with RN R revealed:
*Medication administration was a part of the discharge process and patient education.
*They would have received direction on when to start that education from the nurse supervisor or case manager.
-There had been no set timeframe for when that would have started.
*The patient's medication education would have consisted of injections, patches, and insulin administration.
*She stated:
-"No, the patient wouldn't have to ask for their meds or know the time to take them."
-"Speech therapy works on more of those specifics with their med education."
-"We don't go over the meds with them."

Interview on 8/24/22 at 11:40 a.m. with RN I and again on 8/25/22 at 2:30 p.m. regarding patient 6 revealed:
*The patient had already discharged to home with her caregiver.
*She had:
-Not reviewed the required care for her feeding tube as he had received education on that the day before.
-Reviewed the meds she was going home with and educated him on how to crush them.
-Given him the crusher to take with them.
*She stated: "Typically we do education on crushing and preparing meds during their stay. Not the last day."
*Pharmacy would have reviewed the meds with them the day before discharge.
*The family does medication administration training with the therapy department.
*On the day of discharge, the nurse would have reviewed with the patient and caregiver what they had been educated on for med administration by the therapy staff. Such as:
-How to setup the meds.
-Ensure they know how to open the bottles.
-Time-of-day on the meds and the list provided on the discharge sheet.
*She was not sure what education was required for the patients and their caregivers on injections, insulin administration, and patches.
-She would have to follow up with the nurse manager on that process.
*The education she had provided to the caregiver on crushing the patient's meds was not documented and should have been.

Review of patient 6's discharge instructions and education for 8/24/22 revealed:
*The discharging nurse, RN I, had reviewed the following information with the patient and care giver:
-Diet.
-Referrals made to home health aide and nursing, outpatient physical, occupational, and speech therapies.
-Case managers discharge instructions for the above referrals and medical equipment she would need at home.
-Signs and symptoms for when to seek emergency services.
-Her medical doctor follow-up appointment scheduled for 8/26/22.
-All three therapies discharge recommendations.
*She further reviewed:
-New meds started during her stay and those that had been updated.
-The patient required supervision and setup help with her medications.
-The recommendation for a pill organizer as she could not open the pill bottles on her own.
-That she took all her pills orally.
*There was no documentation to support:
-The patient and caregiver had been educated on the care her feeding tube required until her doctor appointment on 8/26/22.
-She had required her meds to be crushed and administered in applesauce to ensure aspiration and choking would not have occurred.
-The caregiver had been educated on how to prepare and administer her meds.

Review of patient 6's daily staff documentation from 8/1/22 through 8/24/22 revealed no documentation to support the patient and caregiver had received education on:
*Medication setup, organization, and preparation.
*Food preparation to include thickening of liquids to ensure she was free from choking and aspiration.
*Preventative maintenance and care of her feeding tube post discharge and until her doctor appointment on 8/26/22.

Review of patient 6's daily therapy documentation from 8/1/22 through 8/23/22 revealed:
*On 8/15/22 the patient's primary care giver had received education on how to assist her with:
-Transfers and mobility.
-Toileting.
-Dressing.
-Bathing. Bed baths were recommended until the care giver's bathroom could be remodeled to support a walk-in shower.
*No documentation to support the patient and caregiver had received education on:
-Medication setup, organization, and preparation.
-Food preparation to include thickening of liquids to ensure she was free from choking and aspiration.
-Preventative maintenance and care of her feeding tube post discharge and until her doctor appointment on 8/26/22.

Interview on 8/24/22 at 4:25 p.m. with CMs F and K regarding patient 6 revealed:
*They were not responsible for the communication between therapy, case management, and nursing services.
*The nursing department would have attended the weekly team conference meetings and were able to hear the progress on each patient.
*It was not their responsibility to make sure the nurses and care techs were kept informed of the patients current therapy status, capabilities, and discharge status
*What the nurses reported on during the team conference meetings and educated the direct caregivers after the meeting, was a question for the chief nursing officer (CNO) B.
*Medication education and administration was not a specific task of theirs.
-Pharmacy and nursing were responsible for educating and preparing the patient and/or caregiver on their medications.
-They could not speak to the nursing or pharmacy process with this task.

Interview on 8/25/22 at 4:20 p.m. with nurse manager E regarding patient 6 and/or caregiver medication administration education revealed:
*The OT department would have educated the patients and their caregivers on the setup and organization for the meds.
*The pharmacy department would have completed a med review with them prior to discharge.
*Nursing would have been responsible for educating the patients and their caregivers on injections, insulin administration, and patches if that was a new process for them.
*Education should:
-Have been initiated as soon as the patient's discharge status and destination were determined.
-Not have been initiated the day prior or day of discharge.
*She would have expected the nursing to document when any type of education had been provided.

Continued interview on 8/25/22 at 4:40 p.m. with nurse manager E revealed:
*The direct caregivers would have used the white boards in the patient's rooms to guide them with their care.
*She would have expected the white boards to be kept up-to-date on the patient's status.
-It was everybody's responsibility to ensure they were updated and in a timely manner.
*She was not aware the care techs had not been kept informed on the status and care required for the patients.
-She agreed they should have been.

Interview on 8/25/22 at 5:00 p.m. with CEO A, CNO B, and director of quality and risk (C) revealed:
*When asked how direct care staff received current and changed information on a patient's status.
-They stated the direct care staff could have looked in their charts.
*When asked how direct care staff are kept informed of a patient's discharge status:
-CEO A had inquired and asked the surveyors, if non-licensed staff should have known more than licensed staff?
*When surveyors inquired about patient's profiles and IPOCs not being loaded into the care techs' IPADs:
-They stated the staff can go to a computer at any time to see that information.
*The purpose of the team conference meetings was to discuss the patient's barriers to discharge.
-Surveyors brought up patients who are fluid overloaded could be tired and not able to participate as well in therapy.
-CEO A, "well, did they miss any minutes?" and refused to answer the surveyors' questions regarding barriers to discharge.
*They would have expected the staff to document any patient non-compliance and if they had not followed physician orders.
*CNO B stated there was not a hard answer on how staff were expected to follow the plan of care.
*She stated:
"They have access to the patient's charts and can check on any computer."
"We would use our critical thinking skills."
*The public health surveyor advisor ended the interview to ensure professionalism was maintained and a hostile environment would not occur..
-CEO A and CNO B were argumentative, answered surveyors' questions with questions, and were defensive during the entire interview.
-All areas of concern identified with nursing services and discharge planning could not be reviewed and addressed with the management staff due to the negative and argumentative nature of the interview.

5. Review of the provider's undated Readmission Prevention Playbook revealed:
*The pillars of readmission prevention were:
-Medication management.
-Patient centered health records.
-Follow-up with providers and specialists.
-Patient knowledge regarding red flags.
*Plan for discharge as early in the day as possible (by 11 a.m.).
-Discharge by 11 a.m. (in preparation of same day home health start of care).
*Post-Discharge phase:
-"Communication to ensure successful implementation of the discharge plan for High Risk Patients does not stop at discharge. Phone contact in the days following discharge provides an opportunity for the patient to ask questions about their discharge plan and also allows the case management staff to verify the discharge status, address any confusion related to follow-up appointments, outstanding diagnostic testing, medications, diet, activity, etc. and to reinforce the instructions given prior to discharge. This may also help reduce patient/patient representative anxiety as they manage post-discharge care needs."
*Post-Discharge calls to patients who are not deemed as High Risk, on the High Risk Patients custom list, are performed by the CMA [certified case manager] and documented in the Post-Discharge Outreach SharePoint site[.]
-The CMA will compare the Callback List on the Post-Discharge Outreach SharePoint site with the High Risk Patients list in ACE IT [provider's electronic charting system].

Review of the provider's 6/7/22 Discharge Planning policy revealed:
*"Discharge planning is a patient-centered, interdisciplinary process that involves the patient, caregiver(s), support person(s), authorized representative(s), physicians, hospital clinical staff, and case managers. The discharge planning process begins during the preadmission screening and continues throughout the inpatient rehabilitation stay. It is re-evaluated and adjusted as the patient's condition, functional status and clinical care needs change throughout the stay. The discharge plan is individualized and supports patient independence and self-management. The goal of the discharge planning process is to ensure an effective transitio