HospitalInspections.org

Based on interview, record review, policy review, event reporting review, root cause analysis (RCA) review, and job description review, the hospital failed to meet the Conditions of Participation (CoP) for the Governing Body (GB) when it failed to ensure:
*The safety of all patients after one of one sampled patient (10) had reported inappropriate touching by two of two (F and M) rehabilitation nurse technicians (RNT).
*The reported incident had been fully investigated to include a physical examination and interviews with other patients.
*Education had been provided to one of two (M) RNT's after the reported incident.
*One of five discharged patients (10):
-Had an effective transition from the hospital to post-discharge care to reduce a hospital readmission.
-Discharge plans had been consistent with the patients goals.
-Focused on the patients goals and treatment preferences.
-Included the caregiver support person in discharge planning.
-Re-evaluation of the patients condition to identify changes for modification of the discharge planning.
-Assistance for the patient and representative in selecting a post-acute care provider by using and sharing data.
*The discharge planning process had been assessed on a regular basis.
Findings include:

1. Review of a 8/3/21 healthcare online report from the provider to the South Dakota Department of Health revealed:
*A report of inappropriate touching from patient 10 by two RNTs.
*The initial interviews with patient 10 and staff.
*A final conclusionary summary of the provider's investigation.
*The investigation had not included:
-If patient 10 had been examined by a physician.
-What time RNTs F and M had been placed on suspension after the allegation.
-How other patients safety had been maintained.

2. Review of resident 10's medical record revealed she had been discharged on 8/3/21 with home health services.

Interview on 8/12/21 at 1:30 p.m. with patient 10's family members revealed:
*They were involved with her placement and care at the rehabilitation hospital.
*She had been given three options for her discharge plan from case manager C:
-Have a family member or someone help her in her home.
-Have home health services arrange to assist her at home as it was already set up for handicap accessibility.
-Discharge to a skilled nursing facility, but chemotherapy treatments would not be available while there.
*The case manager recommended she discharge to a skilled nursing facility.
*They agreed to have home health services set-up.
*They believed she would have agreed to discharge to a skilled nursing facility if she could have had chemotherapy treatments continue.
*She had been discharged to her home on 8/3/21.
*Her family had transported her in a private vehicle and it had been difficult to transfer her from the wheelchair to the vehicle.
*It took three people to get her into the private vehicle.
*Her significant other lived with her but was on hospice services and was unable to assist in her care.
*They were concerned about her condition so a family member stayed overnight to ensure she did not fall.
*She had not improved during the night.
*It had taken three people to assist her into the restroom the morning of 8/4/21.
*She was not able to get off of the toilet without their assistance.
*The home health nurse was called and agreed to come earlier than scheduled.
-She assisted in making arrangements to transfer patient 10 to the hospital.
*The primary physician was called and advised them to send her to the hospital.
*An ambulance was called and took her to the hospital.
*She was admitted to swing bed care at the hospital until a skilled nursing facility bed was available.
*They thought she should not have left the rehabilitation hospital because she was not strong enough and she had been discharged too early.

Interview on 8/12/21 at 2:25 p.m. with home health RN O revealed:
*She had been assigned to work with patient 10.
*She worked with patient 10's significant other who was on hospice and was familiar with her.
*Family members called her to see if she could come earlier than scheduled due to her weak condition.
*Once she arrived to the home she discovered patient 10 was unable to walk.
*She needed more care than home health could provide such as a swing bed unit or skilled nursing care.
*The family asked her to assist in placement.
*She was able to assist in arrangements for her placement in the swing bed unit at the hospital.
*She felt the discharge from the rehabilitation hospital had been "odd and unorganized."
*The family had not been aware of appointments and changes to her medications.

3. Review of the provider's 5/18/20 Sentinel Events policy revealed:
*"The hospital's Governing Body is responsible for the oversight of the reporting, analysis, and prevention of Sentinel Events and for consistent and effective efforts to carry out this responsibility including:
-Reviewing this policy annually to determine whether, considering the setting and population served, quality and risk trending data and state-specific requirements, the definition of Sentinel Events should be expanded.
-Tracking all adverse events, no-harm events, near misses/good catches and unsafe conditions, in addition to Sentinel Events and using the information as opportunities to prevent harm.
-Training of all hospital staff annually regarding the events considered to be Sentinel Events and the site-specific process for reporting.
-Arranging for the review of the action plan of each RCA [Root Cause Analysis] and modified RCA by the appropriate staff/committee."

Review of the provider's 5/18/20 Education Plan policy revealed:
*"The Governing Body of (provider's name) delegates the authority and responsibility of the education plan to the Human Resources Director with input from the Leadership Team and Quality Council."
*"Program outcomes, staff input, and performance improvement recommendations will be utilized in the development of a plan to deliver programs assuring the highest obtainable level of understanding and knowledge to continually improve clinical performance."
*"The plan is to be implemented through joint responsibility of the Human Resource Director and the Department Leaders."

Review of the provider's February 18, 2021 Discharge Planning Policy revealed:
*"Informed choice:
-Once the physician and interdisciplinary care team determine the anticipated discharge plan, the case manager assists the patient/patient representative in selecting a post-discharge care provider by providing a list of providers for the applicable post-discharge setting.
-The case manager informs the patient of their freedom to choose a post-discharge care provider.
-The case manager uses quality data and resource use measures to assist the patient is [in] selecting a provider and may shares [share] the data with the patient/patient representative.
-For patients who require an admission to a facility-based provider after discharge; SNF [skilled nursing facility], LTACH [long-term acute-care hospital], another IRF [in-patient rehabilitation facility], or inpatient Hospice facility, the case manager provides a list of Medicare participating facilities that serve the geographic area requested by the patient.
-For patients who require home health services or home hospice services, the case manager provides a list of Medicare certified Home Healthcare or Hospice agencies that have requested to be on the hospital's list and which serve the geographic area where the patient will be discharged.
-If the patient requests a specific HHA [home health agency], SNF, or LTACH, the case manager attempts to arrange post-hospital care to meet that request. If the case manager is unable to secure the requested provider arrangement (i.e. there is no bed available or the HHA cannot provide the services needed) the reason the request could not be fulfilled is explained to the patient and a list of alternative facilities are provided.
-If the patient does not have a provider preference, the case manager may make a recommendation from the provider list that provides high quality, efficient care that best meets the needs of the patient.
-If the case manager provides a printed provider list to the patient/patient representative, the list will comply with the requirements set forth in the Medicare Requirements for Discharge Planning for Hospitals."
*"Discharge Planning Process and Documentation:
-The case manager documents the anticipated discharge plan throughout the stay on initial evaluation, during team conferences, and during the days leading up to discharge.
-The case manager reviews IRF Discharge Criteria and assesses patient's readiness for discharge (attached).
-The case manager documents the review of or provision of post-discharge provider lists to the patient/patient representative.
-The case manager documents if quality data and resource data was used and shared with the patient during the discharge planning process.
-Case manager discusses the results of the interdisciplinary team's evaluations and recommendations for post-discharge care with the patient/patient representative.
-The case manager researches and discusses applicable community resource options and services and assesses the patient's access to those resources.
-The case manager documents in the medical record their efforts to connect patients with community-based services.
-The case manager, in collaboration with the physician and interdisciplinary care team, helps to determine the most appropriate post-discharge care setting and durable medical equipment to meet the patient's needs."
*"Review of the Discharge Planning Process:
-The hospital assesses the effectiveness of the discharge planning process on a regular basis. The assessment process includes a review of a representative sample of discharge plans in closed medical records to determine whether the discharge plan was effective and responsive to the patient's post-discharge needs. Based on the findings and identified trends, the discharge planning process may be modified.
-The Discharge Planning Plan is reviewed and updated annually and stored on the Hospital Policies on Demand site."

Review of the provider's 1/1/20 Chief Executive Officer (CEO) job description revealed:
*The CEO was responsible for all day-to-day operations of the hospital. This position was accountable for planning, organizing, and directing the hospital to ensure quality patient care was provided.
*The CEO ensured compliance with applicable laws and regulations as well as all policies and procedures set forth by the governing board and medical staff, and those required by joint commission standards.

Review of the provider's undated Chief Nursing Officer (CNO) job description revealed:
*The CNO was responsible for the development and implementation of the plans for providing nursing care, treatment, and services.
*Determines the types and numbers of nursing personnel necessary to provide nursing care.
*Develops patient care programs, policies, and procedures to include:
-"Describes how patients' needs for nursing care, treatment, and services are assessed, evaluated, and met for the programs, policies, and procedures developed."

Refer to A115, A145, and A799.

Based on interview, record review, policy review, job description review, healthcare online report, the provider failed to ensure:
*The safety of all patients after one of one sampled patient (10) had made an allegation of abuse by two of two (F and M) rehabilitation nurse technician (RNT).
*The incident had been fully investigated to include a physical examination of patient 10, interviews with other patients, and interviews with potential witnesses.
*Education had been provided to one of two (M) RNT's after the alleged incident.
Findings include:

Surveyor: 26632
1. Review of a 8/3/21 submitted online adverse outcome report to the South Dakota Department of Health revealed:*A report of inappropriate touching from patient 10 by RNTs F and M.
*The initial interviews with patient 10 and staff.
*A final conclusionary summary of the provider's investigation.
*The investigation had not included:
-If patient 10 had been examined by a physician.
-What time RNTs F and M had been placed on suspension after the allegation.
-How other patients safety had been maintained.

Surveyor: 42477
Interview on 8/11/21 at 2:48 p.m. with quality and risk director H revealed:
*There were not cameras in the hallways of the facility.
-Therefore they had not able to review who came in and out of patient 10's room.
*They had not interviewed other patients.
*They had not interviewed other technicians.

Interview on 8/12/21 at 10:05 a.m. with rehab nurse tech (RNT) F revealed:
*He had:
-Worked in the facility for a month.
-Walked into patient 10's room the morning of 8/3/21 to obtain vital signs.
-RNT M in patient 10's room when he entered.
*RNT M had just finished helping the patient in the bathroom.
*RNT F stated RNT M was standing at the foot of the bed.
*Patient 10 became upset and told them:
-She knew what they were up to and wanted them to leave.
*He and RNT M had left patient 10's room.
*Patient 10 had not appeared to be confused, and he had not known her to be confused.

Surveyor: 41088
Interview on 8/12/21 at 1:30 p.m. with patient 10's family members revealed:
*After she had been discharged from the rehabilitation hospital and was being transported home she told them she had been molested by two male staff at the hospital.
*She was crying and very upset.
*She did not want to return to the hospital even though she had felt weak and family thought she had not been ready to discharge home.
*The family took her home as she wished.
*Due to her continued anxiety from the event at the hospital they had arranged for her to have counseling services.

Interview on 8/12/21 at 1:45 p.m. with home health Registered Nurse (RN) O revealed:
*Patient 10 had informed her she had been molested by two male staff at the rehabilitation hospital during her stay.
*She had no reason to believe the information was not true.
*Resident 10's conversation had been clear and without confusion.
*She suggested the familiy report the information to the rehabilitation hospital and to the South Dakota Department of Health.

Interview on 8/12/21 at 2:48 p.m. with respiratory therapist (RT) J regarding patient 10 revealed:
*She had worked with the patient almost everyday.
*She would help patient 10 with her inhaler and continuous positive airway pressure (CPAP) machine.
*On 8/3/21 she had entered the patient's room and she was hysterical and very tearful.
*The patient informed her she had experienced unwanted sexual contact from two male staff.
-RNT M had rubbed her back with his genitals and had touched her vagina and clitoris inappropriately when doing personal cares.
-RNT F had been the lookout for RNT M.
*RT J went and told the charge RN K.
*RT J stated she had never seen patient 10 upset like this before.

Surveyor: 42477
Interview on 8/12/21 at 3:00 p.m. with RN K revealed:
*RT J had called her down to patient 10's room.
*Patient 10 was crying when she had entered the room.
*Patient 10 told RN K she was not sure who she could trust.
*RN K stated this occurred at about 7:30 a.m.
*Patient 10 informed RN K:
-Unwanted sexual contact began on day one in the facility.
-It involved RNT M and RNT F.
-RNT M rubbed her back with his genitals.
-RNT M had penetrated her vaginally with his fingers and touched her clitoris.
-RNT F had performed look out while this happened.
*RN K had informed RNT M and RNT F to avoid any further contact with patient 10.
*RN K stated she had never observed any concerning behavior from RNT M or RNT F before.
*Doctor of osteopathic medicine (DO) P did not perform a physical exam on patient 10.

Interview with chief nursing officer (CNO) E revealed:
*Surveyors asked what time RNT M and RNT F were clocked out on the day of the allegiations.
-CNO E stated they clocked out at 6:02 p.m. and 5:58 p.m..
-They did not continue working with patient 10 but they did work with other female patients.

Review of facility 8/3/21 facility census revealed:
*They had 32 patients in the building that day.
-17 of those patients were females.
-15 of those patients were males.

Surveyor: 41088
Review of the provider's June 7, 2021 Allegations of Abuse/Neglect policy revealed:
*"Responsibility: Hospital staff will take all necessary steps to ensure that patients are kept safe from abuse/neglect and that allegations of abuse/neglect by employees or visitors are investigated promptly, thoroughly, and reported to the proper authorities as necessary."
*"Policy: The immediate response of staff will be guided by whether there has been a witnessed/confirmed act of abuse/neglect or whether there have been reports or suspicions of abuse/neglect that have not been witnessed/confirmed. All clinical and non-clinical staff must be trained on how to report substantiated/suspected abuse/neglect."
*"Un-witnessed report of abuse:
-1. Take immediate action to protect the patient from harm.
-2. Unit staff must contact their supervisor and/or a supervisor on duty immediately upon notification of allegation/findings of any form of abuse/neglect.
-3. The patient must be:
--A. Examined immediately for injury.
--B. Treated, if necessary.
--C. Secured from harm by taking any additional necessary actions to ensure the patient's safety and welfare, including, but not limited to
---i. Moving the patient to another unit.
---ii. Reassigning staff and/or suspending accused staff pending investigation.
---iii. Restricting visits from alleged abusers.
-4. The supervisor must immediately notify the hospital CEO [chief executive officer]/CNO [chief nursing officer]/designee who will promptly contact Home Office Risk Management.
-5. In the event that staff can confirm abuse has occurred, notification to the appropriate law enforcement, state and licensure agencies will be determined on a case by case basis after consultation with Home Office Risk Management.
-6. In the event that staff cannot confirm abuse has occurred, notification to the appropriate law enforcement, state and licensure agencies will be determined on a case by case basis after consultation with Home Office Risk Management."
*"Subsequent notifications:
-For all acts of abuse/alleged acts of abuse/neglect, the hospital CEO/CNO/designee must contact the following people, as soon as possible after receiving notification:
--1. The hospital Risk Manager and Human Resources Director (when allegations involve an employee).
--2. The attending physician to discuss options relative to physical examination.
--3. Home Office Risk Management (if not already notified) and Home Office Human Resources (when allegations involve an employee).
--4. The legal guardian/responsible party of a minor or vulnerable adult."
*"Investigation Procedures:
-The investigation should proceed according to the Checklist for Investigation and Evaluation of Reports of Abuse/Neglect Ocurring [occurring] Within the Hospital Setting.
-The investigation shall include, but is not limited to:
--1. Interview with person reporting the incident.
--2. Interview with alleged victim.
--3. Review of medical record.
--4. Interview of all pertinent staff that may have knowledge of the events surrounding the alleged incident (to include individual alleged to have abused/neglected the patient, if identified).
--5. Any disciplinary action taken regarding accused staff must be reviewed prior to implementation with the Regional Human Resource Director and Home Office Human Resources."
*"Documentation:
-1. Allegations of abuse/neglect are pertinent to assessment/treatment decisions and should be reflected as reported in the medical record.
-2. Physical assessment findings by nursing staff and the physical should be documented in the medical record.
-3. An RL Solutions Safety/Security event report will be completed and documentation related to the investigation will be attached to that report.
-4. Investigation documentation involving employees should be recorded and maintained separate from the employee's personnel file. Copies of investigation document should not be provided to employees."

Surveyor: 26632
Review of the provider's 1/1/20 Chief Executive Officer (CEO) job description revealed:
*The CEO was responsible for all day-to-day operations of the hospital. This position was accountable for planning, organizing, and directing the hospital to ensure quality patient care was provided.
*The CEO ensured compliance with applicable laws and regulations as well as all policies and procedures set forth by the governing board and medical staff, and those required by joint commission standards.

Review of the provider's undated Chief Nursing Officer (CNO) job description revealed:
*The CNO was responsible for the development and implementation of the plans for providing nursing care, treatment, and services.
*Determines the types and numbers of nursing personnel necessary to provide nursing care.
*Develops patient care programs, policies, and procedures to include:
-"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 1/1/20 Quality/Risk Director job description revealed:
*"Communicates and collaborates with other departments to coordinate care and promptly resolve customer concerns or complaints as outline in the HealthSouth Corporate Patient Complaint/grievance policy."
*"Coordinates all RCA [root cause analysis]/sentinel event report development and reporting to local, state, federal and accreditation agencies related to sentinel events and mortality as required by local/state/federal jurisdiction and/or accreditation agencies."
*"Oversees risk management activities including completion of incident reports, notice of potential claims, corrective action planning and incident reporting to Corporate Risk Manager."
*"Oversees complaint process including complaint investigation; verbal and written complaint follow-up; corrective action planning; and maintenance of complaint log. Ensures verbal/written follow-up occurs within required timeframe and in accord with Corporate Risk Management policy."




41088




26632

42477




26632

Based on interview, record review, policy review, and job description review, the provider failed to ensure:
*One of five discharged patients (10):
-Had an effective transition from the hospital to post-discharge care to reduce a hospital readmission.
-Discharge plans were consistent and focused on the patients goals and treatment preferences.
-Focused on the patients goals and treatment preferences.
-Included the patient's support person/representative in discharge planning.
-Re-evaluation of patient 10's condition to identify changes for modification of the discharge planning.
-Assistance had been provided for the patient and support person/representative in selecting a post-acute care provider by using and sharing data.
*Assessment of the discharge planning process on a regular basis.
Findings include:

Surveyor: 42477
1. Review of doctor of osteopathic medicine (DO) P's 8/4/21 signed Discharge (DC) Info/Summary report for patient 10 revealed:
*Patient 10 was medically stable for discharge.
*She was discharged home with home health in stable condition.
*Chemotherapy was currently on hold and patient wanted to reinitiate chemotherapy after leaving the facility.
*She was admitted to the facility for low back pain that radiated down both legs and caused weakness in her legs.
*She received physician visits three times per week.
*Occupational therapy (OT) and physical therapy (PT) services were provided.
*She had a urinary tract infection (UTI) and had been treated.
*She was one to two person assist when she arrived at the facility.
*According to the report upon discharge on 8/3/21 she was evaluated needed the following assistance:
-Supervision for lower body dressing.
-Set up or clean-up assistance for taking footwear on and off.
-Supervision or touching assistance for toileting hygiene.
-Set up or cleanup assistance for upper body dressing.
-Supervision or touching assistance for toilet transfers.
-Set up or clean up assistance for chair to bed transfers.
-Supervision or touching assistance for moving from lying to sitting position.
-Supervision or touching assistance for rolling from left to right.
-Partial or Moderate assistance for walking 50 feet with two turns.
-Partial or Moderate assistance for walking 10 feet.

Review of patient 10's Case Management notes revealed:
*On 7/18/21 notes included:
-She was expected to discharge with family or relatives.
-Length of stay was anticipated to be one to two weeks.
-Patient 10's goal was to be strong enough to resume chemotherapy.

*On 7/23/21 CM director G documented :
-"Met with patient at the bedside and discussed team conference update from yesterday. Discussed that a discharge plan has not be determined yet at this time. Discussed that returning home by herself at this time does not appear to be a feasible option. Discussed that her SO [significant other] [significant other's name] is at home on hospice and is unable to assist her with any functional tasks. Discussed at length going home with home health, potential private duty nursing services, ALF [assisted living facility], home with family, skilled nursing home etc. Discussed when she would be restarting chemotherapy and that this may be affected based on her discharge destination..."

*On 7/29/21 CM C documented:
-"Met with patient in her room. Discussed team conference and discharge plan. Discussed option of ALF, patient does not feel that this is affordable. Discussed SNF [skilled nursing facility]. Patient would like to continue with cancer treatment, eliminating SNF option. Discussed option of returning home with home health. Patient would like to return home but will first discuss it with her significant other, [SO's name]..."

*On 8/3/21 CM C documented:
-"Message received from patient son, [son's name]. Returned call to [son's name]. [son's name] stated that he does not feel that his mom is ready to be at home. Discussed with [son's name] that we recommended further level of care but patient was insistent that she continue chemotherapy and would not be able to do that at a skilled nursing facility..."
*Patient 10's primary care physician (PCP) contacted the case managers on 8/4/21 inquiring about discharge and stated:
-Patient 10 and family decided to go to a nursing home.
-PCP was going to purse nursing home placement for patient 10.

Review of patient 10's team conference notes revealed:
*She had a team conference on 7/21/21 which included case management (CM), OT, PT, Speech therapy, DO P, dietician, and registered nurse (RN).
The conference completed on 7/21/21 stated:
-Discharge plan was to be determined.
-Chemotherapy was on hold right now due to weakness.
-Her physical function was dependent on the pain she was experiencing at the time.
-Lived with significant other who was on hospice care and unable to provide assistance.
-Patient 10's goal was listed as: "get strong enough to return home and restart chemotherapy, be able to go to the bathroom by myself."
-Anticipated discharge plan was listed as Home/community with home health services.

*She had another team conference on 7/28/21 which included: PT, OT, CMs, RN, speech therapy, physician, and dietician:
-She was listed to have no medical or mental barriers.
-She needed variable assistance for transfers and ambulating 40 ft.
-She had no support at home.
-Anticipated discharge plan was home/community with home health services.

Interview on 8/12/21 at 9:00 a.m. with CM C regarding patient 10 revealed:
*She had been in the facility for 17 days.
*She had refused to go to a nursing home because she wanted to resume chemotherapy.
*CM C had stated nursing homes do not accept patients that need outpatient chemotherapy.
*She did not call any nursing homes to inquire about accepting patient 10.

Interview on 8/12/21 at 10:41 a.m. with CM director G revealed:
*They did not have a formal auditing process for their discharged patients.
*She was involved in some way in all of the discharges.
*From her experience nursing homes do not accept chemotherapy patients.
*They did not call any nursing homes to inquire about accepting patient 10.

Surveyor: 41088
Interview on 8/12/21 at 1:30 p.m. with patient 10's two sons revealed:
*They were involved with her placement and care at the rehabilitation hospital.
*She had been given three options for her discharge plan from case manager C:
-Have a family member or someone help her in her home.
-Have home health services arrange to assist her at home as it was already set up for handicap accessibility.
-Discharge to a skilled nursing facility, but chemotherapy treatments would not be available while there.
*The case manager had recommended she discharge to a skilled nursing facility.
*They agreed to have home health services set-up.
*They believed she would have agreed to discharge to a skilled nursing facility if she could have had chemotherapy treatments continue.
*She had been discharged to her home on 8/3/21.
*Her family had transported her in a private vehicle and it had been difficult to transfer her from the wheelchair to the vehicle.
*It took three people to get her into the private vehicle.
*Her significant other lived with her but was on hospice services and was unable to assist in her care.
*They were concerned about her condition so a family member stayed overnight to ensure she did not fall.
*She had not improved during the night.
*It had taken three people to assist her into the restroom the morning of 8/4/21.
*She was not able to get off of the toilet without their assistance.
*The home health nurse was called and agreed to come earlier than scheduled.
-She assisted in making arrangements to transfer patient 10 to the hospital.
*The primary physician was called and advised them to send her to the hospital.
*An ambulance was called and took her to the hospital.
*She was admitted to swing bed care at the hospital until a skilled nursing facility bed was available.
*They thought she should not have left the rehabilitation hospital because she was not strong enough and she had been discharged too early.

Interview on 8/12/21 at 2:25 p.m. with home health RN O revealed:
*She had been assigned to work with patient 10.
*She worked with patient 10's significant other who was on hospice and was familiar with her.
*Family members called her to see if she could come earlier than scheduled due to the patient's weak condition.
*Once she arrived to the home she discovered patient 10 was unable to walk.
*She needed more care than home health could provide such as a swing bed unit or skilled nursing care.
*The family asked her to assist in placement.
*She was able to assist in arrangements for her placement in the swing bed unit at the hospital.
*She felt the discharge from the rehabilitation hospital had been "odd and unorganized."
*The family had not been aware of appointments and changes to her medications.

Review of the provider's February 18, 2021 Discharge Planning Policy revealed:
*"Informed choice:
-Once the physician and interdisciplinary care team determine the anticipated discharge plan, the case manager assists the patient/patient representative in selecting a post-discharge care provider by providing a list of providers for the applicable post-discharge setting.
-The case manager informs the patient of their freedom to choose a post-discharge care provider.
-The case manager uses quality data and resource use measures to assist the patient is [in] selecting a provider and may shares [share] the data with the patient/patient representative.
-For patients who require an admission to a facility-based provider after discharge; SNF [skilled nursing facility], LTACH [long-term acute-care hospital], another IRF [in-patient rehabilitation facility], or inpatient Hospice facility, the case manager provides a list of Medicare participating facilities that serve the geographic area requested by the patient.
-For patients who require home health services or home hospice services, the case manager provides a list of Medicare certified Home Healthcare or Hospice agencies that have requested to be on the hospital's list and which serve the geographic area where the patient will be discharged.
-If the patient requests a specific HHA [home health agency], SNF, or LTACH, the case manager attempts to arrange post-hospital care to meet that request. If the case manager is unable to secure the requested provider arrangement (i.e. there is no bed available or the HHA cannot provide the services needed) the reason the request could not be fulfilled is explained to the patient and a list of alternative facilities are provided.
-If the patient does not have a provider preference, the case manager may make a recommendation from the provider list that provides high quality, efficient care that best meets the needs of the patient.
-If the case manager provides a printed provider list to the patient/patient representative, the list will comply with the requirements set forth in the Medicare Requirements for Discharge Planning for Hospitals."
*"Discharge Planning Process and Documentation:
-The case manager documents the anticipated discharge plan throughout the stay on initial evaluation, during team conferences, and during the days leading up to discharge.
-The case manager reviews IRF Discharge Criteria and assesses patient's readiness for discharge (attached).
-The case manager documents the review of or provision of post-discharge provider lists to the patient/patient representative.
-The case manager documents if quality data and resource data was used and shared with the patient during the discharge planning process.
-Case manager discusses the results of the interdisciplinary team's evaluations and recommendations for post-discharge care with the patient/patient representative.
-The case manager researches and discusses applicable community resource options and services and assesses the patient's access to those resources.
-The case manager documents in the medical record their efforts to connect patients with community-based services.
-The case manager, in collaboration with the physician and interdisciplinary care team, helps to determine the most appropriate post-discharge care setting and durable medical equipment to meet the patient's needs."
*"Review of the Discharge Planning Process:
-The hospital assesses the effectiveness of the discharge planning process on a regular basis. The assessment process includes a review of a representative sample of discharge plans in closed medical records to determine whether the discharge plan was effective and responsive to the patient's post-discharge needs. Based on the findings and identified trends, the discharge planning process may be modified.
-The Discharge Planning Plan is reviewed and updated annually and stored on the Hospital Policies on Demand site."

Surveyor: 26632
Review of the provider's undated Certified Case Management Director job description revealed:
*"As a member of Senior Leadership, the Certified Director of Case Management (CDCM) is responsible for the day to day operations and human resource management of the department of Case Management."
"With a central focus on census management, patient care outcomes, and key care indicators, the CDCM oversees the interdisciplinary plan of care and the discharge planning process to ensure the effectiveness and appropriateness of services."
*"The CDCM is a patient and family advocate to ensure that services are delivered to meet the needs of patients and their families, and that the utilization of resources is appropriate."
*"Coordinates/communicates effectively with administration, medical staff, and interdisciplinary team."
*"Consults on service delivery, financial management, and discharge planning process."
*"Oversees team conference process and educates staff in facilitation and reporting."
*"Leads daily case management operations meeting."
*"Performs case management analysis."
*"Oversees concurrent review functions with appropriate follow-up action plan and intervention."
*"Builds relationships as defined through targeted goals of the business plan."
-That included networking with other health care networks.

Review of the provider's undated Case Manager II job description revealed:*"The Case Manager (CM II) serves as a key member of the interdisciplinary team and actively manages and directs resource utilization to achieve the highest quality of outcomes during a patient's rehabilitation experience."
*"The CM II coordinates and advocates for the patient during their hospitalization and from pre-admission to post-discharge."
*"As an effective communicator, the CM II manages information to effectively oversee health care delivery and facilitate interdisciplinary plan of care decisions."
*"The CM II facilitates timely communication regarding the patient's care, and establishes and monitors the discharge plan implementation while identifying and addressing patient's psychosocial and support system issues."
*"The CM II oversees the effective coordination of services and manages issues in the following main areas: admission and discharge, team conference and interdisciplinary plan of care communication, patient and family education, payer relations, and total fiscal management."
*"The case manage assures that regulations regarding patient's rights are fulfilled."
*"Coordinates with interdisciplinary team to establish tentative discharge plan and contingency plans." Includes:
-"Incorporates information from initial interview and consultation with team and patient/family."
-"Establishes contingency discharge plans for high risk cases."
""Actively identifies barriers to discharge plan and communicates with patient/family and team to decrease or eliminate such barriers."
*"Participates in planning for, and ensures successful execution of, patient discharge experience." Includes:
-"Confirms final discharge plans after consultation with team and patient."
-"Prepares and reviews case management paperwork and reviews with patient/representative at least 24 hours prior to discharge."
*"Identifies potential complications relative to patient care and discharge plan after initial and ongoing team conference."

Review of the provider's undated Chief Nursing Officer (CNO) job description revealed:
*The CNO was responsible for the development and implementation of the plans for providing nursing care, treatment, and services.
*Determines the types and numbers of nursing personnel necessary to provide nursing care.
*Develops patient care programs, policies, and procedures to include:
-"Describes how patients' needs for nursing care, treatment, and services are assessed, evaluated, and met for the programs, policies, and procedures developed."

42477




26632

Based on interview, record review, policy review, job description review, and the healthcare online report to the South Dakota Department Of Health, the provider failed to ensure the safety of all patients from abuse. Findings include:

1. Review of a 8/3/21 initial healthcare online report revealed :
*Patient 10 had verbalized having been sexually abused by two rehabilitation nurse technicians (RNT).
*Patient 10 had not been examined for any injuries.
*The provider did not ensure the safety of all other patients after patient 10 had reported the incident.
*RNTs F and M had been re-assigned to other areas that included care for other patients for the rest of their shift.
*RNT F left at 5:58 p.m.
*RNT M left at 6:02 p.m.

Refer to A115.