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Based on staff interview and review of meeting minutes, policies, medical records, bylaws, and quality documents, it was determined the hospital's Governing Board failed to provide effective oversight and direction to hospital staff. This resulted in a lack of specificity of hospital programs and services. Findings include:

1. A change of ownership took place on 1/01/19. Safe Haven Hospital of Treasure Valley became Lifeways Hospital. All hospital policies and procedures and bylaws contained the Safe Haven Hospital title. None contained the Lifeways title.

No Lifeways Governing Board meeting minutes were present.

A document, dated 1/16/19, stated "The Governing Board of Lifeways Hospital approves the current policies and procedures set forth by the previous Safe Haven Hospital of Treasure Valley's Governing Body." It was signed by the Lifeways CEO and the Medical Director.

Another document, dated 1/24/19, Granted privileges to current members of the Medical Staff. The document also stated "...the Lifeways' Board of Directors approves and accepts the Medical Staff Bylaws, including rules and regulations, as currently written through June 30, 2019." It was signed by the president of the Board of Directors.

Even though the Medical Staff Bylaws and policies were approved, no documentation was present that the Governing Board for Lifeways Hospital had performed a review of those bylaws or policies. There was no review of hospital systems in order to determine whether they were viable.

For example, the hospital had 2 psychiatrists who provided psychiatric care. The hospital also contracted with a group of NPs and PAs to "provide histories, physicals and basic medical care to patients." The contract stated the group would provide these services between 8:00 AM and 5:00 PM seven days a week. No plan was in place to provide medical services to patients between 5:00 PM and 8:00 AM.

There was no documentation the Governing Board considered how medical care would be provided to patients on a 24 hour basis.

The Administrator was interviewed on 3/20/19 beginning at 3:00 PM. She stated there was no documentation of the Lifeways Governing Board review of the hospital's programs or systems.

The Director of Quality was interviewed on 3/21/19 beginning at 8:55 AM. She stated the hospital board was waiting for a Medicare survey to make changes to hospital processes and systems.

The Governing Board did not effectively manage the hospital.

2. Refer to A093 as it relates to the failure to the Governing Board to ensure the Medical Staff had written policies and procedures for appraisal of emergencies.

3. Refer to A309 as it relates to the failure to the Governing Board to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained.

4. Refer to A338 as it relates to the failure to the Governing Board to ensure the Medical Staff assumed responsibility for the quality of medical care provided to patients by the hospital.

Based on staff interview and review of policies, bylaws, and medical records, it was determined the Governing Board failed to ensure the Medical Staff had written policies and procedures for appraisal of emergencies. This affected the care of 3 of 4 patients (#5, #8, and #9), who were transferred to other hospitals and whose records were reviewed. The failure to adopt policies and procedures resulted in a lack of direction to staff and a lack of care for patients. Findings include:

1. Medical Staff Bylaws, dated June 2016, did not address provisions for the care of patients during emergencies. The bylaws did state the physician on call would respond to the hospital within 1 hour of call, but there was no further clarification. The bylaws did not state the physician would come to the hospital.

A Nursing Services policy titled "Emergency Physician Care," dated 5/23/16, stated all emergent patients would be evaluated by an RN who would then call a physician. The policy stated the physician would come to the hospital. This was not the practice of the hospital, however.

The Medical Director was interviewed on 3/20/19 beginning at 3:40 PM. He stated the hospital did not have a policy defining the role of physicians in an emergency.

The hospital's Governing Board did not assure that the medical staff has written policies and procedures for appraisal of emergencies,

2. Patient #8 was a 49 year old female who was admitted to the hospital on 3/13/19 with a diagnosis of schizophrenia. She was currently a patient as of 3/20/19.

Patient #8's psychiatric evaluation by a psychiatrist, dated 3/14/19 at 9:08 AM, stated she was seen in the office of a psychiatric NP, who was a member of the Medical Staff. From the NP's office, Patient #8 was sent directly to the hospital for admission. Patient #8's psychiatric evaluation stated she wanted to "stitch up her genitals" as part of her psychosis. Patient #8's record did not include a note by the psychiatric NP who admitted her.

Patient #8's record contained an order, dated 3/13/19 at 7:30 PM, to send her to a local emergency room "...to be evaluated & placed on a mental hold." An assessment of the patient by a member of the Medical Staff was not documented prior to the order to send her to the ER.

A note by the ER physician, dated 3/13/19 at 9:54 PM, stated Patient #8 "...took a sewing kit and placed a [single] suture across her vagina..." The note stated there was no bleeding, cell changes, or other problems at the site of the suture. The physician removed the suture and Patient #8 was returned to Lifeways hospital.

The physician, who ordered Patient #8's transfer to the ER, was interviewed on 3/20/19 beginning at 3:40 PM. He stated the nurse called him and stated she was uncomfortable removing the suture from Patient #8, so he ordered the transfer. The physician stated he took calls from nurses, but said he did not come to the hospital to see patients after he made rounds. He stated if patients had a medical emergency after 5:00 PM, they were transferred to an ER for diagnosis and treatment.

The hospital did not evaluate Patient #8 prior to transferring her to an ER. The medical record did not contain sufficient information to show her condition was sufficient to warrant the transfer.

3. Patient #9 was a 41 year old male who was admitted to the hospital on 3/15/19 with a diagnosis of suicidal ideation and a history of alcohol abuse. Orders for an Ativan detoxification protocol were dated 3/15/19 at 1:30 PM. Patient #9's record contained an order, dated 3/16/19 at 5:30 PM, to transfer him to a local ER "...for evaluation & [treatment and] medical detox."

A Psychiatric Technician note, dated 3/16/19 at 5:00 PM, stated Patient #9 had eaten well and attended groups. The note stated later Patient #9 complained of seeing a "swarm of cockroaches."

An assessment of Patient #9 by a member of the Medical Staff was not documented prior to the order to send him to the ER.

Patient #9's physician was interviewed on 3/20/19. She stated a provider did not examine the patient prior to transferring him to the ER. She stated she did not come to the hospital for changes in patients' medical condition. She stated she would come to the hospital to place a patient on a mental hold if needed.

The hospital did not evaluate Patient #8 prior to transferring him to an ER.

4. Patient #5 was a 45 year old female who was admitted to the hospital on 3/01/19 with a diagnosis of schizoaffective disorder. She was discharged on 3/04/19.

Patient #5's psychiatric evaluation, dated 3/02/19 at 12:06 PM, stated she was having auditory hallucinations and was gravely disabled. She was placed on a mental hold by police prior to her arrival at Lifeways Hospital.

A telephone order, dated 3/04/19 at 1:20 PM, stated "Direct admit to another facility. If unable to, then change to non-emergent transport to [a local ER]."

A Nursing Narrative Note, dated 3/04/19 at 12:45 PM, stated Patient #5 was pacing the floor holding a coffee cup. The note stated 2 staff were with the patient. The note stated Patient #5 told the staff to get away. The note stated Patient #5 kicked the door and stated she wanted out of the locked unit. The note stated the RN attempted to engage Patient #5, but she walked away. The next note, dated 3/04/19 at 12:50 PM, stated the nurse paged the physician. The note stated the DNS called police because Patient #5 struck a staff member. The next note, dated 3/04/19 at 12:55 PM, stated the nurse spoke with the physician who approved of the assessment by the RN. The next note, dated 3/04/19 at 1:05 PM, stated police arrived and assumed custody of Patient #5. The final note, dated 3/04/19 at 1:45 PM, stated Patient #5 stayed in the hospital lobby from 12:45 PM to 1:45 PM and then left with paramedics.

Another nurse wrote narrative notes on 3/04/19. The note at 11:40 AM, stated a Psychiatric Technician notified her of Patient #5's increased agitation and aggressiveness. The note stated 10 staff members gathered and proceeded with "a code." The next note, at 11:45 AM, stated Patient #5 was pacing and kicking walls. The next note, at 11:50 AM, stated the nurse attempted to de-escalate Patient #5. It said a message was left for the physician and police were called. The note at 12:17 AM stated police arrived and assumed custody of Patient #5. A summary note by the same nurse was written at 1:00 PM. The note stated Patient #5 became agitated and asked to go back to the homeless shelter she came from. The note stated Patient #5 told staff to get away from her. The note stated Patient #5 began pushing staff and grabbing at staff. The note stated Patient #5 took a staff members glasses [which were hanging from his shirt] and broke them into several pieces. The note stated at this point, Patient #5 was given space. The note then stated police arrived.

Patient #5 was not examined by a member of the Medical Staff prior to being sent to the ER. The rationale for the transfer was not documented.

The order to transfer Patient #5 was not signed by the physician. Patient #5's physician was interviewed on 3/20/19 beginning at 3:40 PM. He stated he did not see her that day. He stated he was not sure what order he gave to the RN. He stated he did not know what happened with Patient #5 the day she was transferred. He stated he did not think Patient #5 was sick enough that she needed to be transferred to another facility.

The hospital did not evaluate Patient #5 prior to transferring her to an ER.

Based on staff interview and review of medical records, policies, and quality documents, it was determined the hospital failed to ensure the use of restraint was implemented in accordance with safe and appropriate restraint techniques as determined by hospital policy, for 1 of 1 patient (Patient #5), who was restrained and whose record was reviewed. The failure to implement safe and appropriate restraint techniques placed the patient at risk of injury and psychological trauma. Findings include:

1. The hospital utilized a behavioral system called Mandt for preventing, de-escalating, and intervening when patient behavior posed a threat of harm to themselves or others.

The policy "Restraints," dated 5/03/16, stated the hospital used Mandt approved methods to prevent patients from causing harm to themselves or others. The policy stated restraints could only be used "...in order to protect the patient from imminent risk of harm from self or from harming others. The policy defined "Chemical Restraint" as a medication "...that results in controlling behavior or restricting freedom of movement that is not a standard medication treatment for a patient's medical or psychiatric condition." The policy did not include further detail as to which medications might be considered chemical restraints.

The policy "Less Restrictive Alternatives to Seclusion and Restraint," dated 5/01/13, stated less restrictive alternatives included:

a. the use of de-escalation procedures
b. natural consequences, restrictions, or limit setting
c. time out
d. line of sight
e. one to one staffing

The policy did not include backing off and allowing the patient to de-escalate on their own.

Restraint policies were not complete.

2. Patient #5 was a 45 year old female who was admitted to the hospital on 3/01/19 with a diagnosis of schizoaffective disorder. She was discharged on 3/04/19.

Patient #5's psychiatric evaluation, dated 3/02/19 at 12:06 PM, stated she was having auditory hallucinations and was gravely disabled. The evaluation stated she was placed on a mental hold by police prior to her arrival at Lifeways Hospital.

An incident involving Patient #5 occurred during shift change on the evening of 3/02/19.

A narrative note by the PT, dated 3/02/19 at 7:25 PM, stated Patient #5 was given a snack. The note stated Patient #5 ended up throwing the snack and a drink on the floor. The note stated Patient #5 then went into her room and "barricaded the door with her body. The note stated Patient #5 refused to let staff into the room. The note stated Patient #5 was then observed through the window in the door. The note did not state that Patient #5 was in danger of harm to self or others.

A nursing narrative note by the night nurse, dated 3/02/19 at 8:00 PM, stated during shift change, Patient #5 "...barricaded self in room. [Night] shift came down to unit and found several staff members outside of room 201 with [patient] yelling & screaming from inside the room." The note stated the physician was called and orders were received for Haldol 10 mg IM [an antipsychotic] and Ativan 10 mg IM [an anti-anxiety medication]. The note stated the medication was given to Patient #5. Subsequent nursing notes stated Patient #5 slept through the night.

A nursing narrative note by the day nurse, dated 3/02/19 at 7:15 PM, stated the nurse was notified Patient #5 had "...barricaded herself in her room with her body." The note stated the nurse called the physician on call for medication and for "restraint to give" the medication. The note did not describe events after that.

A telephone order for Patient #5, dated 3/02/19 at 7:40 PM, stated "Haldol 10 mg IM stat, Ativan 10 mg IM stat." The order did not state the drugs were a chemical restraint. In addition, there was no order to physically restrain the patient to administer the medication.

None of the notes described events after the medication was ordered.

The verbal order for the Haldol and Ativan was not signed by the physician. The next physician progress note following the incident was dated 3/03/19 at 9:52 PM. The note did not mention the incident of 3/02/19.

Patient #5's physician was interviewed on 3/20/19 beginning at 3:40 PM. He stated he did not examine the patient. He stated the use of Haldol and Ativan together was a restraint. He stated the order he gave for the Haldol and Ativan was not correct as written. He stated he gave an order to give Patient #5 the Haldol, wait 10 minutes, and then give the Ativan if needed. He stated he had not yet signed the orders. He stated his progress note on 3/03/19 did not mention the restraint incident.

Documentation did not justify Patient #5's restraint.

3. The hospital conducted an investigation of the incident. An "investigation Form," not dated, stated the day nurse claimed Patient #5 barricaded herself in her room and staff were unable to open the door. The day nurse's statement said she "...was able to hold both client's hands and hugged her from behind while in a right side lying position and I was sitting behind her. Meds given per [night nurse] without incident of thrashing, only screaming and crying out. Released immediately after injections given." The hold used by the day nurse constituted a physical restraint.

Another document, titled "Follow up to Occurrence Report," was not dated. The document stated an investigation of the restraint incident found:
a. The hold utilized was not a Mandt approved hold.
b. Documentation does not support chemical restraint.

Recommendations listed in the document included:
a. Termination of a nurse
b. written "disciplines" for the other 3 staff members involved in the incident
c. Additional training for the other 3 staff members involved in the incident
d. Training for all staff on the policy "Less Restrictive Alternatives to Seclusion and Restraint"

The investigation report did not evaluate the adequacy of policies related to the use of restraints. The investigation did not identify the lack of complete orders for the restraint. The investigation did not identify the lack of specificity of the use of medications as restraints. The investigation did not identify variances from the restraint policies. The investigation did not identify the lack of documentation of details of the incident, including documentation of specific restraints used during the incident. The investigation did not identify the lack of involvement by the physician. The investigation did not evaluate the effectiveness of restraint training nor did it identify whether all staff were adequately trained. Finally, the investigation did not evaluate the need for restraint. At the time of the restraint, Patient #5 was sitting in her room with her back to the door. When Patient #5 was restrained, she was not currently behaving in a destructive way. Staff were able to observe her. It was not clear why she needed to be restrained or otherwise engaged at that point. The report did not confirm the need for restraint.

The DNS was interviewed on 3/20/19 beginning at 1:20 PM. She stated she was notified of Patient #5's chemical restraint on Saturday 3/02/19, but said she was not notified of the physical restraint until 3/04/19. She confirmed the orders and documentation were not complete. She stated the investigation of the incident was not complete.

The hospital did not implement Patient #5's restraints in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy. The hospital did not complete a comprehensive evaluation of the incident.

Based on review of facility policies, staff interview and review of personnel training records and staff scheduling, it was determined the hospital failed to ensure staff was sufficiently trained in the application of restraints, for 1 of 2 RNs whose training records were reviewed. This had the potential for patients being subjected to unsafe restraint interventions. Findings include:

A policy titled "Mandt Training," dated 11/01/15, stated "All nursing services personnel will be proficient and certified in Mandt System and recertify once a year...All nursing personnel will initiate Mandt System restraint orders if any staff or patients are in danger or patient is dangerous to themselves. A lead (Mandt System certified instructor, Charge R.N., M.D.) will take over and instruct other staff during the restraint."

Personnel files were reviewed on 3/21/19.

One RN had been hired on 2/01/19. She had not received Mandt System initial training as of 3/21/19. She was assigned as the Charge Nurse, from 7:00 AM - 7:00 PM, on 3/18/19 and 3/19/19.

Without Mandt System training she was not able to assume the Charge Nurse responsibility of taking over a restraint and instructing other staff during a restraint.

In an interview on 3/21/19 at 9:00 AM, the Administrator confirmed the RN had not been trained in the Mandt System.

The facility failed to ensure staff were trained and competent to apply restraints to patients.


40733

Based on staff interview and review of quality documents, it was determined the hospital failed to ensure PIPs were conducted in proportion to the scope and complexity of the hospital's services and operations. The hospital also failed to ensure PIPs were fully documented. This prevented the hospital from conducting a thorough analysis of its operations and processes. Findings include:

The hospital had 1 documented PIP between 1/01/18 and 3/20/19. It was ongoing. It was titled "Hand Hygiene Audits." The project was not defined. There was no written explanation of the project that included; why it was conducted, time frames, goals, and actions to be taken by the hospital to improve outcomes.

The numbers for the Hand Hygiene Audits were reported monthly. No analysis of these numbers was documented. No recommendations were present based on the results. There was no documentation regarding the future of the PIP.

No other projects were documented during the time frame. No projects related specifically to the care of psychiatric patients were documented.

The Director of Quality was interviewed on 3/21/19 beginning at 8:55 AM. She stated the PIP was ongoing. She stated the reasons, analysis, and recommendations regarding the PIP were not documented.

The hospital did not conduct PIPs proportional to the scope and complexity of the hospital's services and operations. In addition, the hospital did not maintain documentation sufficient to justify the PIP and its findings.

Based on staff interview and review of quality documents and meeting minutes, it was determined the Governing Board failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained.
The Governing Board also failed to ensure PIPs were conducted in proportion to the scope and complexity of the hospital's services and operations. This prevented the hospital from evaluating its services to improve care. Findings include:

1. A change of ownership took place on 1/01/19. Safe Haven Hospital of Treasure Valley became Lifeways Hospital.

No documentation was present that the new Governing Board reviewed the hospital's QAPI program or provided direction to staff responsible for the program.

The Director of Quality was interviewed on 3/21/19 beginning at 8:55 AM. She stated there was no documentation the current Governing Board had reviewed or was involved in the direction of the QAPI program.

The Governing Board did not oversee the QAPI program.

2. Refer to A297 as it relates to the failure of the Governing Board to ensure it approved the number of distinct improvement projects was conducted annually.

Based on staff interview and review of meeting minutes and call schedules, it was determined the hospital failed to ensure the Medical Staff assumed responsibility for the quality of medical care provided to patients by the hospital. The lack of Medical Staff involvement resulted in a lack of direction for the care of patients. Findings include:

1. A change of ownership took place on 1/01/19. Safe Haven Hospital of Treasure Valley became Lifeways Hospital.

A medical peer review meeting was documented on 4/11/18. Psychiatric peer review meetings were documented on 5/01/18 and 11/14/18. No Medical Staff meetings, which included discussion of hospital issues and topics were documented since at least 4/01/18. No evidence was present that the Medical Staff reviewed policies or procedures related to medical care at the hospital since at least 4/01/18.

The Medical Director was interviewed on 3/20/19 beginning at 3:40 PM. He confirmed no Medical Staff meetings had occurred since at least 4/01/18. He stated a meeting was held when the change of ownership occurred where "we signed a bunch of stuff." He stated there were no minutes from this meeting.

Except for peer review, there was no evidence the Medical Staff assumed responsibility for the quality of medical care provided to patients by the hospital.

2. Medical Staff call schedules did not include physician coverage for 2 of 3 months after Lifeways assumed ownership.

Medical Staff on call schedules listed psychiatric providers who were on call for the hospital. Medical Staff on call schedules for January 2019 listed physician coverage for all days. The on call schedule for February 2019 listed the psychiatric NP as the on call provider for 9 days. No physician back up was listed for those days. The on call schedule for March 2019 listed the psychiatric NP as the on call provider for 8 of those days. No physician back up was listed. In addition, none of the call schedules listed who was on call for patients with medical problems.

The Medical Director was interviewed on 3/20/19 beginning at 3:40 PM. He was one of the providers listed on the call schedules. He confirmed the lack of documented physician coverage for February and March 2019. He also stated if he was called by a nurse, he would give telephone orders. However, he stated he did not come to the hospital except for scheduled rounds.

3. Refer to A93 as it relates to the lack of Medical Staff response to patients with potential emergent conditions.

Based on record review and staff interview, it was determined the facility failed to ensure the use of verbal orders was not a common practice and was not used for the convenience of the ordering practitioner. This failure directly impacted 8 of 8 patients (Patients #3, #4, #6, #7, #11, #13, #14, and #15) whose written physician orders were reviewed, and had the potential to impact all patients receiving care at the facility. This failure increased the risk of miscommunication or error resulting in an adverse patient event. The findings include:

1. Verbal order policies were requested. None of the policies provided addressed limiting the use of verbal/telephone physician orders.

2. Examples of frequent use of verbal physician orders included, but were not limited to:

- Patient #3's record showed 7 physician orders, with 4 being verbal orders.

- Patient #4's record showed 6 physician orders, with 3 being verbal orders.

- Patient #6's record showed 12 physician orders, with 1 being a verbal order.

- Patient #7's record showed 15 physician orders, with 6 being verbal orders.

- Patient #11's record showed 27 physician orders, with 10 being verbal orders.

- Patient #13's record showed 15 physician orders, with 6 being verbal orders.

- Patient #14's record showed 38 physician orders, with 23 being verbal orders.

- Patient #15's record showed 21 physician orders, with 6 being verbal orders.

This practice resulted in 40% of changes to patients' treatment and medication being made without the direct assessment of the patient by the medical provider approving the change.

In an interview on 3/20/19 at 1:00 PM, the DNS said the majority of physician orders, used by nursing staff to administer patient care, were received by telephone. She said this practice was used because providers made visits to the facility once a day.

The facility failed to ensure the use of verbal physician orders was limited.

Based on record review, policy review, and staff interview it was determined the hospital failed to ensure medication and treatment orders were signed by prescribing providers for 5 of 9 patients (Patients #4, #5, #7, #11, and #14), whose physician orders were reviewed. This had the potential to result in medications and/or treatments being given to patients without the order of a provider. Findings include:

A hospital policy "Nursing Process - Transcription of Treatment Orders," dated 5/01/13, stated "All verbal orders received from the provider must be counter-signed by the provider. Every attempt must be made for telephone orders to be counter-signed by the provider within 48 hours of receiving the verbal order."

A hospital policy "Countersignatures for Verbal Orders," dated 5/01/13, stated "Verbal orders by hospital staff shall be countersigned by the original prescribing staff as soon as possible, but no later than the completion of the record as stipulated in the Hospital's Bylaws."

Examples of physician orders with no counter signature included, but were not limited to, the following:

- Patient #4 was a 25 year old female who was treated at the facility from 2/20/19 - 2/27/19. Review of her medical record showed no counter signature for a verbal physician order for medication on 2/26/19.

- Patient #5 was a 45 year old female who was treated at the facility from 3/01/19 - 3/04/19. Review of her medical record showed no counter signatures for four verbal physician orders for medication, treatment, and transfer on 3/02/19 and 3/04/19.

- Patient #7 was a 41 year old male who was treated at the facility from 1/22/19 - 2/07/19. Review of his medical record showed no counter signature for a verbal physician order for medication on 1/30/19.

- Patient #11 was a 56 year old male who was treated at the facility from 1/07/19 - 1/24/19. Review of his medical record showed no counter signature for a verbal physician order for medication on 1/19/19.

- Patient #14 was a 24 year old female who was treated at the facility from 1/24/19 - 2/19/19. Review of her medical record showed no counter signatures for verbal physician orders for medication, x-rays, and monitoring on 1/25/19, 1/27/19, 1/28/19, 2/08/19, 2/12/19, and 2/15/19.

In an interview on 3/21/19 at 10:00 AM, the Administrator confirmed physicians were responsible for counter signing all telephone and verbal orders per facility policy.

Physicians did not counter sign verbal orders as required.



40733

Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure discharge summaries were completed in a timely manner. This failure directly impacted 5 of 15 patients (Patients #7, #10, #12, #13, and #14) whose records were reviewed for discharge summaries, and had the potential to impact all patients who received care at the facility. This failure prevented the ability to provide the patients with continuity of care, after discharge, by other health care providers. Findings include:

A policy titled "Content of the Medical Record," dated 01/2013, stated "The discharge summary is to be dictated by the attending physician within 20 days following discharge."

Examples of the policy not being implemented included, but were not limited to:

- Patient #7 was discharged from the facility on 2/07/19. No discharge summary was present in his medical record when reviewed on 3/20/19.

- Patient #10 was discharged from the facility on 2/05/19. No discharge summary was present in his medical record when reviewed on 3/20/19.

- Patient #12 was discharged from the facility on 1/09/19. No discharge summary was present in his medical record when reviewed on 3/20/19.

- Patient #13 was discharged from the facility on 1/15/19. No discharge summary was present in her medical record when reviewed on 3/20/19.

- Patient #14 was discharged from the facility on 2/19/19. No discharge summary was present in her medical record when reviewed on 3/20/19.

On 3/20/19 at 11:00 A.M., the facility was asked to provide the missing discharge summaries. The Medical Records representative stated the summaries had not yet been completed.

The facility failed to ensure discharge summaries were completed to provide for continuity of patient care upon discharge.



40733

Based on staff interview and review of hospital policies, it was determined the hospital did not have a process to reassess its discharge planning process on an on-going basis, including a review of discharge plans. This interfered with the identification of problem areas that could be addressed for process improvements. Findings include:

Discharge planning policies were requested. None of the policies provided addressed the necessity for the hospital to reassess its discharge planning processes on an ongoing basis.

The Administrator was interviewed on 3/21/19 beginning at 10:00 AM. She stated the hospital did not have a system to review its discharge planning process. She stated the hospital did not review discharge plans for quality and completeness.

The Quality Assurance Nurse was interviewed on 3/21/19 beginning at 10:20 AM. She stated Discharge Planning was not a part of the hospital's quality program.

The hospital did not review its discharge planning process.