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Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING, was out of compliance.

A0820 - Standard: The hospital must arrange for the initial implementation of the patient's recommended discharge plan. As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care. The facility failed to implement the patient's discharge plan and failed to prepare the patient and patient representatives for their post-hospital care needs. This failure led to the potential for poor patient outcomes post discharge due to improper implementation of the patient's discharge plan and lack of post-hospital care education.

A0821 - Standard: The hospital must reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan. The facility failed to reassess the appropriateness of discharges that deviated from the recommended plan. This failure led to patients being discharged to an unsafe level of care with the potential for unmanaged medical care after discharge.

A0837 Standard: The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care. The facility failed to transfer a patient to an appropriate facility with the necessary medical information. This failure led to the patient's medical care not being continued when discharged and poor patient outcomes with readmission to a different facility as a result.

Based on interviews and record review, the facility failed to implement the patient's recommended discharge plan and failed to prepare the patient representatives for their post hospital care needs in 1 out of 10 medical records reviewed (Patient #2).

This failure led to the potential for poor patient outcomes post discharge due to improper implementation of the patient's discharge plan and lack of post hospital care education.

FINDINGS:

POLICY

According to Case Management & Discharge Planning, as soon as possible and prior to the patient's release from the hospital, the hospital
will consult with the patient or that patient's legal representative and the caregiver and issue a discharge plan that describes the patient's aftercare needs. The discharge plan must include: A description of the aftercare tasks necessary to maintain the patient's ability to reside in his/her residence. Contact information for any health care, community resources, and longer services and supports necessary to successfully carry out a patient's discharge plan. Hand Off: Hospital staff will document in the patient's electronic health record (EHR) the arrangements made for initial implementation of the discharge plan, including training and material provided to the patient or patient's family or representative, as applicable. Case Manager documents final discharge plan. The staff registered nurse (RN) communicates report to the receiving facility.

According to Personal Representatives Acting on Behalf of Patients and Protected Health Information, if a patient is an adult the personal representative is a person with legal authority to make health care decisions on behalf of the individual. Examples: Medical durable power of attorney. Court appointed legal guardian. Proxy decision maker.

According to Documentation of Patient Care, the patient's education needs are assessed at relevant times during hospitalization such as prior to discharge or transfer. Educational topics may include: Management of diagnosis or condition, safe and effective use of medication, plan for discharge and continued care. Written/printed instruction will be provided, including medication reconciliation.

According to Hand Over Communications, caregivers will use a standardized approach for hand over communication during, but not limited to the following exchanges: Transfer of care from a registered nurse (RN) to a patient transporter. Transfer of care to another department, facility or agency. Formal documentation of a patient hand off is completed in the electronic medical record.

1. The facility failed to implement the patient's recommended discharge plan.

a) Document review of Patient #2's medical record revealed s/he was admitted to the facility from his/her long term residential facility on
07/03/16 due to a change in mental status. Patient #2 underwent brain surgery on 07/04/16 for a previously placed shunt (medical device that
relieves pressure on the brain caused by fluid accumulation) revision. After Patient #2's shunt revision, s/he was admitted to the facility for continuation of medical care. Patient #2 was cleared by neurosurgery for discharge on 07/11/16; however, according to Physician #1's progress note, dated 07/13/16, Patient #2 still required significant re direction from staff and was considered unable to care for him/herself.

Patient #2's previous long term residential facility declined re admission. On 07/16/16 Patient #2 bit a security guard and criminal charges were filed. On 07/16/16 police determined Patient #2 could not be charged with a crime due to his/her mental illness. On 07/19/16 at 2:46 p.m. Case Manager (CM) #3 documented Patient #2 would require an inpatient treatment program for discharge. Later that day, at 4:54 p.m. Patient #2 was discharged into police custody and taken to jail. Discharge instructions and medication reconciliation were not present in the medical record. Registered Nurse (RN) #3 documented "no report given to facility" in the medical record.

Patient #2 was on approximately 20 medications at time of discharge. Patient #2's proxy decision maker was updated to Patient #2's disposition after his/her discharge was already complete. On 07/28/16 Patient #2's proxy decision maker reported to the facility the patient did not receive medication for 2 days while in jail. This caused him/her to have multiple seizures and Patient #2 was subsequently admitted to a different facility.

b) During an interview with Health Informatics Management Employee (HIM #9) on 09/29/16, s/he could not find a print date for Patient #2's discharge instructions and was unable to determine when or if the discharge instructions were printed for Patient #2's discharge. S/he
printed Patient #2's discharge instructions as they should have been printed for the discharge at the request of the surveyor. The discharge instructions did not include any information of Patient #2's surgery. Patient' #2's discharge instructions listed 16 medications for him/her to start taking and listed 22 medications for him/her to stop taking. Further, there were no referrals listed for Patient #2 regarding follow up care. This was in contrast to facility policy.

c) During an interview on 09/29/16 at 11:12 a.m., CM #3 stated it was important for a patient's discharge to be safe so further injury did not
occur. S/he stated the discharge disposition was a collaborative decision made with the patient or patient's representative. According to Patient #2's medical record, on 07/19/16 at 2:46 p.m., CM #3 documented Patient #2 would require an inpatient treatment program. On 7/19/16 at 4:54 p.m. Patient #2 was discharged to jail. During the interview with CM # 3 on 09/29/16, CM #3 stated s/he was unaware jail was an option for Patient #2.

d) On 09/29/16 at 11:58 a.m., the Case Management Manager (Manager #6) was interviewed. Manager #6 stated s/he expected all patients were discharged with a referral discharge list and a medication reconciliation list as part of their discharge education. Manager #6 stated it was a RNs responsibility to ensure report was given to the accepting facility. S/he further stated patient's family or care givers should be involved in the discharge process. Manager #6 expected his/her staff to follow facility policies.

A review of Patient #2's medical record was conducted during Manager #6's interview on 09/29/16 at 11:58 a.m. Manager #6 stated the team never directly talked to Patient #2's care giver regarding jail as an option for discharge disposition. According to Patient #2's medical record, on 07/18/16, the day before Patient #2's discharge, Manager #6 contacted the facility's corporate office to reach out to the Police Department as part of Patient #2's discharge plan. Manager #6 documented Physician #2 would write a letter of attestation that stated Patient #2 had the capacity to understand his/her actions and the potential consequences. Further, this would be placed on the medical record and available if needed. This letter was not part of Patient #2's medical record and could not be produced at time of survey. Patient #2 was discharged into police custody on 07/19/16 at 4:54 p.m.

e) During an interview on 09/29/16 at 3:38 p.m. with Director of Patient Care Services (Director #8), s/he stated the RNs on the patient care units were expected to follow policy. Director #8 stated policy was not followed regarding the discharge of Patient #2. No discharge instructions could be found in Patient #2's medical record and the RN documented "no report given." Director #8 further stated jail was not considered a safe place for a patient's discharge.

f) During an interview with Physician #2 on 09/29/16 at 6:23 p.m., s/he stated s/he had no idea if Patient #2 went to general population or the medical infirmary upon discharge from the facility. Physician #2 further stated it was the RNs responsibility to give report to the jail including medication reconciliation. Physician #2 stated s/he did not give report to the jail regarding Patient #2, but completed the electronic discharge summary. His/her expectation was for the RN to give report. Physician #2 stated Patient #2 was in the facility because s/he did not have options for a safe discharge.

2. The facility failed to educate the patient representatives in preparation for post hospital care.

a) During an interview on 09/28/16 at 12:55 p.m., RN #5 stated the expectation was to educate the patient and/or patient representative and print out all the education materials, including education regarding any drugs that were new to the patient, prior to the discharge of a patient.

b) During an interview on 09/29/16 at 11:12 a.m., CM #3 stated the patient's care team was expected to discuss the discharge disposition with the patient's representative prior to the patient's discharge. If a patient was being discharged to jail, CM #3 would expect to see coordination discussed with the jail to determine if Patient #2 was appropriate for general population versus the infirmary.

c) On 09/29/16 at 11:58 a.m., Manager #6 stated in order for a patient to have a safe discharge s/he would expect to see all appropriate patient referrals listed along with a medication reconciliation list. Manager #6 expected RNs to give a hand off report including medication reconciliation. Referrals, medication reconciliation, and report were not present in Patient #2's medical record.

d) During an interview with RN #11 on 09/29/16 at 4:44 p.m., s/he stated the patient, or the patient's representative, and the RN should review the medication reconciliation at the time of discharge to ensure the patient, or the patient's representative, understood the importance of the prescribed medication. S/he further explained if a member of the patient's care team did not give the patient clearance to be discharged, the patient stayed at the facility. This did not occur for Patient #2. Further, RN #11 stated s/he would have given report to someone prior to Patient #2's discharge from the facility.

f) During an interview on 09/29/16 at 3:38 p.m. with Director #8, s/he stated RNs on the patient care units were expected to follow policy. Director #8 stated RNs should document education on medications and self care instructions. Further, any cognitive barriers should be addressed. S/he stated nurse to nurse report should be documented to discuss the patient's history, medications and care needs. Director #8 stated policy was not followed for Patient #2; no report was given to the facility and written instructions could not be found.

g) During an interview with Physician #2 on 09/29/16 at 6:23 p.m., Physician #2 stated Patient #2 was in the facility because s/he did not have options for a safe discharge. Physician #2 stated s/he had no idea if Patient #2 went to general population or the infirmary upon discharge from the facility. S/he further stated it was the RNs responsibility to give report to the jail including medication reconciliation. Physician #2 stated s/he did not give report to the jail regarding Patient #2, but completed the electronic discharge summary. His/her expectation was for the RN to give report and review the discharge instructions with the patient.

Based on interviews and document reviews the facility failed to reassess the appropriateness of discharges that deviated from the recommended plan.

This failure led to patients being discharged to an unsafe level of care with unmanaged medical care after discharge.

FINDINGS:

POLICY

According to Case Management & Discharge Planning, as soon as possible and prior to the patient's release from the hospital, the hospital will consult with the patient or that patient's legal representative and the caregiver and issue a discharge plan that describes the patient's aftercare needs. The discharge plan must include: a description of the aftercare tasks necessary to maintain the patient's ability to reside in his/her residence and contact information for any health care, community resources, and longer services and supports necessary to successfully carry out a patient's discharge plan. Hand Off: Hospital staff will document in the patient's electronic health record (EHR) the arrangements made for initial implementation of the discharge plan, including training and material provided to the patient or patient's family or representative, as applicable. Case Manager documents final discharge plan. 3. The staff registered nurse (RN) communicates report to the receiving facility.

According to Documentation of Patient Care, the patient's education needs are assessed at relevant times during hospitalization such as: prior to discharge or transfer. Educational topics may include: Management of diagnosis or condition, safe and effective use of medication, plan for discharge and continued care. Written/printed instruction will be provided, including medication reconciliation

According to Hand-Over Communications, caregivers will use a standardized approach for hand-over communication during, but not limited to the following exchanges: transfer of care from a registered nurse (RN) to a patient transporter, transfer of care to another department, facility or agency and formal documentation of a patient hand-off is completed in the electronic medical record

According to Admission to the ED/Hospital & Discharge from the Emergency Department, discharge vital signs will be performed and recorded no less than 30 minutes prior to a patient's discharge or transport out of the Emergency Department.

1. The facility failed to reassess the appropriateness of the discharge plan once the recommended plan had changed.

a) Document review of Patient #2's medical record revealed s/he was admitted from his/her long term residential facility on 07/03/16 due to a change in mental status. Patient #2 underwent brain surgery on 07/04/16 for a previously placed shunt (medical device that relieves pressure on the brain caused by fluid accumulation) revision. After Patient #2's shunt revision, s/he was admitted for continuation of medical care. Patient #2 was cleared by neurosurgery for discharge on 07/11/16; however, according to Physician #1's progress note dated 07/13/16, Patient #2 still required significant re-direction from staff and was considered unable to care for him/herself.

Patient #2's previous long term residential facility declined re-admission. On 07/16/16 Patient #2 bit a security guard and criminal charges were filed. On 07/16/16 police determined Patient #2 could not be charged with a crime due to his/her mental illness. On 07/19/16 at 2:46 p.m. Case Manager (CM) #3 documented Patient #2 would require an inpatient treatment program for discharge. Later that day, at 4:54 p.m. Patient #2 was discharged into police custody and taken to jail. Discharge instructions and medication reconciliation were not present in the medical record. Registered Nurse (RN) #3 documented "no report given to facility" in the medical record.

Patient #2 was on approximately 20 medications at time of discharge. Patient #2's proxy decision-maker was updated to Patient #2's disposition after his/her discharge was complete. On 07/28/16 Patient #2's proxy decision-maker reported to the facility the patient did not receive medication for 2 days while in jail. This caused him/her to have multiple seizures and Patient #2 was subsequently admitted to a different facility.

b) During an interview on 09/29/16 at 11:12 a.m., CM #3 stated it was important for a patient's discharge to be safe so further injury did not occur. S/he stated the discharge disposition was a collaborative decision made with the patient or patient's representative. According to Patient #2's medical record, on 07/19/16 at 2:46 p.m., CM #3 documented Patient #2 would require an inpatient treatment program. On 7/19/16 at 4:54 p.m. Patient #2 was discharged to jail. During the interview with CM# 3 on 09/29/16, CM #3 stated s/he was unaware jail was an option for Patient #2.

c) On 09/29/16 at 11:58 a.m., the Case Management Manager (Manager #6) was interviewed. S/he stated patient's family or care givers should be involved in the discharge process. Manager #6 expected his/her staff to follow facility policies.

A review of Patient #2's medical record was conducted during Manager #6's interview on 09/29/16 at 11:58 a.m. Manager #6 stated the team never directly talked to Patient #2's representative regarding jail being an option for discharge disposition. According to Patient #2's medical record, on 07/18/16, the day before Patient #2's discharge, Manager #6 contacted the facility's corporate office to reach out to the Police Department as part of Patient #2's discharge plan. Manager #6 documented Physician #2 would write a letter of attestation that stated Patient #2 had the capacity to understand his/her actions and the potential consequences. Further, this would be placed on the medical record and available if needed. This letter was not part of Patient #2's medical record and could not be produced at time of survey. Patient #2 was discharged into police custody on 07/19/16 at 4:54 p.m. There was no documentation involving the patient's designated representative's involvement with the discussion.

Based on interviews and document review, the facility failed to transfer a patient to an appropriate facility with the necessary medical information.

This failure led to the patient's medical care not being continued when discharged. As a result, the patient did not receive medication for 2 days leading to admission to another facility.

FINDINGS:

POLICY

According to Case Management & Discharge Planning, as soon as possible and prior to the patient's release from the hospital, the hospital will consult with the patient or that patient's legal representative and the caregiver and issue a discharge plan that describes the patient's aftercare needs. The discharge plan must include: a description of the aftercare tasks necessary to maintain the patient's ability to reside in his/her residence and contact information for any health care, community resources, and longer services and supports necessary to successfully carry out a patient's discharge plan. Hand Off: Hospital staff will document in the patient's electronic health record (EHR) the arrangements made for initial implementation of the discharge plan, including training and material provided to the patient or patient's family or representative, as applicable. Case Manager documents final discharge plan. The staff registered nurse (RN) communicates report to the receiving facility.

According to Documentation of Patient Care, the patient's education needs are assessed at relevant times during hospitalization such as: prior to discharge or transfer. Educational topics may include: Management of diagnosis or condition, safe and effective use of medication, plan for discharge and continued care. Written/printed instruction will be provided, including medication reconciliation

According to Hand-Over Communications, caregivers will use a standardized approach for hand-over communication during, but not limited to the following exchanges: transfer of care from a registered nurse (RN) to a patient transporter and transfer of care to another department, facility or agency. Formal documentation of a patient hand-off is completed in the electronic medical record

According to Personal Representatives Acting on Behalf of Patients and Protected Health Information, if a patient is an adult the personal representative is a person with legal authority to make health care decisions on behalf of the individual. Examples: Medical durable power of attorney. Court appointed legal guardian. Proxy decision-maker.

1. The facility failed to provide necessary medical information to the accepting facility, the patient, or the patient's representative once the patient was discharged.

a) Document review of Patient #2's medical record revealed s/he was admitted to the facility from his/her long term residential facility on 07/03/16 due to a change in mental status. Patient #2 underwent brain surgery on 07/04/16 for a previously placed shunt (medical device that relieves pressure on the brain caused by fluid accumulation) revision. After Patient #2's shunt revision, s/he was admitted for continuation of medical care. Patient #2 was cleared by neurosurgery for discharge on 07/11/16; however, according to Physician #1's progress note dated 07/13/16, Patient #2 still required significant re-direction from staff and was considered unable to care for him/herself.

Patient #2's previous long term residential facility declined re-admission. On 07/16/16 Patient #2 bit a security guard and criminal charges were filed. On 07/16/16 police determined Patient #2 could not be charged with a crime due to his/her mental illness. On 07/19/16 at 2:46 p.m. Case Manager (CM) #3 documented Patient #2 would require an inpatient treatment program for discharge. Later that day, at 4:54 p.m. Patient #2 was discharged into police custody and taken to jail. Discharge instructions and medication reconciliation were not present in the medical record. Registered Nurse (RN) #3 documented "no report given to facility" in the medical record.

Patient #2 was on approximately 20 medications at time of discharge. Patient #2's proxy decision-maker was updated to Patient #2's disposition after his/her discharge was complete. On 07/28/16 Patient #2's proxy decision-maker reported to the facility the patient did not receive medication for 2 days while in jail. This caused him/her to have multiple seizures and Patient #2 was subsequently admitted to a different facility.

b) During an interview on 09/28/16 at 12:55 p.m., RN #5 stated the expectation was to educate the patient and/or patient representative and print out all the education materials, including education regarding any drugs that were new to the patient, prior to the discharge of a patient.

c) During an interview on 09/29/16 at 11:12 a.m., CM #3 stated it was important for a patient's discharge to be safe so further injury did not occur. S/he stated the discharge disposition was a collaborative decision made with the patient or patient's representative. According to Patient #2's medical record, on 07/19/16 at 2:46 p.m., CM #3 documented Patient #2 would require an inpatient treatment program. On 7/19/16 at 4:54 p.m. Patient #2 was discharged to jail. During the interview with CM# 3 on 09/29/16, CM #3 stated s/he was unaware jail was an option for Patient #2. CM #3 would expect to see coordination discussed with the jail to determine if Patient #2 was appropriate for general population versus the infirmary. This was not documented in Patient #2's medical record and Patient #2's discharge was not discussed with his/her patient representative until after his/her discharge to jail.

d) On 09/29/16 at 11:58 a.m., Case Management Manager (Manager #6) stated in order for a patient to have a safe discharge s/he would expect to see all appropriate patient referrals listed along with a medication reconciliation list. When transferring to a new facility, Manager #6 expected RNs to give a hand off report including medication reconciliation. Referrals for Patient #2, medication reconciliation discussion with Patient #2, and report to the facility were not evident in Patient #2's medical record.

e) During an interview with a Health Informatics Management Employee (HIM #9) on 09/29/16 Patient #2's medical record was reviewed. HIM #9 could not find Patient #2's signed discharge instructions or a print date for Patient #2's discharge instructions. HIM #9 was unable to determine when or if the discharge instructions were printed for Patient #2's discharge. S/he printed Patient #2's discharge instructions as they would have been printed for his/her discharge at request of surveyor on 09/29/16. The discharge instructions did not include any information of Patient #2's surgery. Patient #2's discharge instructions listed 16 medications for him/her to start taking and listed 22 medications for him/her to stop taking. There was no evidence in the medical record this had been reviewed prior to discharge. Further, there were no referrals listed for Patient #2 regarding follow up care. This was in contrast to facility policy.

f) During an interview with RN #11 on 09/29/16 at 4:44 p.m., s/he stated the patient and the RN should review the medication reconciliation at the time of discharge to ensure the patient or the patient's representative understood the importance of the prescribed medication. Further, RN #11 stated that she would have given report to someone while discharging Patient #2

g) On 09/29/16 at 1:55 p.m., during an interview with ER Director #7, s/he stated the expectation for a patient's discharge included his/her instructions and prescriptions. If a patient was being transferred to a different facility report should be given every time.

h) During an interview on 09/29/16 at 3:38 p.m. with Director of Patient Care Services (Director #8), s/he stated the RNs on the patient care units were expected to follow policy. Director #8 stated RNs should document education on medication and self-care instructions and cognitive barriers should be addressed. S/he stated nurse to nurse report should be documented to discuss the patient's history, medications and care needs. Director #8 stated policy was not followed for Patient #2.

i) During an interview with Physician #2 on 09/29/16 at 6:23 p.m., Physician #2 stated Patient #2 was in the facility because s/he did not have options for a safe discharge. Physician #2 stated s/he had no idea if Patient #2 went to general population or the infirmary upon discharge from the facility. Physician #2 further stated it was the RNs responsibility to give report to the jail including medication reconciliation. Physician #2 stated s/he did not give report to the jail regarding Patient #2, but completed the electronic discharge summary. His/her expectation was for the RN to give report and review discharge instructions.

Based on interviews and record review, the facility failed to meet the post discharge needs of emergency department patients (Patient #1).

This failure led to the potential for patients unable to care for themselves to be discharged home without the services needed to meet their needs.

POLICY

According to Case Management & Discharge Planning, as soon as possible and prior to the patient's release from the hospital, the hospital will consult with the patient or that patient's legal representative and the caregiver and issue a discharge plan that describes the patient's aftercare needs. The discharge plan must include: A description of the aftercare tasks necessary to maintain the patient's ability to reside in his/her residence. Contact information for any health care, community resources, and longer services and supports necessary to successfully carry out a patient's discharge plan.

According to Documentation of Patient Care, the patient's education needs are assessed at relevant times during hospitalization such as prior to discharge or transfer. Educational topics may include: Management of diagnosis or condition, safe and effective use of medication, plan for discharge and continued care. Written/printed instruction will be provided, including medication reconciliation.

1. The facility failed to ensure Patient #1 was safe for discharge and that post discharge needs were arranged for and met.

a) Document review of Patient #1's medical record revealed s/he was placed in observational status in the emergency room (ER) on 09/07/16 with goals to further his/her mental health evaluation and to have case management help with potential placement. According to the Emergency Department Report Patient #1 had previously been cared for at home, but now had nobody at home to help them and was incapable of caring for themselves. On 09/08/16 at 8:50 p.m., a Crisis Evaluation was completed. The evaluation revealed his/her "judgement grossly impaired health/safety was endangered;" however, the assessor's summary read in part: "(Patient #1) does not meet the criteria for danger to self or others and based on the client's ability to assess (his/her) situation and acknowledge untoward behaviors, as well as ability to care for adls (activities of daily living) and transfer, (s/he) does not meet criteria for grave disability."

On 09/09/16 at 8:20 a.m. Patient #1 was discharged home to care for his/herself. Patient #1's last set of documented vital signs were at 09/09/16 at 7:13 a.m. No additional crisis evaluations were completed regarding his/her ability to care for his/herself prior to Patient #1's discharge.

b) During an interview on 09/29/16 at 11:12 a.m., Case Manager (CM #3) stated it was important for a patient's discharge to be safe so further injury did not occur. S/he stated the discharge disposition was a collaborative decision made with the patient or patient's representative.

c) On 09/29/16 at 11:58 a.m., Case Management Manager (Manager #6) stated in order for a patient to have a safe discharge s/he would expect to see all appropriate patient referrals listed along with a medication reconciliation list. Review of Patient #1's medical record revealed resources for him/her to include Brain Injury Alliance and Colorado All Health. No information was given to Patient #1 at discharge regarding these resources. This was in contrast to facility policy.

d) On 09/29/16 at 1:55 p.m., during an interview with ER Director #7, s/he stated given the documentation, or lack thereof, in Patient #1's medical record s/he was concerned and suspect as to if the discharge was safe. Director #7 stated s/he expected to see documentation with instructions regarding follow up with long term care facilities. Further, s/he stated the discharge instructions did not discuss follow-up with Colorado Access or Brain Alliance. Director #7 stated vital signs should be done within 30 minutes of discharge, according to policy. Patient #1's last set of vital signs were taken over an hour before s/he was discharged.