HospitalInspections.org

Based on review of facility documents, credential files (CF), and interview with staff (EMP), it was determined the facility failed to ensure the reappointment to the Active Medical Staff and approval of the delineation of clinical privileges was granted for one of one credential files reviewed (CF1).

Findings include:

Review on August 14, 2018, of facility document, "Amended and Restated Governing Board laws" dated June 7, 2018, revealed "... 2.5 Medical Staff ... 2.5 Staff Appointment and Privileges ... In order for any licensed practitioner to practice in the Hospital, such individual must first be appointed to either the Medical Staff or the AHP staff and be granted specific Clinical Privileges. Only these appointees to the Medical Staff who have been granted admitting privileges shall admit patients to the Hospital ... The Governing Board shall appoint only those Practitioners meeting the qualifications prescribed in the Medical Staff Bylaws and other Hospital standards. The Medical Staff Bylaws shall set forth (a) the procedures by which, and criteria pursuant to which, appointments and reappointments are made and Clinical Privileges may be modified or terminated ... (d) the procedures and systems of governance of the Medical Staff ...".

Review on August 14, 2018, of facility document, "Medical Staff Bylaws and Rules and Regulations" dated June 2018, revealed "... Article XI - Action Affecting Medical Staff Members ... Section 1 - Procedure for Reappointment ... a. Any member of the Medical Staff who, at the designated time of processing the reappointment to the Medical Staff, wishes to be considered for a change in Medical Staff category or in clinical privileges, or who does not desire reappointment, shall so indicate on the appropriate form to the Executive Committee. All members of the Medical Staff who do not otherwise indicate otherwise shall be considered for reappointment to the same category of the staff with the same privileges they then hold unless the Executive Committee recommends otherwise. Reappointment to the Medical Staff will be done on a six months basis and will be valid for a two year period. Any practitioner who desires a change in clinical privileges or Medical Staff status during the term of appointment shall follow the reappointment procedures set forth ... b. Each member who wishes to be reappointed shall be responsible for renewing the initial application form and stating the on the reappointment form any material changes in the information given there ... The Medical Staff reappointment form shall be developed by the Medical Staff and approved by the Board ...".

Review on August 14, 2018, of CF1 revealed a clinical appointment in the category of " Department of Medicine ... Department of Medicine Division of Hospitalist Service ... Clinical Privileges ... Appointment 07/01/2016 - 06/30/2018 ... Requested ... Approved ...". Further review revealed this appointment period had expired June 30, 2018. Further review of CF1 approval letter revealed no documented evidence of reappointment and delineation of clinical privileges was granted after June 30, 2018.

Interview on August 14, 2018, with EMP4 at 11:19AM, confirmed no documented evidence of reappointment to the Active Medical Staff and delineation of clinical privileges was granted after June 30, 2018, for CF1.

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Based on review of facility policy and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to protect and promote the rights of each patient: by failing to ensure the patient participated in the treatment planning; by failing to ensure patient's family participated or was given the option to participate in patient's treatment; by failing to note whether or not the patient/family/significant other were present at the treatment team meeting (A0130); by failing to ensure consent for medication administration was completed and signed by the patient or family representative (A0131); by failing to use restraints in accordance with physician or other licensed independent practitioners' orders; and by failing to designate the use and type of restraint (A0168).

Cross Reference:
482.13(b)(1) Patient Rights: Participation in Care Planning
482.13(b)(2) Patient Rights: Informed Consent
482.13(e)(5) Patient Rights: Restraint or Seclusion

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the patient participated in patient treatment planning in one of eight medical records reviewed (MR33); and failed to ensure patient's family participated or was given the option to participate in patient's treatment planning and failed to note whether or not the patient/family/significant other were present at the treatment team meeting for three of eight medical records reviewed (MR1, MR33, MR34).
Findings include:
Review on August 15, 2018, of the facility policy "Interdisciplinary Treatment Policy, "no date revealed, "... 5.0 Procedure for Completing Interdisciplinary Treatment Plan ... F. The Patient/Family/Significant Other Involvement in Treatment Plan is completed by the assigned staff member and is based on the patient's consent for others to be involved in the treatment. The patient and family goals for treatment are written in their own words ... J. Patient's [sic] and their family/significant other should be involved in the treatment planning to the degree possible and as appropriate based on patient consent. The patient and family/significant other should complete this section after the Interdisciplinary Treatment Plan and Individual Treatment Plans have been reviewed with them ... K. It should be noted whether or not the patient/family/significant other were present at the treatment team meeting and if so the signatures of each person attending ... . "
Review on August 15, 2018, of MR1's, "Interdisciplinary Treatment Plan, dated June 4, 2018, revealed, there was no documentation of participation by patient 's family, as there was no patient family signature. Further revealed, family was to be involved. Further revealed, no documentation of patient family being present or why they were not present at Treatment Team Meeting.
Review on August 15, 2018, of MR33's, "Interdisciplinary Treatment Plan, dated August 2, 2018, revealed, there was no documentation of participation by patient or patient's family, as there were no patient signature or patient family signature. Further revealed, no documentation of whether patient wanted family involved or not involved in Treatment Plan. Further revealed, no documentation of patient or family being present or why they were not present at Treatment Team Meeting.
Review on August 15, 2018, of MR34's, "Interdisciplinary Treatment Plan, dated May 24, 2018, revealed, there was no documentation of participation by patient ' s family, as there was no patient family signature. Further revealed, no documentation of whether patient wanted family involved or not involved in Treatment Plan. Further revealed, no documentation of patient family being present or why they were not present at Treatment Team Meeting.
Interview with EMP1 on August 15, 2018 at approximately 2:30 PM, confirmed the above findings identified in the Interdisciplinary Treatment Plans related to MR1, MR33, and MR34.

Based on review of facility policy and procedures, facility documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the consent for medication administration was completed and signed by the patient or family representative for one of one of medical record reviewed (MR1).

Findings include:
Review on August 15, 2018, of facility policy, "Informed Consent Medications/Psychoactive" dated July 2017, revealed "... Purpose: To provide patients/guardians with information relative to all psychoactive medication given and to obtain consent from patients and/or guardians for the administration of said medication ... Procedure: A. The physician will discuss use of medications, reason for treatment, target symptoms, justification, risk of not using medication, and possible alternatives to medication with patient and/or guardian. The patient/guardian will be provided with information explaining their right to refuse ... C. The patient and/or guardian will be offered the opportunity to ask questions. D. The parent and/or guardian will sign the Informed Consent after reading the possible side effects ...".
Review on August 15, 2018, of facility policy, "Inpatient Behavioral Health Admission Criteria" dated October 2017, revealed "... Procedure ... 6. The patient is assigned a legal status to protect their rights and allow for treatment ... Have a legal guardian with the legal right to admit a patient to a mental health unit, who is willing to consent to admission and treatment; or have a Power of Attorney for which specifically includes a mental health clause; specifically allowing for mental health decisions, and they are willing to consent to admission, on the patient's behalf ...".
Review on August 15, 2018, of facility policy, "Decision-Making: Consent Requirements for Medical Treatment/Informed Consent" dated August 2018, revealed "... 2. Where patients cannot make their own decisions, respect for persons is upheld by recognizing the decision-making role of an appropriate alternate decision maker ...".
Review on August 15, 2018, of MR1 "Health Care Power of Attorney" revealed "... I appoint my daughter ... as my health care agent to make health decisions for me ... Effective immediately, my health care agent have full power and authority to: a. Request, receive and review any information, oral or written, regarding my physical or mental health ... d. The Health care power of attorney shall take precedence over my living will with such that my agent may exercise substituted judgment in all medical decision making ... h. Give consent to any medical procedure ... create, change and administer a medical treatment plan ...". Further review revealed signature of patient representative/POA for MR1.
1. Review on August 15, 2018, of MR1 revealed "Admit Diagnosis ... Altered mental status, unspecified ... Principal Diagnosis Alzheimer ' s disease, unspecified, Present on Admission: Y ... Secondary Diagnosis ... Dementia ... Present on Admission: Y ...".
Review on August 15, 2018, of MR1 revealed the patient was admitted to the Senior Behavioral Health Unit on June 1, 2018, for voluntary inpatient treatment with signed consent of a family representative/Power of Attorney. Further review of MR1, facility document, "Informed Health Consent for Medications" dated June 2, 2018, revealed "... My physician has prescribed Trazadone for the treatment of my psychiatric problems. My physician has discussed with me the nature of my psychiatric problems for which the above medication has been prescribed ... I understand that I may change my decision to accept medications and that if I change my decision I must inform the staff ... Having read the above, I have decided to voluntarily accept medications as prescribed for treatment of my psychiatric problem ... Patient Signature ... Relative or Legal Guardian (Signature) ... Relationship ... I have informed the patient of the possible risks and benefits of taking the medication and have explained the "side effects" frequently encountered by people taking this medication. It is my belief that the patient had the ability to understand the risks and benefits of taking the prescribed medication ... Physician Signature ... Date ...". Further review revealed no documented evidence of consent signature obtained by the patient or family representative for MR1.
2. Review on August 15, 2018, of MR1 "Senior Behavioral Health Unit - Physician Orders" dated June 1, 2018, revealed "... Medications: Lorazepam (Ativan) 1 mg PO/Intramuscular injection every 4 hours as needed for severe agitation and out of control behavior ... Ativan 0.5 mg by mouth every 6 hours as needed for anxiety or moderate agitation ...". Further review of MR1 revealed this medication was a new medication and was not listed as a previous medication prior to admission. Further review of MR1 revealed no documented evidence of patient of family representative consent form and signature obtained for the administration of Lorazepam for MR1.
Review on August 15, 2018, of MR1 "Physician Orders" dated June 3, 2018, revealed "... Klonopin 0.5 g am/6 pm Po D/C Trazadone ...". Further review of MR1 revealed this medication was a new medication and was not listed as a previous medication prior to admission. Further review of MR1 revealed no documented evidence of patient or family representative consent form and signature obtained for the administration of Klonopin for MR1.
Interview on August 15, 2018, with EMP6 between 3:00PM and 4:00PM, confirmed no documented evidence the consent for medication administration of Trazadone was obtained by the patient or family representative. Further interview confirmed documented evidence that the patient's family representative was the POA and the consent form should have been signed. Interview with EMP7 further confirmed Ativan and Klonopin were new medications and confirmed no documented evidence of patient or family representative consent for the administration of these medications. Further interview confirmed consent should have been obtained for MR1.

Based on review of facility policy and procedures, facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with physician or other licensed independent practitioners' (LIP) orders by failing to designate the reason for use of restraint for five of five restraint orders; failing to designate the type of restraint for three of three restraint orders for one of one medical records reviewed (MR1).
Findings include:
Review on August 16, 2018, of facility policy "Restraint Non-Violent" dated July 2018, revealed "... 2. All patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 3. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others ... 10. The type or technique of restraint used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm ... 12. The use of restraint is in accordance with the order of a physician or other LIP who is responsible for the care of the patient ...".
Review on August 16, 2018, of MR1 revealed the patient was admitted to Medical Unit on June 6, 2018. Further review revealed documented evidence of the patient in restraints June 7, 2018 to June 11, 2018. Further review revealed bilateral wrist restraints were used as the form of restraint.
1. Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 7, 2018, revealed "... Physician: Complete the following ... Reason for Use (check one) ... Prevent Dislodging of tubes, lines or other medical equipment ... Other ... Prevent inadvertent injury ... Date 6/7/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the designated Reason for Use of the Restraint for MR1.
Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 8, 2018, revealed "... Physician: Complete the following ... Reason for Use (check one) ... Prevent Dislodging of tubes, lines or other medical equipment ... Other ... Prevent inadvertent injury ... Date 6/8/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the designated Reason for Use of the Restraint for MR1.
Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 9, 2018, revealed "... Physician: Complete the following ... Reason for Use (check one) ... Prevent Dislodging of tubes, lines or other medical equipment ... Other ... Prevent inadvertent injury ... Date 6/9/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the designated Reason for Use of the Restraint for MR1.
Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 10, 2018, revealed "... Physician: Complete the following ... Reason for Use (check one) ... Prevent Dislodging of tubes, lines or other medical equipment ... Other ... Prevent inadvertent injury ... Date 6/10/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the designated Reason for Use of the Restraint for MR1.
Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 11, 2018, revealed "... Physician: Complete the following ... Reason for Use (check one) ... Prevent Dislodging of tubes, lines or other medical equipment ... Other ... Prevent inadvertent injury ... Date 6/11/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the designated Reason for Use of the Restraint for MR1.
2. Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 7, 2018, revealed "... Physician: Complete the following ... Type of Restraint (Check all that apply) ... Soft Wrist ... bilateral ... L only ... R only ... Soft Ankle ... bilateral ... L only ... R only ... Vest ... Geri Chair with Tray ... 4 Side Rails Up ... Date 6/7/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the Type of Restraint to be utilized for MR1.
Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 10, 2018, revealed "... Physician: Complete the following ... Type of Restraint (Check all that apply) ... Soft Wrist ... bilateral ... L only ... R only ... Soft Ankle ... bilateral ... L only ... R only ... Vest ... Geri Chair with Tray ... 4 Side Rails Up ... Date 6/10/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the Type of Restraint to be utilized for MR1.
Review on August 16, 2018, of MR1 physician "Non-Violent Restraint Order" dated June 11, 2018, revealed "... Physician: Complete the following ... Type of Restraint (Check all that apply) ... Soft Wrist ... bilateral ... L only ... R only ... Soft Ankle ... bilateral ... L only ... R only ... Vest ... Geri Chair with Tray ... 4 Side Rails Up ... Date 6/11/2018 Time 20:00 ... Physician Signature ... RN Signature ...". Further review of MR1 revealed documented evidence of Physician and RN signature on the Order. Further review revealed no documented evidence of the Type of Restraint to be utilized for MR1.
Interview on August 16, 2018, with EMP1 and EMP2 at 12:05 PM, confirmed no documented evidence of the designated reason for use or type of restraint to be utilized on the Non-Violent Restraint Order as specified on the dates above for MR1. Further interview confirmed the order should have been completed in its entirety.

Based on review of facility policies and procedures, review of facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure the QAPI program involved the review of specific quality indicators for all hospital services including the discharge planning process.

Findings include:

Review on August 15, 2018, of the facility policy, "Performance Improvement Plan", dated July 2018, revealed "... Goal and Objectives: ... to provide a comprehensive Performance Improvement Program that will coordinate and integrate ALL performance improvement activities (HOSPITAL) - wide to assure that the highest achievable safe and quality of care is delivered throughout the (HOSPITAL) ... ."

A request was made to EMP1 for documented evidence of the QAPI ongoing monitoring, review and analysis of specific performance indicators and/or data elements related to the reassessment of the discharge planning process, including reassessment and tracking of all readmissions. None provided.

Review on August 15, 2018, of facility's, "Quality Council" meeting minutes, dated January 2018 through June 2018, revealed no documented evidence of reassessment of the discharge planning process on an ongoing basis. Further revealed, no documented evidence of assessment and tracking of all readmissions, which includes an evaluation of whether the readmissions were potentially preventable.

Review on August 15, 2018, of facility's, " ... Governing Board Bylaws" dated June 7, 2018, revealed, " ... 3.8 Duties: ... The current duties of the Governing Board are as follows: ... (n) Require the development of a Performance Improvement Program that includes a mechanism for ... reviewing and monitoring the Performance Improvement Program and the quality of patient care rendered at the Hospital on an ongoing basis, ... ."

Review on August 15, 2018, of facility's, "2018 Performance Improvement Dashboard," revealed no documented evidence of reassessment of the discharge planning process on an ongoing basis. Further revealed, no documented evidence of assessment and tracking of all readmissions, which includes an evaluation of whether the readmissions were potentially preventable.

Interview with EMP2 and EMP3, on August 15, 2018, between 1:30 and 2:30 PM, confirmed there was no documented evidence of the ongoing monitoring, review, and analysis of specific performance indicators and/or data elements for the discharge planning process. Further confirmed, all readmissions are not tracked and assessed.

Based on review of facility policies and procedures, facility documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure adopted policies and procedures were followed for administration of medications for one of one medical records reviewed (MR1).
Findings include:
Review on August 15, 2018, of facility policy, "Standard of Medication Administration" dated June 2018, revealed "Purpose: To provide guidelines in administering medications ... Patients' Rights: As with all medications, it is the nurse's responsibility for observing the six rights as well as having knowledge of indications, contraindications, side effects and administration protocol ... Six Right: Right Medication ... Right Dose ... Right time ...".
Review on August 15, 2018, of facility policy, "Medication Management" dated August 2018, revealed "... Administering ... Before administering a medication, the nurse will verify selection is correct, stability, no contraindications, proper time, prescribed dose, correct route and correct patient ...".
Review on August 15, 2018, of MR1 "Physician Orders" dated June 1, 2018, revealed "... Medications: Lorazepam (Ativan) 1mg PO/Intermuscular injection every 4 hours as needed for severe agitation and out of control behavior ...".
Review on August 15, 2018, of MR1 "Medication Administration Record (MAR)" revealed documented evidence Ativan 1mg PO was administered to the patient on "6/3/18 9:30AM ... 6/7/18 10:30AM ... 6/8/18 00:55 ... 6/9/18 20:30 ... 6/10/18 05:15 ... 6/10/18 11:35 ... 6/10/18 17:02 ... 6/10/18 20:40 ... 6/11/18 10:25 AM ...". Further review revealed Ativan 1mg PO administered on "6/10/18 20:40" was not administered at the proper time. Further review revealed Ativan 1mg PO was administered too soon and was given before the four (4) hour time frame as prescribed, according to physician orders.

Interview on August 15, 2018, with EMP6 between 3:00PM and 4:00PM, confirmed Ativan 1mg PO administered on "6/10/18 20:40" was administered too soon and was given before the four (4) hour time frame as prescribed, according to physician orders.

Based on review of facility policy and procedures, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure adopted policies and procedures were followed for clarification of medication orders for one of one medical records reviewed (MR1).

Findings include:

1. Review on August 16, 2018, of facility policy, "Clarification of Medication Orders" dated August 2017, revealed "Purpose: A: To establish and implement the processes and procedures to assure that incomplete, conflicting and incompatible orders are corrected and any required missing information is obtained prior to dispensing and administration of medication. B. To avoid medication errors due to ambiguous, incomplete or conflicting orders for medications ... Policy: 1. Medication orders that are compatible appear to conflict with clinical issues or established policies and procedures regarding medication use shall be clarified and/or verified by the pharmacist ... b. Medications ordered for the same indication, without clearly indicating circumstances in which to administer either medication (i.e. mild vs. moderate pain, nausea/vomiting vs. refractory nausea/vomiting). 2. All clarifications of prescribers' orders shall be documented in patients' medical records. Procedure: A. Pharmacists shall review orders for medications for appropriateness. The pharmacist shall intervene regarding any orders that require clarification or are inconsistent with approved policies and procedures and standards of practice regarding medication use, including circumstances when additional information is needed to complete the required elements of the order ... B. The pharmacist shall contact the physician to discuss any orders that require clarification or completion ... a. ... iv. All other information that was obtained to verify and/or clarify the order, including but not limited to monitoring parameters or indications for use ...".

Review on August 16, 2018, of MR1 "Physician Orders" dated June 1, 2018, revealed "... Medications: Lorazepam (Ativan) 1 mg PO/Intramuscular injection every 4 hours as needed for severe agitation and out of control behavior ...". Further review revealed a PO route for Ativan and an Intramuscular Route for the same indication of the medication. Further review revealed no documented evidence of any clear indication or circumstances of which route to select to administer either medication. Further review of MR1 revealed no documented evidence that the pharmacist clarified the order with the prescribing physician. Review on August 16, 2018, of MR1 "Medication Administration Record (MAR)" revealed Ativan 1 mg PO was administered to the patient "6/3/18 9:30AM ... 6/7/18 10:30AM ... 6/8/18 00:55 ... 6/9/18 20:30 ... 6/10/18 05:15 ... 6/10/18 11:35 ... 6/10/18 17:02 ... 6/10/18 20:40 ... 6/11/18 10:25 AM ...".

Interview on August 16, 2018, with EMP8 and EMP9 at 2:40PM, confirmed the Ativan prescribed had the same indication for the PO and Intramuscular route. Further interview confirmed the order for the medication should have a clear indication for use between the two routes and that the medication order should have been clarified.

2. Review on August 16, 2018, of facility policy, "Clarification of Medication Orders" dated August 2017, revealed Review on August 16, 2018, of facility policy, "Clarification of Medication Orders" dated August 2017, revealed "Purpose: A: To establish and implement the processes and procedures to assure that incomplete, conflicting and incompatible orders are corrected and any required missing information is obtained prior to dispensing and administration of medication ... Procedure: A. Pharmacists shall review orders for medications for appropriateness ... ...B. The pharmacist shall contact the physician to discuss any orders that require clarification or completion ... E. Indication for Use of a PRN Medication is Missing a. The orders for PRN medications will not be completely reviewed or processed without documentation of the indication for use b. If a verbal or telephone order, all such orders will be referred to the nurse on the nursing unit for clarification and completion prior to pharmacist completing the review and processing the order. c. If directly written/ordered by prescriber, the pharmacist will contact the prescriber for clarification and completion prior to the pharmacist completing the review and processing the order ...".

Review on August 16, 2018, of facility policy, "Standard of Medication and Administration" dated June 2018, revealed "... AS NEEDED "PRN" ORDERS ... The indication for use must be specified with PRN orders ...".

Review on August 16, 2018, of MR1 "Medication Administration Record (MAR)" revealed "... Order Date 6/11 ... Klonopin 0.5mg PO BID PRN ...". Further review revealed no documented evidence of the indication for use of the medication. Further review of MR1 revealed no documented evidence that the pharmacist clarified the order with the prescribing physician. Further review of MR1 MAR revealed Klonopin 0.5mg PO was administered to the patient on June 11, 2018, at 21:10.

Review on August 16, 2018, of MR1 "Medication Administration Record (MAR)" revealed "... Order Date 6/11 ... Percocet 5/325 I tab PO q6h PRN ...". Further review revealed no documented evidence of the indication for use of the medication. Further review of MR1 revealed no documented evidence that the pharmacist clarified the order with the prescribing physician. Further review of MR1 MAR revealed Percocet 5/325 PO was administered to the patient on June 11, 2018, at 2:45.

Review on August 16, 2018, of MR1 "MAR" dated June 7, 2018, revealed "... Order Date 6/7/18 ... Ativan 1 mg IV x 1 dose now ...". Further review revealed no documented evidence of the indication for use of the medication. Further review of MR1 revealed no documented evidence that the pharmacist clarified the order with the prescribing physician. Further review of MR1 "MAR" revealed Ativan 1mg IV was administered to the patient on June 7, 2018, at 00:30.

Interview on August 17, 2018, with EMP8 at 11:30AM, confirmed no documented evidence of the indication for the use of Klonopin and Percocet PRN orders. Interview also confirmed no documented evidence of the indication for the use of the Ativan order. Further interview confirmed the use for the medications should have been indicated and that the medication orders should have been clarified.

Based on review of facility policies and procedures, facility documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to transfer patients to another facility with the necessary medical information on the transfer form to ensure post discharge continuity of care for one of one medical records reviewed (MR1).
Findings include:
Review on August 15, 2018, of facility policy, "Transfer Policy: Acute, LTAC, Skilled Nursing Facility, and Sub-Acute Placement" dated August 2018, revealed "Purpose: The purpose of this policy is to ensure that a patient requesting or requiring a transfer is transferred appropriately for further medical care and follow up ... 4. Non Acute Transfer: Physician Duties: ... Review and sign patient transfer form ... Nursing/Case Management/Discharge Planner Duties: ... Send copies of all pertinent medical records which generally includes the following: Completed SNF Patient Transfer Form ...MD Signed Medication Reconciliation sheets (on patient transfer form) ...".
Review on August 15, 2018, of facility policy, "Medication Reconciliation/Medication History" dated May 2018, revealed "Purpose: Medication reconciliation is the process of identifying the most complete and accurate list of medications a patient is taking and using this list to provide correct medications for the patient during hospitalization and then at discharge ... Procedure ... 2. As part of the nursing admission assessment process, all home medications will be entered into Exit Care, the nurse will print the input form, then the medications will be reconciled with Physicians Orders and a status report will be printed and signed by the RN ... 3. The physician/licensed practitioner will complete and sign the Input Form upon discharge. The nurse will enter the information into Exit Care, including all new medications ... 5. Upon discharge the nurse will review all medications and changes with the patient ...".
Review on August 15, 2018, of facility policy, "Discharge Planning" dated October 2017, revealed "... The discharge plan includes: expected disposition ... referrals for follow-up ... patient medications at the time of discharge. The plan is implemented by appropriate disciplines, including physicians, nurses, social work services ... case managers ...".
1. Review on August 15, 2018, of MR1 revealed the patient was discharged and transferred to a skilled nursing facility on June 12, 2018 for further management of care. Further review of MR1 revealed documented evidence the patient was taken for a right ureteral stent on June 7, 2018, for right hydronephrosis and became hypotensive during the procedure and remained hypotensive post-op and later developed a urinary tract infection which continued to improve with antibiotics. Further review revealed the plan was changed to have lithotripsy on an outpatient basis on June 10, 2018. Further review revealed the patient was improving medically, with slow gains in baseline mentation and the POA decided to have the patient transferred to a skilled nursing facility on June 12, 2018.
Review on August 15, 2018, of MR1 "Patient Transfer Form" dated June 12, 2018, revealed a designated section for Consultants and Follow Up Appointments to be completed. Further review revealed no documented evidence the section for Consultants and Follow Up Appointments was completed. Further review revealed no documented evidence of follow up for Lithotripsy on the Patient Transfer Form.
2. Review on August 15, 2018, of MR1 "Patient Drug Verification" dated June 11, 2018, revealed "... Ativan 1 mg PO/IM q 4 prn severe agitation ... Ativan 0.5mg PO q6h prn mod anxiety ... Dilaudid 0.5mg IV q 4 prn pain ... Klonopin 0.5mg PO daily ...". Further review revealed documented evidence of physician signature on patient drug verification form "13:00 ".
Review on August 15, 2018, of MR1 "Physician Orders" dated June 11, 2018, revealed "... D/C Ativan ... change Klonopin to PRN ... D/C all narcotics ... Percocet 5/325 1 tab q 4 hrs PRN ..." with documented evidence of physician signature. Further review revealed orders were checked and signed off "6/11/18 17:35". Further review of MR1 physician orders revealed no further changes made to the medications prescribed after June 11, 2018.
Review on August 15, 2018, of MR1 "EXITCARE PATIENT INFORMATION" dated June 12, 2018, revealed "... Drug Summary: Stop taking these medications ... Take these medications: Status: New: Dilaudid 4mg/ml Solution for injection 0.5mg as needed for pain every 4 hours ... New: Ativan 1mg Tablet 1 tab as needed for severe agitation every four hours ... New: Ativan 0.5mg Tablet 1 tab orally by mouth as needed for anxiety every 6 hours ... Klonopin 0.5mg Tablet 1 tab orally by mouth 1 time a day ...". Further review revealed no documented evidence of the medication changes made by the physician on June 11, 2018, "... D/C Ativan ... change Klonopin to PRN ... D/C all narcotics ... Percocet 5/325 1 tab q 4 hrs PRN ..." were reconciled and transferred over accurately.
Review on August 15, 2018, of MR1 "Patient Transfer Form" dated June 12, 2018, revealed "... Discharge Instructions ... 3. Medication Treatments and Therapies: ... Ativan 1 mg PO/IM q 4 prn severe agitation, Ativan 0.5mg PO q 6 prn mod anxiety ... Dilaudid 0.5mg IV q 4 prn pain ... Klonopin 0.5mg PO daily ...". Further review revealed documented evidence of physician signature on transfer form. Further review revealed no documented evidence of the medication changes made by the physician on June 11, 2018, "... D/C Ativan ... change Klonopin to PRN ... D/C all narcotics ... Percocet 5/325 1 tab q 4 hrs PRN ..." were reconciled and transferred over accurately on the transfer form being sent to the receiving facility.
Interview on August 15, 2018, with EMP6 between 3:00 and 4:00PM, confirmed the medications as specified above were listed on the Patient Drug Verification, ExitCare Patient Information and Patient Transfer Form. Further interview confirmed documented evidence of the mediation changes prescribed by the physician on June 11, 2018, "... D/C Ativan ... change Klonopin to PRN ... D/C all narcotics ... Percocet 5/325 1 tab q 4 hrs PRN ...". Further interview confirmed no documented evidence these medications were reconciled and transferred over accurately on the transfer form being sent to the receiving facility. Interview also confirmed no further medication changes were made on the "Physician Orders" after June 11, 2018. Interview with EMP6 further confirmed the orders should have been rechecked and the medications reconciled.

Based on review of facility policies and procedures, review of facility documents, and interviews with staff (EMP), it was determined the facility failed to reassess its discharge planning process, including tracking and assessing of all readmissions identifying potentially preventable readmissions on an on-going basis.

Findings include:

Review on August 15, 2018, of the facility policy, "Performance Improvement Plan", dated July 2018, revealed "... Goal and Objectives: ... to provide a comprehensive Performance Improvement Program that will coordinate and integrate ALL performance improvement activities (HOSPITAL) - wide to assure that the highest achievable safe and quality of care is delivered throughout the (HOSPITAL) ... ."

A request was made on August 15, 2018 to EMP1 for documented evidence of QAPI's ongoing monitoring, review and analysis of specific performance indicators and/or data elements related to the reassessment of the discharge planning process, including reassessment and tracking of all readmissions. None provided.

Review on August 15, 2018, of facility's, "Quality Council" meeting minutes, dated January 2018 through June 2018, revealed no documented evidence of reassessment of the discharge planning process on an ongoing basis. Further revealed, no documented evidence of an assessment and tracking of all readmissions, which includes an evaluation of whether the readmissions were potentially preventable.

Review on August 15, 2018, of facility's, "2018 Performance Improvement Dashboard," revealed there was no documented evidence of the reassessment of the discharge planning process on an ongoing basis. Further revealed, no documented evidence of an assessment and tracking of all readmissions, which includes an evaluation of whether the readmissions were potentially preventable.

Interview with EMP1, EMP7 and EMP22, on August 15, 2018, between 1:30 and 2:30 PM, confirmed there was no documented evidence of the ongoing monitoring, review, and analysis of specific performance indicators and/or data elements for the discharge planning process. Further confirmed, all readmissions are not tracked and assessed.