HospitalInspections.org

Based on observation, interview, record review and document review, the facility failed to:

1) To identify discharge planning needs in a patient with documented barriers to continued treatment and care (See Tag A0800).

2) Ensure a patient was re-evaluated for discharge needs after experiencing a change in condition (See Tag A0802).

3) Ensure a discharge planning evaluation was included in the patient's record (See Tag A0808).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated care to its patients.

Based on interview, clinical record review, and document review, the facility failed to identify discharge planning needs in a patient with documented barriers to continued treatment and care for 3 of 45 sampled patients (Patient 23, 29, and 17).

Findings include:

1) Patient 23 (P23) was admitted to the facility on 04/09/22, and discharged on 04/10/22, with diagnoses including stage IV breast cancer and malignant pleural effusion.

A Registered Nurse Progress Note for P23, dated 04/09/22, documented the patient was Spanish speaking only. The patient was on two liters per minute of oxygen and the family advised the patient did not have oxygen at home but had been trying to get an order for home oxygen.

The oxygen therapy flowsheet for P23, documented home oxygen was requested by the patient on 04/10/22 at 10:53 AM.

The Discharge Summary for P23, dated 04/10/22, documented the patient's family informed the physician the family had requested home oxygen from the patient's oncologist's office. The patient's family had communicated to the physician the patient wanted to be discharged home because the patient did not have insurance and was concerned about hospital bills. The patient did not have a primary care physician.

On 05/25/22 at 1:48 PM, a Quality Coordinator (QC) confirmed the electronic health record (EHR) for P23 lacked discharge planning notes and orders for discharge planning. The QC verbalized if the patient had been sent home with oxygen or if oxygen had been ordered for the patient this information would be documented on the After Visit Summary (AVS). The QC confirmed the AVS did not indicate the patient had received oxygen or an order for oxygen at discharge.

On 05/26/22 at 9:10 AM, the Director of Clinical Excellence confirmed a patient's report of lack of insurance, concerns with paying for necessary medical care, and being non-English speaking were all potential barriers to care and should have triggered a discharge planning evaluation. The Director of Clinical Excellence confirmed the EHR for P23 lacked documentation the patient's request for home oxygen was communicated to a discharge planner.



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2) Patient 29 (P29) was admitted to the facility on 05/09/22 with a diagnosis of hyponatremia. The patient was a transfer from another facility, for subspecialty care.

P29's Pulmonary and Critical Medicine History and Physical examination dated 05/09/22, documented P29 had a history of cerebral palsy, was non-verbal and lived in rural area, with mother. The patient was taken by Emergency Medical Services to a local facility on 05/09/22 for complaints of pain and shaking. After being treated for constipation and an episode of supraventricular tachycardia, patient was transferred to this facility for subspecialty care. The history was obtained from healthcare providers, the medical record, and the mother at bedside with the use of Spanish speaking interpreter.

P29's Hospital Medicine Daily Progress Note, dated 05/15/22, documented patient was noted to have bacteremia secondary to an 8-millimeter (mm) left ureteral stone with obstruction and hydronephrosis. Patient was evaluated by urology and underwent cystoscopy with left ureteral stent placement and placement of Foley catheter. Urology recommended to keep the Foley catheter in place and plan for left contact ureteral lithotripsy in two to three weeks.

On 05/24/22 at 12:55 PM, the Director of Case Management verbalized the initial assessment to identify discharge planning needs was done on all patients in the first 24-48 hours. After the initial assessment, if the team talked about patients during the rounds and the plan was for patients to go home without needing anything from the case management, a note had to be entered under the discharge planning tab in the EHR, documenting the patient was ready to go home pending medical clearance and no case management was needed at the time.

P29's EHR lacked documented evidence of an initial assessment to identify discharge planning or case management needs.

On 05/25/22 at 2:10 PM, QC2 verbalized P29's evaluation for discharge needs and barriers to discharge was not completed. Patient was non-verbal, had a Foley catheter and lived with mother, only Spanish speaker. The QS confirmed the EHR for P29 lacked discharge planning documentation.

On 05/26/22 at 9:10 AM, the Director of Clinical Excellence confirmed the EHR for P29 lacked documentation of a discharge planning.

The facility Case Management "Standard Work: Discharge Planning," for Care Management Social Workers and Registered Nurses Case Manager, approved on 09/2020, documented the Care Management team was to ensure all patients had a chart note every 72 hours minimum.



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3) Patient 17 (P17) was admitted to the facility on 03/14/22, with diagnoses including congestive heart failure (CHF), diabetes, sleep apnea, morbid obesity, and respiratory failure.

P17 was discharged on 03/19/22, and then returned and was placed in observation status on the telemetry unit on 03/22/22 through 03/25/22, then returned to the emergency department (ED) on 03/26/22, 03/27/22, 04/25/22, 04/26/22, 05/11/22, and was again readmitted to the hospital on 05/16/22. During the 05/16/22 admission, P17 was placed in the Intensive Care Unit (ICU) and was intubated.

P17's Emergency Department Provider Note, dated 03/15/22, documented P17 presented to the ED due to dyspnea and body aches. P17 had previously been discharged from the ED on 03/10/22, with a prescription for ketorolac to treat pericarditis. P17 reported to the ED physician they were unable to fill the prescription due to social factors and homelessness.

P17's Critical Care Consultation, dated 03/15/22, documented P17 had multiple rapid responses due to worsening respiratory function and lethargy. P17 was transferred to the ICU for bilevel positive airway pressure (BIPAP - machines have two air pressure setting one for the inhalation phase and one for exhalation, allowing users to breathe more naturally) therapy and airway monitoring.

On 03/16/22, the Attending Physician documented P17 had "multiple admissions of acute hypoxic/hypercapnic respiratory failure who is now admitted for another episode of acute hypercapnic resp failure, started on BiPaP" and "Respiratory failure likely from his suboptimal use of BiPaP after discharge. This has been an ongoing issue resulting in recurrent hospital admissions"

P17's Care Transition Team Assessment, dated 03/17/22, documented discharge risks and barriers to discharge included bariatric, complex medical needs, living alone, lack of outside support, and homelessness. The discharge disposition documented a discharge home to self-care.

P17's Registered Nurse Case Management note, dated 03/17/22, documented an assessment was completed through a chart review, the patient was homeless, could not go to a homeless shelter due to being wheelchair bound, had no family support, had no primary care physician, and barriers to discharge included homelessness.

P17's Pulmonary Attending Note, dated 03/18/22, documented P17 had severe restrictive lung disease, needed BiPaP routinely, and the physician would order ongoing BiPaP use at discharge if the facility was able to support a better social situation for the patient.

P17's Pulmonary Consult Note, dated 03/18/22, documented P17 reported being unable to use continuous positive airway pressure (CPAP - machines which direct pressured air into a user's airway while they sleep which keeps air passages open and ensure the user can breathe properly, allowing the user to avoid pauses in breathing) while not in the hospital due to being homeless and having nowhere to plug the machine in.

P17's Hospital Medicine Daily Progress Note, dated 03/18/22, documented P17 continued to need BiPaP at bedtime and during naps.

P17's Licensed Social Work (LSW) note, dated 03/19/22, documented P17 requested placement in another medical facility. The LSW explained to P17 they were not medically qualified to remain in the hospital, no skilled nursing facility (SNF) would accept the patient, and the patient's only option was to discharge back to the street. The LSW documented a conversation with P17's representative which indicated the representative expressed concern about the discharge as P17 was unable to care for themself and the LSW explained P17's only option for discharge was back to the street.

P17's clinical record lacked documented evidence of discharge planning including placement to SNF or group homes, the need for ongoing BiPaP /CPAP use, and a primary care provider (PCP) referral and appointment.

On 05/25/22 at 1:20 PM, a Quality Coordinator (QC) confirmed the clinical record for P17 lacked documented evidence of SNF or group home placement referrals, BiPaP /CPAP management, or a PCP appointment, and transportation. The QC verbalized if the patient had been discharged with BiPaP /CPAP the information would be documented on the After Visit Summary (AVS). The QC confirmed the AVS did not indicate the patient had received BiPaP /CPAP, a PCP referral, a scheduled appointment, or transportation planning for appointments after discharge.

On 05/25/22 at 2:00 PM, the Registered Nurse Case Management Manger (RNCM Manager) The RNCM Manager confirmed the patient was well known to the facility and had not been referred for SNF placement during this admission.

On 05/25/22 at 2:15 PM, the LSW Manager verbalized the first evaluation of a patient's discharge needs occurs within 24-72 hours of admission and after a change in condition. The LSW Manager verbalized P17's evaluation was completed by a chart review and confirmed a reevaluation for discharge needs and barriers to discharge was not completed after the patient was transferred to telemetry when released from the ICU. The LSW Manager verbalized they were unable to provide documented evidence of when SNF referrals were completed for P17.

On 05/25/22 at 3:00 PM, P17 was in bed and intubated. P17 was alert and oriented and used a white board with a marker to write the patient had been requesting assistance for placement in a SNF for three years due to being unable to care for themselves and being homeless. P17 became agitated and wrote "frustrated, can't walk, can't take care of myself, and they (the hospital) won't listen to me".

The facility policy titled "Patient Discharge," dated 10/11/21, documented the planning for a patient's discharge began at admission. The process for discharge of a patient with a physician order included assessing for discharge planning needs prior to discharge and healthcare staff would notify the Hospital Care Management team of any discharge needs identified during the patient's stay so they could be addressed in a timely manner.

The facility "Patient Welcome Guide," undated, documented the patient was to notify the care team if there were concerns about caring for themselves at home.

The facility policy "Patient Rights and Responsibilities," dated 09/07/21, documented patients had the right to know what their ongoing health care requirements were after discharge, to request or refuse treatment, to participate in their discharge planning and outpatient discharge plan, patients or representatives would have any reasonable request satisfied by the facility if it was able to do so, and transfer to another facility would be arranged if the facility was unable to provide the services needed by the patient.

Based on interview, clinical record review, and document review the facility failed to ensure a patient was re-evaluated for discharge needs after experiencing a change in condition for 1 of 45 patients (Patient 17).

Findings include:

Patient 17 (P17) was admitted to the facility on 03/14/22, with diagnoses including congestive heart failure (CHF), diabetes, sleep apnea, morbid obesity, and respiratory failure.

P17 was discharged on 03/19/22, and then was placed in observation status on the telemetry unit on 03/22/22 through 03/25/22, then returned to the emergency department (ED) on 03/26/22, 03/27/22, 04/25/22, 04/26/22, 05/11/22, and again readmitted to the hospital on 05/16/22, where he was placed in the intensive care unit (ICU) and was intubated at the time of the survey.

On 03/16/22, the Attending Physician documented P17 has had "multiple admissions of acute hypoxic/hypercapnic respiratory failure who is now admitted for another episode of acute hypercapnic resp failure, started on BiPaP" and "...respiratory failure likely from his suboptimal use of BiPaP after discharge. This has been an ongoing issue resulting in recurrent hospital admissions".

P17's Critical Care Consultation, dated 03/15/22, documented P17 had multiple rapid responses due to worsening respiratory function and lethargy. P17 was transferred to the intensive care unit (ICU) for bilevel positive airway pressure (BiPaP) therapy and airway monitoring.

P17's Care Transition Team Assessment, dated 03/17/22, documented discharge risks and barriers to discharge included bariatric, complex medical needs, living alone, lack of outside support, and homelessness. The discharge disposition documented a discharge home to self-care.

P17's Registered Nurse (RN) Case Manager Progress Note, dated 05/23/22, indicated the patient had a lapse in Medicare between December 2021, through January 2022, however, the patient received payment from Social Security during those months. The record documented the patient wanted to apply for Medicare and the RN Case Manager forwarded the patient request to the patient financial advisor.

On 05/25/22 at 2:15 PM, the Licensed Social Work (LSW) Manager verbalized the first evaluation of a patient's discharge needs occurs within 24-72 hours of admission and after a change in condition. The LSW Manager verbalized P17's evaluation was completed by a chart review and confirmed a reevaluation for discharge needs and barriers to discharge was not completed after the patient was transferred to telemetry when released from the ICU.

The facility policy titled "Patient Discharge," dated 10/11/21, documented the planning for a patient's discharge began at admission. The process for discharge of a patient with a physician order included assessing for discharge planning needs prior to discharge and healthcare staff would notify the Hospital Care Management team of any discharge needs identified during the patient's stay so they could be addressed in a timely manner.

Based on interview, clinical record review, and document review the facility failed to ensure a discharge planning evaluation was included in the patient's record for 3 of 45 patients (Patient 11, 12, and 19).

Findings include:

1) Patient 11 (P11) was admitted to the facility on 03/07/22, and discharged on 03/13/22, with diagnoses including hypertension and recurrent cellulitis.

P11's UNSOM Family Medicine Discharge Summary, dated 03/13/22, documented P11 had been hospitalized for a similar finding on 03/02/22 and discharged on 03/06/22.

P11's clinical record lacked documented evidence of a discharge needs evaluation.

2) Patient 12 (P12) was admitted to the facility on 03/11/22, and discharged on 03/13/22, with diagnoses including shortness of breath, community acquired pneumonia, and acute hypoxic respiratory failure.

P12's Discharge Summary, dated 03/13/22, documented P12 was to be discharged with home oxygen, medications including Augmentin, prednisone, and albuterol, and was advised to schedule an outpatient appointment for pulmonary function testing.

P12's clinical record lacked documented evidence of a discharge needs evaluation.

3) Patient 19 (P19) was admitted to the facility on 03/15/22, and discharged on 03/19/22, with diagnoses of urinary tract infection, sepsis, and acute pyelonephritis.

P19's Discharge Summary, dated 03/19/22, documented P19 had no primary care physician, needed to follow-up with a Urologist, and needed close outpatient follow-up.

P19's clinical record lacked documented evidence of a discharge needs evaluation.

On 05/25/22 at 1:20 PM, a Quality Coordinator (QC) confirmed the clinical record for P11, P12, and P19 lacked documented evidence of a discharge needs evaluation.

On 05/25/22 at 2:00 PM, the Registered Nurse Case Management Manger (RNCM Manager) verbalized all patients were to be seen for a discharge needs evaluation within 24 - 48 hours of admission.

On 05/25/22 at 2:15 PM, the Licensed Social Work Manager (LSW Manager) verbalized the first discharge needs evaluation of a patient occurs within 24-72 hours of admission unless they were notified of discharge planning needs. The LSW Manager confirmed the need for home oxygen, outpatient testing, and referrals for ongoing outpatient care should trigger a discharge needs evaluation. The LSW Manager verbalized patient referrals are obtained through staff reporting and interdisciplinary rounds.

The facility policy titled "Patient Discharge," dated 10/11/21, documented the planning for a patient's discharge began at admission. The process for discharge of a patient with a physician order included assessing for discharge planning needs prior to discharge and healthcare staff would notify the Hospital Care Management team of any discharge needs identified during the patient's stay so they could be addressed in a timely manner.