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Based on medical record review, policy review and staff interview, it was determined that for 3 of 5 patients in the sample (Patient #'s 1, 4 and 5), nursing staff failed to conduct comprehensive patient assessments and/or implement physician's orders. Findings include:

The hospital policy entitled "Nursing Standards of Care" stated, "...all patients admitted...will have their nursing care delivered in accordance with established standards of care and practice...Assessment Standard of Care: The patient will be assessed by the nurse in a timely, comprehensive, accurate and systematic manner..."

The hospital policy entitled "Chart Documentation Requirements" stated, "...The progress notes document...a precise assessment of the patient's progress in accordance with the original or revised Treatment Plan...Documentation in the progress notes...must document...results of...evaluations of the patient and findings by staff involved in the care of the patient..."

The hospital policy entitled "Vital Signs" stated, "...patients will have vital signs taken...Vital signs include...pulse...Document findings...abnormal findings should be reported to the Charge Nurse and physician..."

I. Patient #1

Review of the medical record revealed:

A. "Medical Consultation"
- 9/29/12 at 12:00 PM: Extremities: 2+ edema (swelling) in legs bilaterally

B. "Physician's Orders"
- 9/29/12 at 12:00 PM: Bilateral lower extremity compression stockings

C. "Medication Administration Record (MAR)"
- Included a treatment for the application of bilateral lower extremity compression stockings every morning at 8:00 AM
- Staff documented "N/A" (not applicable) for the physician ordered treatment on 9/29, 10/1, 10/2, 10/3, 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10 and 10/11/12
- Staff documented patient refused application of stockings on 9/30/12, however, no reason for refusal was documented

D. "Progress Record"
- 9/29 - 10/11/12: No evidence to support why the patient refused compression stockings and/or why staff failed to apply compression stockings as ordered by the physician.

Medical record review revealed and interview with the Director of Nursing (DON) on 12/5/12 at 1:00 PM confirmed that there was no evidence that the physician was notified of the inability to implement the physician's order for compression stockings. In addition, the DON reported the following:

- Staff should have documented why the compression stockings were refused and/or not applied
- Patient refusals should have been documented as refused and not "N/A"
- The physician should have been notified when it was determined that the physician's order could not be implemented

II. Patient #4

Review of the medical record revealed:

A. "Progress Record"
- 11/23/12 11:00 AM "Medical MD Note":
Physician C reported "pt seen today for...L (left) foot Athletes foot..."

B. "Consultation Form"
- 11/23/12 - Physician C identified the presence of a left foot wound and documented, "...denied pain...lots of buildup between toes...maceration...small ulcers stage 1...athletes foot..."

C. "Physician's Orders"
- 11/23/12 - Physician C ordered:
1. Soaks to the left foot daily with warm water and Epsom salts
2. Ensure that area between patient's toes/left foot dried well
3. Application of Tinactin Powder twice daily to foot and ulcerated areas until healed
4. No socks on at night; Leave open to air

D. MAR for the 11/23 - 12/4/12 time period
- Included a physician's treatment order for left foot soaks daily
- Staff documented "N/A" for the physician ordered treatment on 11/23 and 11/24/12
- Staff documented that patient refused daily foot soaks from 11/25 through 12/4/12 (10 treatments)
- No documented evidence on the MAR or in the nursing notes or assessments to support why the treatment order for foot soaks was not implemented or why the patient refused the ordered treatments
- No evidence that the physician was notified of the inability to implement the physician's order for foot soaks

E. MAR for the 11/23 - 12/4/12 time period
- Included a physician's treatment order for the application of Tinactin Powder twice daily
- Staff failed to document the application and/or refusal of the ordered treatment at 5:00 PM on 11/23/12
- Staff documented that patient refused the application of Tinactin Powder on 11/25/12
- Staff documented "N/A" for the physician ordered treatment on 11/23, 11/24, 11/26, 11/27, 11/28, 11/29, 11/30, 12/1, 12/2, 12/3 and 12/4/12 (20 treatments)
- No documented evidence on the MAR or in the nursing notes or assessments to support why the treatment order for Tinactin Powder was not implemented or why the patient refused the ordered treatments
- No evidence that the physician was notified of the inability to implement the physician's order for the application of Tinactin Powder

F. MAR for the 11/23 - 12/4/12 time period
- Included a physician's treatment order for the removal of socks at night, leave open to air
- No documented evidence on the MAR or in the nursing notes or assessments to support why the treatment order for sock removal at night was not implemented (11 nights)
- No evidence that the physician was notified of the inability to implement the physician's order

G. Review of the medical record revealed that Patient #4 was admitted to the hospital on 11/16/12. Review of the medical record and "Wound Care Flow Sheet" documentation revealed:

- No documented evidence in the medical record to support the assessment of Patient #4's left foot/wound(s) by nursing staff prior to the physician's order on 11/23/12
- No documented evidence in the medical record to support that staff had conducted any wound assessments from 11/23 - 12/4/12

On 12/5/12 at 10:00 AM, the DON reviewed the medical record and confirmed these findings.

III. Patient #5

A. Review of "Physician's Orders" dated 9/6/12 at 6:20 PM included a physician's order for vital signs twice each day with findings to be reviewed if the patient's heart rate was greater than 100 beats per minute.

B. Review of the MAR included a treatment order for vital signs twice daily "MD to review if HR (heart rate) > (greater than) 100".

C. Review of "Vital Signs Log Sheet" documentation revealed:

- Vital signs not documented as completed on 9/7 or 9/14/12
- Vital signs documented only once on 9/13/12, instead of twice a day as ordered
- Patient's heart rate/pulse was documented as greater than 100 beats per minute on:

9/8/12 10:00 PM - Pulse 105
9/9/12 2:00 PM - Pulse 110
9/9/12 10:00 PM - Pulse 121
9/11/12 6:00 AM - Pulse 103
9/11/12 10:00 PM - Pulse 120
9/12/12 6:00 AM - Pulse 104
9/12/12 10:00 PM - Pulse 109

Review of the medical record failed to provide evidence that the nurse either reviewed or notified the physician when Patient #5's heart rate was assessed to be greater than 100 beats per minute.

The DON confirmed these findings on 12/5/12 at 1:45 PM.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 3 patients in the sample (Patient #'s 1 and 4) with documented changes in their plan of care, nursing staff failed to revise the plan of care. Findings include:

The hospital policy entitled "Nursing Standards of Care" stated, "...Evaluation...Nursing plan of care is revised based on evaluation data..."

The job description entitled "Registered Nurse" stated, "...Develop a comprehensive outline of care and specific goals and interventions to be included in treatment planning..."

I. Patient #1

Review of the medical record revealed:

A. "Progress Record"
10/5/12
- 6:10 AM: Registered nurse (RN) A observed the presence of rectal bleeding; "...consult has been ordered to see the MD (physician)."

- 2:30 PM: Mental health technician documented that patient had rectal bleeding and the charge nurse was aware.

B. "Physician's Orders"
10/5/12
- 9:50 AM: Patient may use own medical consult for rectal bleeding
- 4:00 PM: Report any recurrence of bleeding

C. "Consultation Form"
- 10/5/12 at 4:20 PM: Medical Consultation conducted and included the following findings and plan:

- Two episodes of blood on wipes after bowel movement
- Examination performed
- No active bleeding, likely hemorrhoidal bleed
- No external hemorrhoids
- History of constipation
- Hold aspirin, monitor blood pressure and hemoglobin
- Diagnostic testing reviewed
- Review for recurrence of bleeding

D. "Master Treatment Plan" and "Treatment Plan Problem Sheet" documentation dated 9/28/12 included the following problem, interventions and goals:

- Constipation: Identified as an active care plan problem on the day of admission
- Patient "admitted on prescribed meds (medications) for constipation"
- Problem by nursing described as "daily"
- Short Term Goal: Compliance with medication
- Long Term Goal: Free of symptoms related to constipation
- All "Target Dates" were documented as 10/5/12

Review of the "Treatment Plan Problem Sheet" documentation revealed that nursing staff failed to revise the care plan, when it was determined by the medical physician that the observation of "rectal bleeding" would require:

- Ordered medication change
- Blood pressure monitoring for changes in patient's hemodynamic status (blood flow in the circulation)
- Continued observation and monitoring for rectal bleeding recurrence with physician notification

On 12/5/12 at 2:25 PM, the Director of Nursing (DON) reviewed the medical record and confirmed that the care plan should have been updated by nursing staff to reflect rectal bleeding and physician contact.

II. Patient #4

Review of the medical record revealed:

A. "Progress Record" 11/23/12 11:00 AM "Medical MD Note"
Physician C reported "pt seen today for...L (left) foot Athletes foot..."
B. "Consultation Form" 11/23/12 - Physician C identified the patient had a wound on his left foot and documented, "...denied pain...lots of buildup between toes...maceration...small ulcers stage 1...athletes foot..."
Physician C documented the following plan:

- Tinactin Powder BID (twice daily) until healed
- Foot soaks, dry between toes/foot well
- No socks on at night, leave open to air

C. "Physician's Orders"
11/23/12 "Physicians Orders" - Physician C ordered, left "foot soaks daily with warm water and epsom salts. Make sure patient drys (sic) well between toes/L foot. Tinactin Powder apply to foot and ulcerated areas BID until healed...no socks on at night leave open to air."

D. Review of the patient's "Master Treatment Plan" and the "Treatment Plan Review/Update" Forms dated 11/23 and 11/30/12 revealed that nursing staff failed to revise the care plan when it was determined by the medical physician that the observation of the patient's foot wound(s) would require:
- Ordered medication change (Tinactin Powder)
- Daily foot soaks
- Continued observation to ensure that the patient's foot was open to air

On 12/5/12 at 10:00 AM, the DON reviewed the medical record and confirmed that nursing staff failed to update the plan of care when it was determined that Patient #4 was assessed to have a foot wound that required physician ordered treatments and observation.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 5 patients in the sample (Patient #'s 2 and 5), the medical record failed to contain relevant health and/or treatment data. Findings include:

The hospital's policy entitled "Chart Documentation Requirements" stated, "...Documentation in the progress notes...must document...results of...evaluations of the patient and findings by staff involved in the care of the patient..."

The hospital policy entitled "Multidisciplinary Assessment" stated, "...patients...receive a thorough and timely assessment...the Intake Clinician will complete the Assessment Referral...will include...Mental Status...the nursing assessment will include current health problems..."

The hospital's job description for the registered nurse stated, "...Duties...Assess patients...Collect and analyze data regarding the patient's physical, psychological...needs...Communicate changes in patient's condition...with...attending physician...Review patient's records for accuracy...ensure that treatment plan and progress notes clearly reflect progress of patient..."

Review of medical records revealed the following:

A. Patient #2

The "Initial Interdisciplinary Assessments Assessment Referral" form, completed on 11/29/12 by the Intake Clinician, failed to provide documented evidence that the Intake Clinician had conducted a mental status evaluation at the time of the initial assessment.

Interview with the Director of Nursing (DON) on 12/5/12 at 8:40 AM confirmed this finding.

B. Patient #5

Review of "Physician's Orders" dated 9/6/12 at 6:20 PM revealed a physician's order for vital signs twice each day with findings to be reviewed if the patient's heart rate was greater than 100 beats per minute.

Review of "Vital Signs Log Sheet" documentation revealed:

- Vital signs not documented as completed on 9/7 or 9/14/12
- Vital signs documented only once on 9/13/12, instead of twice a day as ordered
- Patient's heart rate/pulse was documented as greater than 100 beats per minute on:

9/8/12 10:00 PM - Pulse 105
9/9/12 2:00 PM - Pulse 110
9/9/12 10:00 PM - Pulse 121
9/11/12 6:00 AM - Pulse 103
9/11/12 10:00 PM - Pulse 120
9/12/12 6:00 AM - Pulse 104
9/12/12 10:00 PM - Pulse 109

The DON confirmed these findings on 12/5/12 at 1:45 PM.

Based on medical record review, policy review and staff interview, it was determined that the discharge summary failed to include the disposition of care for 1 of 2 discharged patients in the sample (Patient #1). Findings include:

The hospital policy entitled "Chart Documentation requirements" stated, "...Discharge summary to include...recapitulation of the patient's hospitalization and recommendations concerning follow-up or aftercare..."

A. Patient #1
Review of the medical record revealed that Patient #1 was discharged on 10/11/12. On 12/5/12 at 10:50 AM, the Director of Nursing reviewed Patient #1's medical record and confirmed that the "Discharge Summary", dictated on 10/12/12 at 2:34 PM, failed to include the disposition of care.

During an interview on 12/5/12 at 1:05 PM, Physician A confirmed that Patient #1's "Discharge Summary" failed to include the disposition of care. In addition, Physician A reported that it was his responsibility to ensure that the information related to the disposition of care was included in the discharge summary.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to reassess the discharge plan throughout the continuum of care for 1 of 2 discharged patients (Patient #1) in the sample (refer to A 821). This failure placed Patient #1 at risk for adverse health consequences based on documented medical conditions and physical assistance needs.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to reassess the discharge plan for 1 of 2 discharged patients in the sample (Patient #1). Findings include:

The hospital policy entitled "Discharge/Aftercare Planning" stated, "...Discharge Plan begins on admission...should...Identify problems to be address [sic] in the next level of care...Include...direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care...the following is assessed...Housing needs and/or placement issues..."

The hospital policy entitled "Discharge Policy" stated, "...purpose...provide a uniform method of ensuring that the patient received caring, consistent, collaborative healthcare and reduce risk to patient after discharge...begins from the time of admission through discharge...Social worker...will document the communication involvement in discharge planning...Previous treatment providers/referral sources...Aftercare providers..."

The hospital policy entitled "Chart Documentation" stated, "...Documentation in the progress notes...is performed by physician...SS (social service)...Significant interactions with patient..."

On 10/23/12, the State Survey Agency became aware of a complaint in which it was alleged that Patient #1, who had multiple medical issues and was primarily wheelchair bound, was discharged on 10/11/12 from Dover Behavioral Health System (DBHS) to an unsafe environment (lived at home alone). The complainant reported that a social worker visited Patient #1's home on 10/17/12 and identified the following issues:

1. No working telephone
2. No referral for Home Health/post discharge care (Previous aide services had not been reinitiated)
3. Out of medications and had no way to pick up medication refills at pharmacy
4. No way to acquire food
5. Continuous oxygen ordered, however, oxygen tubing was tangled and in pieces on the floor

A. Review of the medical record revealed that Patient #1 was evaluated in the Emergency Department (ED) of an acute care hospital (Hospital #1) from 9/27 at 6:58 PM until 9/28/12 at 9:40 AM.

Review of the ED record revealed:
1. Medical, psychiatric and social work evaluation was completed
2. Social Worker C's notes contained the following information:
a. Patient with frequent falls and physical needs
b. Spoke with admissions department at DBHS and requested that DBHS's social worker contact Social Worker C to discuss Patient #1's situation

During a phone interview with Social Worker C on 12/7/12 at 12:49 PM, Social Worker C confirmed that he/she had never received a follow-up call from a social worker at DBHS.
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B. Review of the DBHS medical record revealed:

1. "Initial Interdisciplinary Assessments Assessment Referral" dated 9/28/12 at 8:34 PM documented:
- Unsafe at home
- Keeps falling
- Shootings in front of house and was fearful
- Lives alone
- Has home health aide
- Confined to wheelchair
- Unemployed and on disability
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2. "Activity Therapy Assessment" dated 9/29/12 at 10:00 AM documented:
- "...wants to get into a nursing home..."
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3. "Psychosocial Assessment" dated 9/29/12 documented:
- Afraid to be in home due to a shooting that took place nearby
- Heart and lung issues
- Lives alone
- Disabled
- No therapeutic support
- "Home Health aide is a support"
- "...Wants to live in a nursing home...has numerous health issues and is requesting to be set up with a nursing home..."
- Limited social and community support
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4. "Progress Record" dated 10/2/12 at 3:30 PM documented:
- Patient reported that living situation was "not the best" and that he/she wished to move out of the neighborhood
- Reported being "scared" where he/she lived
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5. "Progress Record" dated 10/9/12 at 11:00 AM documented:
- "feeling hopeful to get good housing and possibly go to a nursing home"
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6. "Social Service Progress Note" dated 10/3/12 at 2:30 PM documented:
- Conflicted because sister said that she would not visit if patient went to nursing home
- Fearful of nursing home due to partial loss of family and not being able to participate in Adult Day Care Program
- Friend confirmed that he/she would "gladly" pick the patient up at the time of discharge
- Patient was "OK" with going to a nursing home because of current health issues
- Patient knew that additional assistance was needed
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7. "Psychiatric Progress Note" documented:
- 10/3/12 at 1:50 PM: Seeking nursing home care in the long run
- 10/8/12 at 1:00 PM: Working on disposition
- 10/9/12 at 12:40 PM: Had a visitor for nursing home placement
- 10/10/12 at 1:00 PM: Plan to discharge tomorrow
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8. "Group Notes" documented:
- 10/9/12 at 10:30 AM: Patient had interview for placement
- 10/11/12 9:30 AM: Discharge today
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9. "Continuing Care/Discharge Planning" dated 10/11/12 documented:
- Plan signed by physician and nursing
- "...States...safe for D/C (discharge)"
- Patient #1 discharged to home at 5:25 PM
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10. "Physician's Orders" dated 10/11/12 at 11:02 AM documented:
- Discharge patient home today
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11. "Discharge Summary" dated 10/11/12 at 2:34 PM documented:
- "...had a family meeting, with home health aide, no safety concern today. The patient is stable enough for discharge...Two weeks medication with two refills given."

On 12/5/12 at 10:17 AM, Social Worker A reviewed Patient #1's medical record and confirmed that:
- Patient #1 expressed a desire to go to a nursing home post discharge
- Social work progress notes failed to provide evidence of why the discharge plan had changed

During an interview on 12/5/12 at 11:10 AM, Social Worker B reported that:
- Prior to hospitalization, Patient #1 became suicidal when pressured by the sister to go into a nursing home
- Patient #1 vacillated between going to a nursing home or to her own residence post hospitalization
- Patient #1 had a home health aide/friend that had attended a family meeting
- Patient #1 attended an outpatient program
- Patient #1 had poor communication with family member (sister)
- Patient #1 had a plan to go from hospital to home with long range plan for nursing home placement
- Patient #1 had a new shunt placement for possible dialysis prior to hospitalization
- Social Worker B reported that he/she had several conversations with (name of community case worker), but failed to document communication

During an interview on 12/5/12 at 1:05 PM, Physician A reported:
- Patient #1 should be placed in the least restrictive environment which was home, since safety did not appear to be an issue and patient had friend for support
- Patient #1 was mentally stable with social support
- Patient #1 was being managed by a friend
- Patient #1 was going back and forth about nursing home placement
- Patient #1 had limited ambulation
- Social worker mentioned that an insurance person wanted to put Patient
#1 in a nursing home, but needed to wait to see what happened with the patient

Review of the medical record failed to provide evidence that the discharge plan, developed by the hospital, was reassessed throughout the continuum of care to ensure that the physical and safety needs of Patient #1 were met.

There was no documented evidence in the medical record from admission to discharge, to determine why or when the discharge plan for nursing home placement changed.

During an interview on 12/5/12 at 12:00 PM, Medical Director A confirmed that the medical record failed to reflect the ongoing reassessment of Patient #1's discharge plan. Additionally, Medical Director A reported the following:
- There should have been documentation in the medical record related to the patient's disposition close to the end of Patient #1's hospitalization.
- Documentation should have included what transpired from "placement until now".

Based on record review and interviews, the hospital failed to provide a discharge plan that incorporated the services and supports that were essential to the patient's needs at the time of discharge in 1 of 10 discharge records reviewed (patient D4). This failure resulted in the patient being placed in a potentially life-endangering situation (refer to B134).

Based on record review and interviews, the hospital failed to provide a discharge plan that incorporated the services and supports that were appropriate to the patient's needs at the time of discharge in 1 of 10 discharge records reviewed (patient D4). The patient was discharged to his/her own apartment without the reinstitution of home health services, without a working telephone and without a way to obtain food or medication, resulting in a potentially life-endangering situation.

Record review:

Patient D4 was 55 years old, referred from an emergency room on 9/28/12 because of suicidal ideation. S/he reported depression due to his/her failing physical health. Diagnoses included chronic obstructive pulmonary disease (on continuous oxygen), congestive heart failure, coronary artery disease, chronic renal failure with recent construction of an arteriovenous fistula, and fibromyalgia. S/he was taking 23 medications at the time of admission. S/he was primarily wheelchair-dependent, although s/he could walk a few steps. S/he said that s/he was afraid to return to his/her apartment because "I keep falling" and because there had been shootings in the neighborhood. S/he asked to be referred to a nursing home.

On 10/3/12, after a session with the patient and his/her home health aide, the social worker (SW1) wrote, "Pt. stated [s/he] is OK with going to a nursing home because of [his/her] current health issues. Pt. added [s/he] knows [s/he] needs the additional assistance." There were no subsequent progress notes recorded by the social worker during the duration of the hospitalization.

In a progress note on 10/8/12 the psychiatrist wrote, "mood improving, working on disposition."
In a progress note on 10/9/12 the psychiatrist wrote, "Pt. had a visitor for nursing home placement." In a progress note on 10/10/12 the psychiatrist wrote, "plan for D/C tomorrow," and on the following day wrote an order for "discharge home today." The patient was discharged to his/her apartment on 10/11/12.

There was no documentation in the record regarding the apparent change in discharge plan or the rationale for the change.

According to the complaint filed with the state, a community worker from the state Medicaid managed care entity, after not being able to contact the patient by phone on 10/16/12, went to the patient's apartment on 10/17/12. In the complaint the worker wrote the following: "Worker found this primarily wheelchair bound person with no working telephone which therefore disabled landline Emergency Response System, no way to call out for assistance, and no way for other's [sic] to contact (client) except by going there. Previous aide services had not been reinitiated and client was not referred for Home Health/post discharge care. Pt. was out of medications and had no way to pick up refills at the pharmacy, and no way to acquire food. Oxygen concentrator was running at 2.5 L/min with N/C tubing tangled and in pieces on the floor."

Interviews:

In an interview on 12/5/12 at 10:15 am, the Acting Director of Social Work acknowledged that the discharge plan for patient D4 was inadequate and that the documentation in the record did not reflect the change from the plan of nursing home care post discharge to discharging the patient to his/her apartment alone.

In an interview on 12/5/12 at 11 am, SW1 stated that the discharge plan changed so that the patient would go home first and later seek nursing home care if needed but acknowledged that the record did not reflect this change. She added, "My knowledge of nursing home referrals is limited" and "I don't usually set up medical follow-up."

In an interview on 12/5/12 at 12:10 pm, the Medical Director stated, "I would have liked" to have seen an explanation in the record regarding the change in the discharge plan. The Medical Director acknowledged that the discharge plan for patient D4 was inadequate.

In an interview on 12/5/12 at 1 pm, the attending psychiatrist (Physician 1) stated that the plan changed after SW1 informed him that the patient's friend/health aide indicated she could provide support for the patient. Physician 1 acknowledged that there were no notes to this effect in the record, nor was there any documentation explaining the change in the discharge plan.

Based on record review and interview, the Medical Director failed to provide adequate oversight and supervision of the discharge planning process in 1 of 10 discharge records reviewed (patient D4), resulting in a potentially life-endangering situation for that patient.

Record review:

The 55 year-old patient was referred from an emergency room on 9/28/12 because of suicidal ideation. S/he reported depression due to his/her failing physical health. Diagnoses included chronic obstructive pulmonary disease (on continuous oxygen), congestive heart failure, coronary artery disease, chronic renal failure with recent construction of an arteriovenous fistula, and fibromyalgia. S/he was taking 23 medications at the time of admission. S/he was primarily wheelchair-dependent, although s/he could walk a few steps. S/he said that s/he was afraid to return to his/her apartment because "I keep falling" and because there had been shootings in the neighborhood. S/he asked to be referred to a nursing home.

On 10/3/12 after a session with the patient and the patient's home health aide, the social worker (SW1) wrote, "Pt. stated [s/he] is OK with going to a nursing home because of [his/her] current health issues. Pt. added [s/he] knows [s/he] needs the additional assistance." There were no subsequent progress notes recorded by the social worker during the duration of the hospitalization.

In a progress note on 10/8/12 the psychiatrist wrote, "mood improving, working on disposition."
In a progress note on 10/9/12 the psychiatrist wrote, "Pt. had a visitor for nursing home placement." In a progress note on 10/10/12 the psychiatrist wrote, "plan for D/C tomorrow," and on the following day wrote an order for "discharge home today." The patient was discharged to his/her apartment on 10/11/12.

There was no documentation in the record regarding the apparent change in discharge plan or the rationale for the change.

According to the complaint filed with the state, a community worker for the state Medicaid managed care entity, after not being able to contact the patient by phone on 10/16/12, went to the patient's apartment on 10/17/12. In the complaint the worker wrote the following: "Worker found this primarily wheelchair bound person with no working telephone which therefore disabled landline Emergency Response System, no way to call out for assistance, and no way for other's [sic] to contact (client) except by going there. Previous aide services had not been reinitiated and client was not referred for Home Health/post discharge care. Pt. was out of medications and had no way to pick up refills at the pharmacy, and no way to acquire food. Oxygen concentrator was running at 2.5 L/min with N/C tubing tangled and in pieces on the floor."

Interview:

In an interview on 12/5/12 at 12:10 pm, the Medical Director stated, "I would have liked" to have seen an explanation in the record regarding the change in the discharge plan. The Medical Director acknowledged that the discharge plan for patient D4 was inadequate.

Based on record review and interview, the Director of Social Work failed to monitor and evaluate the quality of the discharge plan in 1 of 10 discharged patient records reviewed (patient D4), resulting in a potentially life-endangering situation for that patient.

Record review:

The 55 year-old patient was referred from an emergency room on 9/28/12 because of suicidal ideation. S/he reported depression due to her failing physical health. Diagnoses included chronic obstructive pulmonary disease (on continuous oxygen), congestive heart failure, coronary artery disease, chronic renal failure with recent construction of an arteriovenous fistula, and fibromyalgia. S/he was taking 23 medications at the time of admission. S/he was primarily wheelchair-dependent, although s/he could walk a few steps. S/he said that s/he was afraid to return to his/her apartment because "I keep falling" and because there had been shootings in the neighborhood. S/he asked to be referred to a nursing home.

On 10/3/12 after a session with the patient and his/her home health aide, the social worker (SW1) wrote, "Pt. stated [s/he] is OK with going to a nursing home because of [his/her] current health issues. Pt. added [s/he] knows [s/he] needs the additional assistance." There were no subsequent progress notes recorded by the social worker during the duration of the hospitalization.

In a progress note on 10/8/12 the psychiatrist wrote, "mood improving, working on disposition."
In a progress note on 10/9/12 the psychiatrist wrote, "Pt. had a visitor for nursing home placement." In a progress note on 10/10/12 the psychiatrist wrote, "plan for D/C tomorrow," and on the following day wrote an order for "discharge home today." The patient was discharged to her apartment on 10/11/12.

There was no documentation in the record regarding the apparent change in discharge plan or the rationale for the change.

According to the complaint filed with the state, a community worker for the state Medicaid managed care entity, after not being able to contact the patient by phone on 10/16/12, went to the patient's apartment on 10/17/12. In the complaint the worker wrote the following: "Worker found this primarily wheelchair bound person with no working telephone which therefore disabled landline Emergency Response System, no way to call out for assistance, and no way for other's [sic] to contact (client) except by going there. Previous aide services had not been reinitiated and client was not referred for Home Health/post discharge care. Pt. was out of medications and had no way to pick up refills at the pharmacy, and no way to acquire food. Oxygen concentrator was running at 2.5 L/min with N/C tubing tangled and in pieces on the floor."

Interview:

In an interview on 12/5/12 at 10:15 am, the Acting Director of Social Work acknowledged that the discharge plan for patient D4 was inadequate and that the documentation in the record did not reflect the change from the plan of nursing home care post discharge to the discharge to her apartment alone.

In an interview on 12/5/12 at 11 am, SW1 stated that the discharge plan changed so that the patient would go home first and later seek nursing home care if needed but acknowledged that the record did not reflect this change. She added, "My knowledge of nursing home referrals is limited" and "I don't usually set up medical follow-up."