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Based on a complaint investigation ACTS Intake PR00000542, fifty three records reviewed, review of policies and procedures related to the Discharge Planning Program with the social worker (employee #1), it was determined that the facility failed to ensure implementation of the patient's discharge plan and orient patient and family members to prepare them for patient post-hospital care for 1 out of 52 records reviewed (R.R #11).

Findings include:

1. A mechanism to ensure that discharge planning process include coordination and referrals to home health or physical therapy services ; to promote continuity of care after discharge patient from hospital was not performed not followed. The following findings were identified on 1/20/16 from 8:30 am through 4:00 pm during survey process:


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a. According to record review (RR) of the complainant case # 11, performed on 01/20/16 at 1:00 pm, is a female patient of 81 years old who arrived to the hospital in an ambulance service on 11/23/15 at 5:18 pm. She was received at the Emergency Room with a complaint of high blood sugar. The Emergency Room physician (employee #4) performed an initial assessment at 5:23 pm establishing that patient had recently a CerebroVascular Accident (CVA), takes Vasotec for high blood pressure and no hypoglycemic agents were order to control high blood sugar. The Emergency Room physician (employee #4) mentions that patient had with her a Glycosilated Hemoglobin (HgbA1C) results on 13%.

The registered nurse obtained a blood sample for Dextrostick at 5:28 pm with a result of 303 mg/dl and one hour later, the Dextrostick results showed that patient's blood sugar was decreasing to 293 mg/dl. The Emergency Room physician (employee #4), after ordering to implement the Insulin protocol, to send blood samples to the laboratory for CBC, BMP, urine sample for analysis and hydration with 0.9 Normal Saline, he placed a consult for an evaluation with the Internal Medicine Consultant (employee #2).

At 10:34 pm on 11/23/15 the consultant physician (employee #2) established a diagnose of Complicated Urinary Tract Infection with Moderate Dehydration. Then, he placed an admission order to the Medicine ward and transferred the case to other Internal Medicine physician (employee #3). However, patient was treated with antibiotics and insulin according to a glucose sliding scale.

The Nursing Initial assessment performed on 11/24/15 at the Medicine ward and the nursing daily progress notes from Medicine and Intermediate Medicine wards from 11/25 thru 11/28/15 do not mention referrals to the discharge planning program nor social work interventions.

On 11/24/15 at 3:39 am the patient was placed on Medicine A ward to continue treatment. At 3:42 pm on 11/24/15, the Social Worker performed an initial evaluation and her documentation establishes that patient is oriented, has family support but no difficulties were identified during interview. The Social Worker offered education related to the discharge planning process but failed to specify which topics she discussed with patient's family members.

On 11/25/15 at 11:57 am the Internal Medicine physician (employee #3) explained that patient has shown tiredness, slurred speech and poor appetite. On her documentation establishes that has to rule out a CVA and ordered a Brain CT Scan. Also, patient has show Bradycardia and ordered to transfer the patient to Intermediate Medicine ward for telemetry. Also, a PMR and Cardiology consults were ordered.

The patient continued hydration therapy with 0.45% Normal Saline 1,000 ml to run at 125 ml per hour. For glucose control the Internal Medicine physician (employee #3) increased twice a day the oral hypoglycemic, Metformin 500mg by mouth, additional to the subcutaneous insulin administration.

On 11/25/15 at 1:29 pm the Brain Ct scan was released and confirmed that patient has a left basal ganglia internal capsule infarct in evolution. On 11/26/15 at 1:18 pm a Brain MRI confirmed that patient has an acute/early ischemic infarct at the genu of the left internal capsule.
The Internal Medicine physician (employee #3) ordered Plavix 75 mg by mouth daily. On 11/27/15 at 11:03 am the PMR (physiatrist) physician evaluated the patient and recommended that Physical Therapy (PT) and Social Worker evaluate the patient and that patient could benefit of in-patient rehabilitation program (IFR) while mental status improves. The PMR physician mentioned on his progress notes that patient is showing signs and symptoms related to right side Hemipharesis, Dysarthria and Dysphagia. On 11/27/15 at 2:41 pm the PT performed an initial evaluation and discussed with patient's son measures to avoid falls and to use a walker.

The surveyor discussed with the Director of the Social Work services (employee #1) on 01/22/16 at 3:30 pm that the Physical Therapist mentioned in her progress notes that she discussed with a Social Worker the patient ' s need for a rolling walker for discharge planning, employee #1 had to request to the Information Technician to download a log book that a former secretary has created to have evidence of all coordination that the Social Workers perform with patients that need services at home when are discharged from the hospital. The complainant case # 11 appears on that log book and the coordination performed was to request to the health insurance a rolling walker for approval.

According to interview with the Director of the Social Worker Services (employee #1) performed on 01/22/16 at 3:30 pm, she stated: "There is evidence that on 11/25/15 a request to authorize a rolling walker was sent to Triple S Advantage and on the same day the item was approved and Clinical Medical Services (CMS), a medical equipment agency, will provide the equipment to the patient."
According to the recommendations established by the PMR physician, no evidence was found of the participation between the Internal Medicine physician (employee #3), PT, Social Worker and nursing for an appropriate discharge planning ensuring continuity of care at home.
On 11/27/15 at 1:56 pm, the Internal Medicine Physician (employee #3) initiated treatment with Decadron 4 mg IV every 8 hours and discussed with patient's son and daughter the therapy that patient needs. The Internal Medicine Physician (employee #3) documented on her progress notes that family members preferred for their mother the physical therapy at home.
On 11/28/15 at 10:03 am, the Internal Medicine Physician (employee #3) documented on the discharge summary that patient will be discharge home and will receive home physical therapy, complete antibiotic therapy and will have follow up with the neurologist and primary physician.
The Internal Medicine Physician (employee #3) established as final disposition home health service. Also, a prescription for medical equipment (rolling walker) was ordered by employee #3 and given to patient/family.
2. No evidence was found on the clinical record a physician's order for Social Worker intervention for discharge planning and coordination with home health services.

Based on the complaint investigation ACTS Intake PR00000542 fifty records reviewed (RR), review of policies and procedures related to the Discharge Planning Program with the social worker (employee #1), it was determined that facility failed to reassess the patient's discharge plan to identify and address factors that may affect continuity of care accordingly with patient needs, as observed in 1 out of 52 records review (RR #11).

Findings include:

1. A mechanism to ensure that discharge planning process include reassessment based on changes in patient condition to adjust plan to patients needs when significant changes in the patient's condition are identified was not performed not followed. The following findings were identified on 1/20/16 from 8:30 am through 4:00 pm during survey procedures:


33356


a.According to record review (RR) of the complainant case # 11, performed on 01/20/16 at 1:00 pm is a female patient of 81 years old who arrived to the hospital in an ambulance service on 11/23/15 at 5:18 pm. She was received at the Emergency Room with a complaint of high blood sugar. The Emergency Room physician (employee #4) performed an initial assessment at 5:23 pm establishing that patient had recently a CerebroVascular Accident (CVA), takes Vasotec for high blood pressure and no hypoglycemic agents were order to control high blood sugar.

The Emergency Room physician (employee #4) mentions that patient had with her a Glycosilated Hemoglobin (HgbA1C) results on 13%. The registered nurse obtained a blood sample for Dextrostick at 5:28 pm with a result of 303 mg/dl and one hour later, the Dextrostick results showed that patient's blood sugar was decreasing to 293 mg/dl.

The Emergency Room physician (employee #4) placed a consult for an evaluation with the Internal Medicine Consultant (employee #2). At 10:34 pm on 11/23/15 the consultant physician (employee #2) established a diagnose of Complicated Urinary Tract Infection with Moderate Dehydration. Then, he placed an admission order to the Medicine ward and transferred the case to other Internal Medicine physician (employee #3).

However, patient was treated with antibiotics and insulin according to a glucose sliding scale as per insulin protocol. The patient had changes in health condition since 11/25/15 due to right side tiredness, slurred speech and poor appetite. On 11/25/15 at 11:57 am the Internal Medicine physician (employee #3) establishes that has to rule out a CVA and ordered a Brain CT Scan and Brain MRI. Also, the patient has showing Bradycardia and ordered to transfer the patient to Intermediate Medicine ward for telemetry.

On 11/25/15 at 1:29 pm the Brain Ct scan was released and confirmed that patient has a left basal ganglia internal capsule infarct in evolution and on 11/26/15 at 1:18 pm the MRI confirmed that patient has an acute/early ischemic infarct at the genu of the left internal capsule. On 11/27/15 at 11:03 am the PMR (physiatrist) physician evaluated the patient and recommended that Physical Therapy (PT) and Social Worker evaluate the patient and that patient could benefit of (IFR) in-patient rehabilitation program while mental status improves. The PMR physician mentioned on his progress notes that patient is showing signs and symptoms related to right side Hemipharesis, Dysarthria and Dysphagia. On 11/27/15 at 2:41 pm the PT performed an initial evaluation and discussed with patient's son measures to avoid falls and to use a walker.

On 11/24/15 at 3:42 pm, the Social Worker performed an initial evaluation and her documentation establishes that patient is oriented, has family support but no difficulties were identified during interview. The Social Worker offered education related to the discharge planning process but failed to specify which topics she discussed with patient's family members.

The surveyor discussed with the Director of the Social Work services (employee #1) on 01/22/16 at 3:30 pm that the Physical Therapist mentioned in her progress notes that she discussed with a Social Worker the patient's need for a rolling walker for discharge planning, employee #1 had to request to the Information Technician to download a log book that a former secretary has created to have evidence of all coordination that the Social Workers perform with patients that need services at home when are discharged from the hospital. The complainant case # 11 appears on that log book and the coordination performed was to request to the health insurance a rolling walker for approval.

According to interview with the Director of the Social Worker Services (employee #1) performed on 01/22/16 at 3:30 pm, she stated: "There is evidence that on 11/25/15 a request to authorize a rolling walker was sent to Triple S Advantage and on the same day the item was approved and Clinical Medical Services (CMS), a medical equipment agency, will provide the equipment to the patient. "
On 11/28/15 at 10:03 am, the Internal Medicine Physician (employee #3) documented on the discharge summary that patient will be discharge home and will receive home physical therapy, complete antibiotic therapy and will have follow up with the neurologist and primary physician. The Internal Medicine Physician (employee #3) established as final disposition home health service.
2. No evidence was found of a referral to the Social Worker ordered and documented by the physician (employee #3) for reassessment and for a discharge planning process for home health services for continuity of care for monitoring blood glucose, physical therapy for muscle strength and manage of the rolling walker.

Also, no evidence of home health services coordination for the intervention of Speech Therapy due to patient's Dysarthria and Dysphagia.