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Based on interview and document review, the hospital failed to provide for patient safety and protection of patient rights.

Failure to protect and promote patient rights risks patients suffering from physical and psychological harm.

Findings included:

The hospital failed to include the patient and family in development of the plan of care.

The hospital failed to ensure that the patient's post discharge needs were included in the discharge plan.

Due to the severity of deficiency under 42 CFR 482.13 (b) (1), the Condition of Participation for Patient Rights was NOT MET.

Cross reference: Tag A 130

Based on interview and document review, the hospital failed to include the patient in decisions regarding development and implementation of their plan of care for 1 of 5 patients reviewed.

Failure to include patients in their plan of care puts all patients at risk for unmet care needs that could result in serious injury or even death.

Findings included:

ITEM #1: Not Including Patient and Family In The Plan of Care

1. On 07/22/19 at 11:10 AM, the investigator interviewed a contact for Patient #1. Contact #1 stated that the patient had previously been diagnosed as a diabetic by their primary care physician (PCP). The patient had not ever been prescribed any oral or injection medication by their PCP for their diabetes. The patient had also not ever received instruction on how to test their blood sugars. The contact explained they had tried to ask the nurse for the patient to receive home health services for a nurse to check the patient's blood sugar. The patient passed away 5 days after being discharged from the ED due to an elevated blood sugar. The contact had found the patient unresponsive and called 911.

2. Review of Patient #1's medical record showed.

a) The patient was seen in ED (Emergency Department) on 12/19/18 for bloodsugar of 600 and frequent urination. The patient had a history of diabetes but was not being treated with any medication for the diabetes. The patient reported drinking soda for the last 3 weeks. The patient was noted to be agitated. The patient was given treatment with insulin to lower the blood sugar (BS) and the BS decreased to 239. The patient was discharged to home on 12/20/18 at 5:10 AM but became agitated in the lobby of the ED while waiting for their family and was brought back to the ED exam room again.

b) The patient was brought back to the ED exam room 12/20/18 at 5:50 AM. The patient's blood sugar was 344 on their second admission to the ED. The blood sugar was not taken again before the patient was discharged home.

c) The patient and his wife expressed concern about wanting the patient to be admitted for a "dry mouth", not being able to "taste food" and not "sleeping well for the past 3-4 weeks".

d) The patient was discharged to home on 12/20/18 at 12:07 PM. The blood sugar was not taken again before the patient was discharged home

3. On 07/25/19 at 12:30 PM, the investigator interviewed a licensed nurse in the ED (Staff #1). Staff #1 stated that patients were to have any abnormal labs rechecked prior to discharge.

4. 07/25/19 at 1:30 PM, the investigator interviewed the nurse manager in the ED (Staff #2). Staff #2 confirmed that patient's needed to have abnormal lab values rechecked prior to discharge. Depending on the results of the lab work being rechecked, the patient may have home health services ordered or may be admitted to inpatient services.

ITEM #2: Post Discharge Needs

1. Document review of the hospital's policy and procedure titled, "Emergency Room Discharge Planning Assessment For Continuity of Care", effective 09/2010, showed that patients were to be assessed for care needs in the home. The hospital was to coordinate home health services, infusion services, rehabilitation care, and other community resources as indicated by the discharge assessment.

2. On 07/22/19 at 11:10 AM, the investigator interviewed a contact for Patient #1. Contact #1 stated that the patient had previously been diagnosed as a diabetic by their primary care physician (PCP). The patient had not ever been prescribed any oral or injection medication by their PCP for their diabetes. The patient had also not ever received instruction on how to test their blood sugars. The contact explained they had tried to ask the nurse for the patient to receive home health services for a nurse to check the patient's blood sugar. The patient passed away 5 days after being discharged from the ED due to a elevated blood sugar. The contact had found the patient unresponsive and called 911.

3. On 07/29/19 at 12:14 PM, the investigator interviewed a contact (Contact #2) from the King County Medical examiners office. Contact #2 stated the patient's cause of death was hyperglycemia/hyperosmolar non ketonic state. The patient was found dead at home.

4. Review of Patient #1's medical record showed.

a) The patient was seen in ED (Emergency Department) on 12/19/18 for bloodsugar of 600 and frequent urination. The patient had a history of diabetes but was not being treated with any medication for the diabetes. The patient was noted to be agitated. The patient was given treatment with insulin to lower the blood sugar (BS) and the BS decreased to 239. The patient was discharged to home on 12/20/18 at 5:10 AM but became agitated in the lobby of the ED while waiting for their family and was brought back to the ED exam room again.

b) The patient was brought back to the ED exam room 12/20/18 at 5:50 AM. The patient's blood sugar was 344 on their second admission to the ED.

c) The patient and his wife expressed concern about wanting the patient to be admitted for a "dry mouth", not being able to "taste food" and not "sleeping well for the past 3-4 weeks".

d) The patient was discharged to home on 12/20/18 at 12:07 PM. The patient was ordered a medication Metformin (medication to lower blood sugar) and to follow-up with their primary care provider (PCP). The discharge instructions also informed the patient they needed to take their blood sugar at home and return to the ED if the BS went above 240.

5. On 07/25/19 at 12:30 PM, the investigator interviewed a licensed nurse in the ED (Staff #1). Staff #1 stated that patients were to be assessed for home needs before discharge from the ED. The ED nurse or physician could order social services to assist patients in getting home health services, rehabilitation services, and other community services as needed by the patient.

6. On 07/25/19 at 1:30 PM, the investigator interviewed the nurse manager in the ED (Staff #2). Staff #2 confirmed that staff were to assess patient home care needs before patients were discharged from the ED.