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Based on staff interviews, medical record review, and review of facility policies and procedures, it was determined the facility staff failed to ensure that steps were taken to ensure the safety of one (1) of four (4) patients (Patient #1).

Findings include:

A review of the record for Patient #1 revealed that he/she was admitted to the facility on 1/23/17 on a TDO (temporary detention order) from a long term care facility due to aggressive behavior towards other residents and suicidal ideations.

Patient #1 was treated for a UTI (urinary tract infection) and a search began for an inpatient psychiatric bed on 1/27/17. On 1/31/17, Patient #1 was transferred to this hospital's Senior Transitions Unit, rather than transferring out to a different psychiatric unit.

While in the Senior Transitions Unit, a progress note by the psychiatrist dated 2/2/17 documented the following under "Plan" "1. Place on intermittent observation for safety; may have to place on constant observation if continues with self-harming behavior on the unit and going into other patients' rooms...".

Documentation in the nursing note dated 2/2/17 at 3:36 AM was "From start of shift at 1900-2130 (7:00 PM to 9:30 PM) pt (patient) was labile. Pt was unable to redirect. Was exit seeking. Assaultive to staff. Pt was hitting/pushing staff. Pt pushed this nurse forcefully into door during medication administration. Pt wandering into other pt's rooms. Will not remain in bed or w/c (wheelchair). Pt ran up and down halls. Throwing items at staff. Staff kept pt on 1:1 (one to one) for the safety of Pt and other patients. Around 2200 (10:00 PM) pt returned to room and has slept since".

A 2/3/17 progress note by the psychiatrist documented under "free text A & P" (assessment and plan) the following information, in part: "...aggressive behavior at (his/her) nursing facility. Patient also exhibits self-injurious behavior of throwing (his/her)self onto the floor, which necessitated (him/her) to wear a helmet. Patient does not have any insight into (his/her) behavior nor current situation and is deemed not to have decision-making capacity".

A nursing note dated 2/3/17 at 8:00 AM documented "Up in hall pacing, anxious attempting to enter other pts rooms. requiring constant redirection. PRN (as needed) Klonopin administered per order".

A cardiopulmonary resuscitation flow sheet dated 2/3/17 at 8:32 AM was noted in the record. Under the heading "history of Event" the following was documented : "pt. sat on floor, layed (sic) down-nursing staff approached (him/her) noticed decreased RR (respiratory rate), decreased LOC (level of consciousness), incontinent-pt. immediately became pulseless-code called".

Staff Member #7, during an interview on 3/27/17 at 3:00 PM, stated "I was there when (he/she) coded we started CPR. We took [him/her] to the ED (emergency department) because there were no ICU beds. Tried to intubate [him/her] twice but couldn't because [he/she] was vomiting. When [he/she] got to the ED [he/she] was coming around, and they put a non-rebreather mask on [him/her]". "CPR only lasted about a minute, not very long".

Documentation in the medical record was that Patient #1 was in the ED between 8:45 AM and 1:15 PM. There was no documentation of 15 minute checks, 1:1, or close observation during that time. There was no documentation that unnecessary equipment was removed from the ED bay.

A note documented that while in the ED on 2/3/17 at 11:34 AM, Patient #1 "pulled out Foley (urinary catheter), OOB (out of bed)".

Staff Member #7 was asked if every 15 minute monitoring would have been ordered or continued for safety while Patient #1 was in the ED, due to agitation, aggressiveness, inability to re-direct, and self injurious behaviors he/she had been exhibiting as an inpatient on the Senior Transitions Unit. Staff Member #7 stated "[he/she] was postictal. [He/she] was discharged from the Senior Transitions Unit when [he/she] went to the ED. A doctor's order isn't needed for observation or 1:1, that's a nursing decision".

The surveyor asked for the facility policy and procedure for ordering observation for safety, and was provided a copy of the policy and procedure titled "Approval Process for Utilizing 1:1 observational sitters", which stated the following in part, under "Procedures: 1. No need for Physician order for 1:1 monitoring-Charge Nurse notifies Nursing Supervisor of nee/reason for 1:1 observation nursing determines need...".

There was documentation on a 15-minute round check sheet dated 2/3/17, that between 12:00 AM and 8:45 AM, while on the Senior Transitions Unit, Patient #1 was on every 15 minute observations; at 8:45 it was documented that Patient #1 was in the hallway, and was crying, agitated, and combative". Between 9:00 AM and 10:00 AM documentation on the check sheet listed the patient as "off unit-ED (emergency department). From 10:00 AM to 1:15 PM there is a line drawn through the columns documenting "off unit ED".

Documentation on the 15-minute check sheet began again at 1:30 PM, upon admission to the ICU, and ended at 7:15 PM. The form included documentation of Patient #1 being "off unit/ICU (intensive care unit)". There was no further documentation of 15-minute round check sheet for 2/3/17.

There was documentation in the medical record that since admission to the facility on 1/31/17, Patient #1 had required 1:1 and intermittent observation for safety, agitation, and aggressiveness. Patient #1 had been on every 15 minute checks while a patient on the facility's Senior Transition Unit, prior to the code blue and subsequent transfer to the ED on 2/3/17. After admission to the ED, there was no documentation that Patient #1 was on any level of observation, and while in the ED, got out of bed, and pulled out his/her Foley catheter.

Concerns above were discussed with Staff Member #7 at the time of discovery, and again on 3/28/17 at 1:30 PM.

Based on staff interview and record review, it was determined the facility staff failed to ensure the medical record for one (1) of four (4) patients (Patient #1) was accurately documented.

Findings include:

A review of Patient #1's medical record revealed a Cardiopulmonary resuscitation (CPR) flowsheet dated 2/3/17. This flowsheet included documentation that CPR was started at 8:32 AM, with a history of the event as follows: "pt. (patient) sat on floor, layed (sic) down-nursing staff approached [him/her], noticed decreased RR (respiratory rate), decreased LOC (level of consciousness)-pt. immediately became pulseless-code called".

At 8:32 AM, there was a number zero with a line through it under "Rhythm and RR" and a note of "agonal breathing". An 8:33 AM note stated, "vomiting-turned to L (left) side". At 8:35 AM the heart rhythm was noted as "ST (sinus tachycardia) and RR 10, attempting to intubate/suctioned". At 8:37 AM rhythm "ST, RR 14, vomiting-RR 14-16". At 8:39 AM rhythm "ST, RR 14, pt. lifted to stretcher and (illegible) to ED (emergency department)".

Under the heading "Procedures Performed" "Bag/Mask was circled, intubated 0835 (8:35 AM) unsuccessful, No. (number) attempts 2". "Yes was marked beside "was the patient successfully resuscitated". "Code was terminated at 0839 (8:39 AM), and disposition of Patient was 0839 (8:39 AM) Location ED".

The "Emergency Provider Report" dated 2/3/17, at 9:02 AM documented the following, in part:
"General: Initial greet date/time 2/3/17 0847 (8:47 AM); Presentation: Chief Complaint Decreased responsiveness; Free text HPI (history present illness): Patient was in GeriPsych had witnessed seizure upstairs. Initial call was for Code Blue but pulses or resp neve (sic) stopped. Appeared to have seizure activity and apparently aspirated. Brought to ED for eval and treat. Patient alert but postictal on ED arrival".

The Hospitalist history and physical dated 2/3/17 stated in part: "...was admitted to geri-psych unit with diagnosis of major neurocognitive disorder with psychotic features. Patient was then stable until this morning when apparently a code blue was called on [him/her]. When I arrived, patient was breathing. I do not think the patient ever lost [his/her] pulse or respiration. [He/She] apparently had an episode of seizure probably. When I arrived at the scene, [he/she] has (sic) already lost [his/her] urinary control and was having some clonic jerks. [He/she] vomited and aspirated. [He/she] was a little unconscious, but [his/her] blood sugar was stable at that time and [he/she] was oxygenating well. [He/she] was placed on oxygen and because of the concern about managing secretions, [he/she] was intubated and was taken to the emergency room. [He/she] stayed several hours in the ER (emergency room). Eventually, [he/she] was extubated and was successfully placed on oxygen by nasal cannula...".

Staff Member #7 who was present during the code blue, was interviewed, and stated "I was there when (he/she) coded. We started CPR, that lasted only a short time, about a minute. We couldn't get (him/her) intubated because (he/she) started vomiting, attempted intubation twice. When (he/she) got to the ED (he/she) was coming around so they just put a non-rebreather mask on (him/her)".

Concerns regarding inconsistent documentation (related to whether the patient was pulseless and was intubated) was discussed with Staff Member #7 at the time of discovery, and at 1:30 PM, with members of administration.

Based on staff interviews, clinical record review, review of facility documents, and in the course of a complaint investigation, it was determined the CONDITION is not met due to the facility failure to ensure one (1) of four (4) discharged patients in the survey sample (Patient #2) had an effective discharge plan that met the patient's post-hospital needs related to (his/her) living situation and an assessment of the ability of the patient and/or family to meet (his/her) needs. The patient also did not have an assessment completed that would have determined whether the patient could have qualified for community based support.

The findings include:

Patient #2 was admitted with bedbugs, received no treatment for bedbugs, and was discharged back to an living situation which included the bedbug infestation.

The patient was discharged to return to his/her home - living alone. There was no assessment of whether or not Patient #2 qualified for community based assistance at home (UAI) due to the diagnosis of dementia and family concerns of "worsening" of the condition over the past months.

Concern of whether the patient's family were able to adequately provide the patient with the needed assistance and supervision as documented in the "call back" information that the patient had been found confused, having lost prescriptions and phone and in an apartment infested with bedbugs the day after Patient #2 was discharged alone via taxi transportation.

Documented in the physician's "History and Physical" indicated "Plan: ...6. Discuss in team meeting whether patient requires a higher level of care at this point than living alone in an apartment..." The surveyor was unable to locate any further team meeting discussion regarding the patient requiring a higher level of care or safety of living alone in an apartment in the clinical record.

Also, there was documentation in the "Progress Notes" prior to and on the date of discharge "...Insight/judgment: insight limited/poor, judgement limited/poor..Assessment...(He/She) does not have decision-making capacity..."

The facility policy and Procedure "Discharge Planning" was reviewed and evidenced, in part, "Purpose: To ensure patients are informed of their options and have a choice in selecting their post discharge provider/service and have been informed of any financial interest the hospital has with the extended care provider/service." There was no documentation in this policy of an evaluation of the patient's ability to care for themselves or the family ability to provide care after discharge.

Please refer to:
Discharge Planning Needs Assessment 482.43(b)(1) and
Implementation of a Discharge Plan 482.43(c)(3)(5)

Based on staff interview, clinical record review and in the course of complaint investigation, it was determined the facility staff failed to ensure the discharge planning evaluation included the patient's capacity for self-care or to be cared for in the environment from which the patient was admitted, for 1 of 4 discharged patients in the survey sample, Patient #2.

Patient #2 was discharged back to (his/her) prior living situation which was infested with bedbugs. No evaluation had been done as to whether the patient was capable of, or the family was able, to provide the needed support after discharge.

The findings included:

Patient #2 was admitted to the facility on 2/5/17 with diagnoses that included, but were not limited to, Vascular Dementia with behavioral disturbances, brief psychotic disorder, hypertension, chronic kidney disease-stage 3, and history of transient ischemic attack (TIA- mini stroke).

Review of the clinical record for Patient #2 revealed the patient was admitted to the facility on a TDO (temporary detaining order) after being found wandering in a grocery store in a confused state and having paranoid thoughts. According to the "History and Physical" dated 2/5/17, "...brought to the ER (emergency room) by police after found wandering around in (name) supermarket talking to self. When approached by police, patient told them that (he/she) was not feeling well, so they transported (him/her) to the ER (emergency room). In the ER, collateral information was provided by (his/her) (spouse). Patient had been deteriorating cognitively since (month) and had not been eating or sleeping well, and had increase in wandering behavior. Patient had also been experiencing persecutory delusions of people climbing the wall of (his/her) apartment building, entering (his/her) room, and trying to kill (him/her)... On admission patient presented as anxious, tearful, and irritable, but denied SI (suicidal intentions) or HI (homicidal intentions). (He/She) appeared to have some insight. Patient stating that (he/she) felt that something was wrong with (him/her) but could not figure out what....Past Psychiatric History: Patient has a history of dementia. (He/She) did not have any history of mental health problems prior to the onset of cognitive problems....Plan: ...6. Discuss in team meeting whether patient requires a higher level of care at this point than living alone in an apartment..."

The surveyor was unable to locate any further evidence in the clinical record of a team meeting discussion regarding the patient potentially requiring a higher level of care or living alone in an apartment.

Documented in the "Patient Notes" on 2/5/17 at 11:55 p.m. by the Registered Nurse (RN) was the following: "...Personal belongings had been double bagged prior to admission due to deputy report that bedbugs had been observed in (his/her) belongings prior to transport... On RN Supervisors advice, those were in turn placed in regular plastic bags for storage in belongings room..."

The "Behavioral Health RN Admission History and Assessment" done on 2/6/17 at 2:59 a.m. documented the following:..."Alert comments: Poor self-care. Poor insight...Functional Assessment: WDP (within defined parameters- meaning the assessment was within the "normal" for this section)." There was no specific documentation on this assessment of the patient's ability to complete ADL (activities of daily living- ability to bathe, toileting or dress with/without help).

On 2/6/17 at 10:24 a.m. the notes evidenced: "Phone call received from (name of ex-spouse) concerning pt (patient)...(name) spoke of patient living alone in senior housing and that (he/she) had been getting "worse" with hallucinations/delusions...states patient has appointment with memory care specialist on 2/26/17..."

On 2/7/17 at 9:20 a.m. the notes evidenced, "...upset that (his/her) clothing is not in (his/her) room and demanding (his/her) shoes. Per report, pts (patients) belongings have been bagged due to reported sighting of bedbugs when patient was in (name of area patient admitted from)..."

A note date 2/7/17 at 12:56 p.m. stated, "Patient is alert, oriented to self, month/year and hospital but lacks insight into situation..."

The "Psychological Assessment" dated 2/7/17 at 4:35 p.m. completed by the facility Social Worker evidenced the following: "...Tell me why you came to the hospital today; "I don't know"...Describe any other family issues: Pt is divorced. (he/she) has 16 children. His/her (adult child) is supportive and takes (him/her) to appointments, medications etc. Pt's other 15 children are not very involved. Pt is not known to have a POA (power of attorney)...Who do you live with: Pt has own apartment...Is your family involved in your care: Yes- (adult child name)...describe who you want to be involved in your recovery: (adult child name)...Approximate monthly income: Pt states (he/she) received Social Security amount (amount) per month...Describe money management abilities: Pt says (he/she) handles (his/her) finances and (adult child) assists if needed...Preliminary Discharge Plan: Return to own apartment...Community Resources recommended: Community outpt (out patient) Medication Management..."

A "Recovery Plan" was present in the clinical record and evidenced the "plan" for the patient which included: Strengths: Ability to perform ADL's, Adequate finances, Adequate housing.

Barriers to Recovery: Limited insight, poor medical condition...Problems: Alteration in thought Processes, Altered Cardiovascular Function, Altered Gastro Function, Falls Risk.

In the section for Discharge Planning Needs was the following: As evidenced by identification of services necessary to meet the patient's continuing care needs, Services may include physical services (home care assistance, home oxygen, nursing home care ect) and/or knowledge (patient or family teaching). Education is to include instruction to the specific knowledge and/or skills needed by the patient/family to meet the patient's ongoing health care needs including but not limited to : safe and effective use of medication, safe and effective use of medical equipment, instruction on potential drug-food interactions and counseling on modified diets, when and how to obtain further treatment, information on available community resources/services...Long term Goal: Patient and family will identify needs/barriers to discharge at least 2 days prior to discharge. Short Term Goal; Patient/family will participate in developing discharge plans from first day of admission...Target interventions: educate patient on safe and effective use of medications and medical equipment, educate patient on when and how to obtain further treatment and community resources..."

A "Case Manager" note dated 2/7/17 at 5:10 p.m., included in the "Patient Notes" section of the clinical record the following information, "...SW (social worker) met with patient to complete psychosocial assessment...pt signed consents for (his/her) PCP (primary Care Physician) and (his/her) (family member-name)...Patient lives in (his/her) own apartment...SW spoke with pt's (patients) (family member- name)...(he/she) is the main source of support and takes (him/her) to (his/her) medical appointments, to the grocery store and makes sure (his/her) needs are met..."

A "Psychiatric Progress Note" dated 2/8/17 revealed the following, in part: "...Patient stated that (he/she) feels a little sad because (he/she) is in the hospital instead of home...Strengths; good social support, stable housing...Diagnosis, Assessment & Plan: Assessment: "...admitted due to persecutory delusions and hallucinations as well as overall deterioration in functioning...limited insight into (his/her) problems...(He/she) does not have decision-making capacity...Plan: 5. Discharge home likely on Friday..." A 2/10/17 note revealed: "...happy to be able to go home today...Insight/judgment: insight limited/poor, judgement limited/poor..Assessment...(He/She) does not have decision-making capacity...Plan: ...Discharge home today..."

A "Reassessment Comment" documented 2/9/17 at 10:23 p.m. evidenced: "...patient stated (he/she) is not being discharged in AM. Later (he/she) talked to (his/her) family and told them that (he/she) was being discharged. Pt (patient) was confused when (he/she) brought the phone back to the nurses' station. (He/she) was talking about a man (he/she) chased but "he is (sic) longer there"...

A Discharge Psych Nurse Assessment dated 2/10/17 at 7:55 a.m. revealed: "...Functional Comment: Pt up ad lib ambulatory with steady gait, independent in ADLS...Discharge Diagnosis: Major Neurocognitive Disorder...Medications reconciled at discharge and completed list provided to patient: "Y" (yes)...Follow-up appointments: (Primary Care) 2/17/17, (name) CSB (community Services Board) 2/14/17, Do we have your permission to call you after discharge to see how you are doing: "Y" (yes)..." Date of Discharge: 2/10/17, Mode of transportation taxi, other disposition type: (Name) House Independent, All personal belongings sent: Y (yes)...additional discharge comment: discharged back to (Name) House Independent living ..."

On 3/28/17 at 11:00 a.m., the surveyor interviewed Staff Member #9 (Social Worker), #7 (RN-Geri-Psych Manager), and #8 (Geri-Psych Director) regarding the admission and discharge of Patient #2. Staff Member #7 stated, "(Patient #2) lived in (city) alone, in a senior housing community. (He/she) reported having 16 children and one (adult child) who did not live with (him/her), but provided support." When interviewed as to whether the facility had looked into the report of bedbugs which were documented as being present on admission, and if the patient's family/support were aware/notified of the bedbugs, Staff Member #7 stated, "I don't know...I set up the appointments for follow up with the PCP (Primary Care Physician), and CSB (Community Services Board) and faxed the info to them. (His/Her) (adult child) was in agreement with the discharge and said (he/she) was going to continue to care for (his/her- Patient #2's) appointments..." Staff Member #8 stated, "When (Patient #2) goes to the appointment at CSB they will do an intake and assessment...that appointment was for Tuesday and (he/she) was discharged on Friday, so that is a reasonable time frame..."

The surveyor inquired as to whether the facility staff had followed up on the issue of the patient's living conditions and the patient's ability to care for (him/herself) as well as the ability of the patient's (adult child) to provided the needed care for the patient. The surveyor also inquired if a UAI (Uniform Assessment Instrument- a document used to assess a patient's need for community based services) had been completed on Patient #2 prior to discharge. Staff Member #9 stated, in regards to the UAI, "No. I did not do one." Staff Member #7 stated, "We had conversations with (adult child) and (ex-spouse) and they said they were support for the patient." The surveyor expressed concerns regarding the fact that the patient had been admitted with bedbugs in (his/her) clothing and that there was no documentation in the clinical record or otherwise as to whether this concern had been addressed with the patient or the family prior to (his/her) returning to the same living conditions as well as the patient's diagnosis of dementia, the safety of the patient living alone, and the documented expressed concerns of the family that the patient had been deteriorating over the past months. Staff Member #7 stated, "We do a follow up call to the patient after discharge to see how things are going." The surveyor requested to view the documentation of the follow-up call that was made for Patient #2.

On 3/28/17 at approximately 1:15 p.m., the surveyor viewed, in the clinical record, the documented "follow up" call for Patient #2. "Call-back Post Discharge Wellness Check: 2/11/17 at 1627 (4:27 p.m) (Name of person who answered call- patient's sibling). "Its a mess. (His/her) home is full of bedbugs and no one wants to go in and (he/she) is confused. (he/she) can't find (his/her) phone or prescriptions."

Further documentation revealed the (family) was reminded of the patients appointments (Yes) - Prescriptions not filled but reviewed med record with patient. Additional comment: Pt (patient) has misplaced prescriptions at present. Pts (family) is checking on (him/her) and trying to give (him/her) guidance but will not go into the room due to bedbug infestation. F/U (follow-up) appointments were verbalized to (name) and (he/she) wrote them down. (He/she family member) stated pts (patients) (ex-spouse) will take (him/her- Patient #2) to appointments...Not taking meds as prescribed...Do you have immediate concerns for safety- Yes. Pt's (family) concerned due to patients confusion. This RN (registered nurse) instructed (family) to call 911 if (he/she) is concerned about pts safety . (Family) verbalized understanding. (family) stated (he/she- Patient #2) is confused..."

The surveyor inquired as to the facility policy regarding call-backs, as to what the staff should do if they encounter a situation such as this. Staff Member #7 stated, (family) was told to call 911 if they had concerns for the patients safety." The surveyor inquired as to what the facility expectation would be since the family had stated the patient returned to a bedbug infested home, and the facility had been aware of the issue upon the patients admission to which there was no evidence the issue had been addressed during the admission. The facility staff gave no response to this inquiry.

The facility policy and Procedure "Discharge Planning" was reviewed and evidenced, in part, "Purpose: To ensure patients are informed of their options and have a choice in selecting their post discharge provider/service and have been informed of any financial interest the hospital has with the extended care provider/service." There was no documentation in this policy of an evaluation of the patients ability to care for themselves or the family ability to provide care after discharge.

The concerns were discussed with the facility Staff Members #2, #3, #4, #7, #8, and #9 on 3/28/17 between 11:00 and 11:30 a.m. and again at 1:30 p.m..

Based on clinical record review and staff interview, the facility staff failed to ensure for 1 of 4 discharged patients in the survey sample (Patient #2), a thorough discussion had been done with the caregiver (family) regarding the patient's current living situation, to which (he/she) would be returning.

Patient #2 was discharged back to (his/her) prior living situation which was infested with bedbugs. There was no documentation that the caregiver (family) was aware of the situation to which the patient was returning.

The findings included:

Patient #2 was admitted to the facility on 2/5/17 with diagnoses that included, but were not limited to : Vascular Dementia with behavioral disturbances, brief psychotic disorder, hypertension, chronic kidney disease-stage 3, and history of transient ischemic attack (TIA- mini stroke).

Review of the clinical record for Patient #2 revealed the patient was admitted to the facility on a TDO (temporary detaining order) after being found wandering in a grocery store in a confused state and having paranoid thoughts. According to the "History and Physical" dated 2/5/17, "...brought to the ER (emergency room) by police after found wandering around in (name) supermarket talking to self. When approached by police, patient told them that (he/she) was not feeling well, so they transported (him/her) to the ER. In the ER, collateral information was provided by (his/her) (spouse). Patient had been deteriorating cognitively since (month) and had not been eating or sleeping well, and had increase in wandering behavior. Patient had also been experiencing persecutory delusions of people climbing the wall of (his/her) apartment building, entering (his/her) room, and trying to kill (him/her)...On admission patient presented as anxious, tearful, and irritable, but denied SI (suicidal intentions) or HI (homicidal intentions). (He/She) appeared to have some insight. Patient stating that (he/she) felt that something was wrong with (him/her) but could not figure out what....Past Psychiatric History: Patient has a history of dementia. (He/She) did not have any history of mental health problems prior to the onset of cognitive problems....Plan: ...6. Discuss in team meeting whether patient requires a higher level of care at this point than living alone in an apartment..." The surveyor was unable to locate any further team meeting discussion regarding the patient requiring a higher level of care or living alone in an apartment in the clinical record.

Documented in the "Patient Notes" on 2/5/17 at 2355 (11:55 p.m.) by the Registered Nurse (RN) was the following: "...Personal belongings had been double bagged prior to admission due to deputy report that bedbugs had been observed in (his/her) belongings prior to transport...On RN Supervisors advice, those were in turn placed in regular plastic bags for storage in belongings room..."

2/6/17 at 1024 (10:24 a.m.) the notes evidenced: "Phone call received from (name of ex-spouse) concerning pt (patient)...(name) spoke of patient living alone in senior housing and that (he/she) had been getting "worse" with hallucinations/delusions...states patient has appointment with memory care specialist on 2/26/17..."

On 2/7/17 at 9:20 a.m. the notes evidenced, "...upset that (his/her) clothing is not in (his/her) room and demanding (his/her) shoes. Per report, pts (patients) belongings have been bagged due to reported sighting of bedbugs when patient was in (name of area patient admitted from)..."

The "Psychological Assessment" dated 2/7/17 at 16:35 (4:35 p.m.) completed by the facility Social Worker evidenced the following: "...Tell me why you came to the hospital today; "I don't know"...Describe any other family issues: Pt is divorced. (he/she) has 16 children. His/her (adult child) is supportive and takes (him/her) to appointments, medications etc. Pt's other 15 children are not very involved. Pt is not known to have a POA (power of attorney)...Who do you live with: Pt has own apartment...Is your family involved in your care: Yes- (adult child name)...describe who you want to be involved in your recovery: (adult child name)...Approximate monthly income: Pt states (he/she) received Social Security amount (amount) per month...Describe money management abilities: Pt says (he/she) handles (his/her) finances and (adult child) assists if needed...Preliminary Discharge Plan: Return to own apartment...Community Resources recommended: Community outpt (out patient) Medication Management..."

A "Case Manager" note 2/7/17 at 1710 (5:10 p.m.) included in the "Patient Notes" section of the clinical record evidenced the following: "...SW (social worker) met with patient to complete psychosocial assessment...pt signed consents for (his/her) PCP (primary Care Physician) and his (family member-name)...Patient lives in (his/her) own apartment...SW spoke with pt's (patients) (family member- name)...(he/she) is the main source of support and takes (him/her) to (his/her) medical appointments, to the grocery store and makes sure (his/her) needs are met..."

A "Psychiatric Progress Note" dated 2/10/17 note revealed: "...happy to be able to go home today...Insight/judgment: insight limited/poor, judgement limited/poor..Assessment...(He/She) does not have decision-making capacity...Plan: ...Discharge home today..."

A "Reassessment Comment" documented 2/9/17 at 2203 (10:23 p.m.) evidenced: "...patient stated (he/she) is not being discharged in AM. Later (he/she) talked to (his/her) family and told them that (he/she) was being discharged. Pt (patient) was confused when (he/she) brought the phone back to the nurses' station. (He/she) was talking about a man (he/she) chased but "he is longer there"...

There was no documentation found in the clinical record of any discussion with the patient's (family/listed support) regarding the bedbug infestation which was reported/documented on admission in the apartment/living situation to which the patient would be returning. There was nothing in the patient's treatment plan regarding treatment for bedbugs, other than (his/her) clothing had been "double bagged" and stored. Documentation on the "Discharge Notes" evidenced the patient was sent home with "personal belongings" to which there was no evidence these belongings had been treated for bedbugs before releasing them to the patient.

On 3/28/17 at 11:00 a.m., the surveyor interviewed Staff Member #9 (Social Worker), #7 (RN-Geri-Psych Manager), and #8 (Geri-Psych Director) regarding the admission and discharge of Patient #2. Staff Member #7 stated, "(Patient #2) lived in (city) alone, in a senior housing community. (He/she) reported having 16 children and one (adult child) who did not live with him, but provided support." When interviewed as to whether the facility had looked into the report of bedbugs which were documented as being present on admission, and if the patient's family/support were aware/notified of the bedbugs, Staff Member #7 stated, "I don't know...I set up the appointments for follow up with the PCP (Primary Care Physician), and CSB (Community Services Board) and faxed the info to them. (His/Her) (adult child) was in agreement with the discharge and said (he/she) was going to continue to care for (his/her- Patient #2's) appointments..." Staff Member #8 stated, "When (Patient #2) goes to the appointment at CSB they will do an intake and assessment...that appointment was for Tuesday and (he/she) was discharged on Friday, so that is a reasonable time frame..." The surveyor inquired as to whether the facility staff had followed up on the issue of the patient's living conditions and the patient's ability to care for (him/herself) as well as the ability of the patients (adult child) to provided the needed care for the patient. The surveyor expressed concerns regarding the fact that the patient had been admitted with bedbugs in (his/her) clothing and that there was no documentation in the clinical record or otherwise as to whether this concern had been addressed with the patient or the family prior to (his/her) returning to the same living conditions as well as the patient's diagnosis of dementia, the safety of the patient living alone, and the documented expressed concerns of the family that the patient had been deteriorating over the past months. Staff Member #7 stated, "We do a follow up call to the patient after discharge to see how things are going." The surveyor requested to view the documentation of the follow-up call that was made for Patient #2.

On 3/28/17 at approximately 1:15 p.m., the surveyor viewed, in the clinical record, the documented "follow up" call for Patient #2. "Call-back Post Discharge Wellness Check: 2/11/17 at 1627 (4:27 p.m) (Name of person who answered call- patient's sibling). "Its a mess. (His/her) home is full of bedbugs and no one wants to go in and (he/she) is confused. (he/she) can't find (his/her) phone or prescriptions." Further documentation revealed the (family) was reminded of the patients appointments (Yes) - Prescriptions not filled but reviewed med record with patient. Additional comment: Pt (patient) has misplaced prescriptions at present. Pts (family) is checking on (him/her) and trying to give (him/her) guidance but will not go into the room due to bedbug infestation. F/U (follow-up) appointments were verbalized to (name) and (he/she) wrote them down. (He/she family member) stated pts (patients) (ex-spouse) will take (him/her- Patient #2) to appointments...Not taking meds as prescribed...Do you have immediate concerns for safety- Yes. Pt's (family) concerned due to patients confusion. This RN (registered nurse) instructed (family) to call 911 if (he/she) is concerned about pts safety . (Family) verbalized understanding. (Family) stated (he/she- Patient #2) is confused..."

The surveyor inquired as to the facility policy regarding call-backs, as to what the staff should do if they encounter a situation such as this. Staff Member #7 stated, (family) was told to call 911 if they had concerns for the patients safety." The surveyor inquired as to what the facility expectation would be since the family had stated the patient returned to a bedbug infested home, and the facility had been aware of the issue upon the patients admission to which there was no evidence the issue had been addressed during the admission. The facility staff gave no response to this inquiry.

The concerns were discussed with the facility Staff Members #2, #3, #4, #7, #8, and #9 on 3/28/17 between 11:00 and 11:30 a.m. and again at 1:30 p.m..