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Based on policy and procedure reviews, medical record review, transfusion services report review and staff and physician interviews, hospital staff failed to maintain care in a safe setting by failing to prevent a delay in treatment for 1 of 1 rehabilitation patients with an acute change in status (Patient #2).

The findings included:

Review of the title Transfusion Services Statement of Services effective date 07/11/2017 revealed "PURPOSE: This policy details the understanding between the Transfusion Service and clinical services at all (Named) facilities ...to provide safe blood products on a timely basis. POLICY STATEMENT: This policy defines expectations for turn-around-time ... PROCEDURES: II. Turn-around-time for red blood cell products- b. For STAT (immediately) orders, 60 minutes if patient has a negative antibody screen and no history of antibodies on file and type and screen is not already completed."

Review on 12/17/2019 of the closed medical record for Patient #2 revealed a 76-year-old female admitted to the Named Hospital's Rehab (Rehabilitation) unit on 07/12/2019 following a stroke. Review of Patient #2's POC (point of care) glucose value dated 07/31/2019 at 0636 revealed it was 431 and at 0748 it was greater than 500. Review of the STAT (immediate) CBC (complete blood count) Hgb (hemoglobin-carries oxygen in the blood) results dated 07/31/2019 at 0826 revealed Patient #2's Hgb was 6.5. Review of the order dated 07/31/2019 at 0919 revealed Nurse Practitioner (NP #2) ordered "GlucoStablizer (CG-a computer application used to calculate insulin dosing): Low target glucose:140 (default); High target glucose: 180 (default) ..." Review of the order dated 07/31/2019 at 1035 revealed Physician Assistant (PA #1) ordered a STAT type and screen (testing to determine donor/recipient blood compatibility) from the Rehab encounter (where Patient #2 was currently). Review revealed an admission to ICU (Intensive Care Unit) order was placed on 07/31/2019 at 1107. Review of MD (Medical Doctor) #1 attestation dated 07/31/2019 at 1113 revealed "The patient was seen in rehab. According to RN no ICU rooms are immediately available. Insulin infusion is ready to be used. POC BG >500mg/dL. Since there is no CG (glucostabilizer) software in the rehab will start IV (intravenous) insulin infusion at 0.1u/kg (units per kilogram)-9 u/hr (units per hour). Will recheck BG (blood glucose) in 1 hr and titrate accordingly ...ICU team is at bedside ..." Review revealed the Insulin Regular drip was started on 07/31/2019 at 1117 (1 hour and 58 minutes after the glucostabilizer order was placed). Review of NP #1's order dated 07/31/2019 at 1159 revealed a STAT "Prepare RBC (red blood cells): Number of Units: 1 ...Department: 2e Cv Icu 2 east cardiovascular ICU" (the ICU unit were a bed was requested for Patient #2) and STAT "Transfuse RBC:1 unit (which means immediate administration of blood to Patient #2) ...Department: 2e Cv Icu." Review of the Blood Transfusion Record dated 07/31/2019 at 1346 (3 hours and 11 minutes after the type and screen order was placed) revealed one unit of RBCs was started by RN #2. Review of Patient #2's Hgb dated 07/31/2019 at 1532 was 5.6. Review revealed Patient #2 suffered cardiac arrest on 07/31/2019 at 1441. Review revealed Patient #2 had ROSC (return of spontaneous circulation) and was transferred from the rehab unit to 2e Cv ICU on 07/31/2019 at 1547. Review revealed on 08/02/2019 Patient #2 expired.

Review of the Transfusion Service report dated 07/31/2019 revealed a type and screen order was requested on 07/31/2019 at 1035. Review revealed the type and screen was collected from Patient #2 on 07/31/2019 at 1052. Review revealed the blood blank received the type and screen on 07/31/2019 at 1130 (38 minutes after the collection and 55 minutes after the STAT type and screen order was placed). Review revealed the type and screen testing was completed on 07/31/2019 at 1229. Review of the unit history revealed the first unit of blood was ready for pickup and linked to the 2e Cv ICU encounter (where Patient #2 was awaiting transfer) on 07/31/2019 at 1306. Review revealed the first unit of blood was later linked to the Rehab unit (where Patient #2 was currently) on 07/31/2019 at 1325 and picked up by RN #4 (Rehab Charge Nurse) at 1325 (2 hours and 50 minutes after the type and screen order was placed).

Interview on 12/18/2019 at 1012 with the Executive Director of Clinical Informatics and Nursing Operations (RN #1) revealed due to Patient #2 being in the rehab there were two patient encounters created in the charting system. Interview revealed the order to admit was submitted to bed placement (staff who find patients available beds) then a second patient encounter was created in the charting system. RN #1 stated depending on which encounter (ICU or Rehab) the providers placed the orders in would depend on where it appeared Patient #2 was. Interview revealed due to PA #1 ordering the STAT type and screen under the Rehab encounter and NP #1 ordering the STAT prepare and transfuse blood under the ICU encounter, that "essentially delay care." RN #1 stated it appeared to the blood bank Patient #2 had already transferred to the ICU because of where the transfuse order was entered, but she was still in the rehab unit. Interview revealed if orders were placed under the Rehab encounter, there would not have been a delay in care.

Interview on 12/18/2019 at 1026 with MD #1 revealed she was the Endocrinologist that cared for Patient #2. Interview revealed her team was consulted by the Rehab team due to Patient #2's blood sugars were high. Interview revealed upon MD #1's assessment the morning of 07/31/2019, Patient #2 appeared "really ill and looked obtunded" (slowed responses to stimulation, depressed level of consciousness). Interview revealed due to Patient #2 being in the rehab unit, there was no glucostabilizer application on the rehab computers. MD #1 explained the glucostabilizer (GS) was an application loaded on the ICU computers and was used to guide the nurses in insulin drip titration. Interview revealed there were efforts made to load the GS application onto the rehab computer but was unsuccessful. Interview revealed due to the GS application not being on the rehab computer, that caused a delay in the insulin drip being started.

Interview on 12/18/2019 at 1043 with NP #2 revealed she was the NP with the Endocrinology team that provided care for Patient #2 on 07/31/2019. Interview revealed NP #1 saw Patient #2 that morning and she was found to be in DKA. NP #2 stated Patient #2 was "very obtunded" and unable to give responses. Interview revealed Patient #2 was "very pale." NP #2 stated Patient #2 needed immediate treatment of DKA and transfer to ICU. Interview revealed NP #2 ordered STAT insulin IV and consulted with PA #1 (rehab provider) to inform her Patient #2 needed to be transferred to ICU immediately. Interview revealed there were no ICU beds available. Interview revealed when the ICU nurses administered an insulin drip, they used the GS application. Interview revealed there was no GS application on the rehab computers because the nurses in rehab do not administer insulin drips. Interview revealed due to the rehab unit not having the GS application on their computers, that did cause a delay in the starting the insulin drip.

Interview on 12/18/2019 at 1203 with RN #2 revealed he was the rounding ICU nurse that stayed at Patient #2's bedside on 07/31/2019. Interview revealed there were no ICU beds available at the time. Interview revealed he had two computers with each computer having a different patient encounter on it, that allowed him to chart and see orders in both encounters.

Interview on 12/18/2019 at 1429 with a Pharmacist revealed standard process was to keep mixed insulin drips readily available. Interview revealed once an order came into the pharmacy for an insulin drip, the pharmacist verified the order and medication and if no issues were detected with the administration, the pharmacist placed a label on the insulin bag, and it was ready for distribution to the unit. Interview revealed there should be no more than a 30-minute turn-around time from time of insulin drip order to the time the insulin drip was available for use.

Interview on 12/18/2019 at 1540 with Nurse Manager of the rehab unit Patient #2 was admitted revealed there seemed to be some confusion due to the two patient encounters.

Interview on 12/18/2019 at 1610 with the Supervisor of Transfusion Services revealed the blood bank had a one hour turn-around time for STAT type and screen orders to be completed and an additional ten minutes to perform an electronic cross match. Interview revealed there was a recorded conversation between RN #4 and a blood bank technician on 07/31/2019. Interview revealed the conversation was about where Patient #2 was located. Interview revealed the type and screen order was placed under Patient #2's rehab encounter and the prepare and transfuse blood order was placed under Patient #2's ICU encounter. Interview revealed due to the two patient encounters, blood bank had to verify which unit Patient #2 was currently on at the time of blood pickup to ensure the unit of blood was properly "linked" to the correct patient encounter. Interview revealed the unit of blood needed to be linked to the correct encounter so the nurse could scan the unit and document the administration of the blood in Patient #2's correct patient encounter. Interview revealed the unit of blood was originally linked to Patient #2's ICU encounter due to the order originating from the ICU patient encounter. Interview revealed once Patient #2's location was determined; the unit of blood was available, and RN #4 picked up the blood from the blood bank. Interview revealed the turn-around time of 70 minutes for STAT type and screen orders to be completed and blood available for pickup was not met.

Interview on 12/19/2019 at 1013 with RN #4 revealed she was Patient #2's charge nurse in rehab on 07/31/2019. Interview revealed RN #4 called the blood bank to check on the status of Patient #2's blood and there was some confusion about the location of Patient #2, but she couldn't recall the specifics. Interview revealed it usually took "about an hour" from the time lab collects a type and screen to the time the blood was available for pick up. Interview revealed RN #4 had never seen a patient have two patient encounters in the computer system like Patient #2 did. Interview revealed RN #2 had two computers at bedside so he could see both encounters. Interview revealed the rehab charting system did not "flow" to the main hospitals charting system. RN #4 stated a patient had to be "discharged" from the rehab unit then a new patient encounter would be created for the main hospital admission. Interview revealed provider orders would not "flow" from the rehab patient encounter to the ICU patient encounter. Interview revealed Patient #2 had a delay in receiving insulin but unable to recall why.

Interview on 12/19/2019 at 1135 with the Manager of Pathology revealed the expectation for Phlebotomist's (PT) to collect STAT orders was 25 minutes and returned to the lab was another 25 minutes (50 minutes total).

Interview on 12/19/2019 at 1307 with Phlebotomist (PT #1) revealed she was the PT that collected Patient #2's STAT type and screen order. Interview revealed PT #1 was unable to recall the specifics of that day. Interview revealed standard process was once they received a STAT order, they immediately collect the blood and deliver blood sample to the lab for testing. PT #1 stated they had 25 minutes to collect STAT orders and expectation was to deliver to the lab "ASAP" (as soon as possible). Interview revealed if there was another STAT order pending in close proximity, then they would collect both STATs and return to lab together. PT #1 stated 38 minutes "seems like a lot" from time of collection to time the blood sample was delivered to the lab.

Interview on 12/19/2019 at 1457 with RN #5 revealed she was the second rounding RN on duty on 07/31/2019. Interview revealed usually within the hour from a STAT type and screen order, the unit of blood would be available. RN #5 stated that if a STAT type and screen order was placed on an ICU patient, then it would take approximately 5-10 minutes to collect the blood sample and send it to the lab via tube system.

Interview on 12/19/2019 at 1538 with NP #1 revealed "usually" within an hour to an hour and a half from the time he ordered a STAT type and screen to the time the blood was infusing on a patient was what he typically saw. Interview revealed NP #1 "may have delayed the blood" due to his concern that Patient #2 needed additional volume (normal saline) because of her elevated glucose levels. Interview revealed at the time NP #1 was not concerned about "active life threatening" bleeding, he felt the DKA was contributing to the abnormal hemoglobin and blood pressures. Interview revealed NP #1 did not consider Patient #2 to be a candidate for emergent release blood (uncross matched red cells-when transfusion is needed before testing can take place). NP #1 stated he did not feel the risk outweighed the benefit of ordering emergent release blood. Interview revealed three hours was a long time to wait on the blood to be administered. Interview revealed it was "hard to say" if the delay in blood administration contributed to Patient #2's negative outcome. Interview revealed the two patient encounters could have been done better to prevent delays in Patient #2's care.

Based on the review of the hospital policy and procedure, medical record review, and staff interviews, the facility staff failed to establish a plan of care for communication for 1 pf 4 patients (#5).

Findings included:

Review on 12/19/2019 of the hospital policy titled "Plan of Care-Interdisciplinary-Nursing" with an effective date of 12/19/2018 revealed, "...Procedures: 1. Assessment: ... b. The plan of care will be based on the nursing process and will consider the patient's treatment goals, physiological and psychosocial factors, sociocultural, spiritual, and discharge planning needs ... V. Evaluation: The RN (Registered Nurse) will evaluate the plan of care by ongoing assessment/reassessment of the patient's needs and response to interventions. a. Every shift, the RN will review the Plan of Care with the patient and/or family. i. Review the entire plan of care and discontinue goals, add new goals, or resolve problems and /or goals that are duplicated or no longer active ..."

Review on 12/19/2019 of the hospital policy titled "Assessment-Nursing" with an effective date of 04/29/2019 revealed, "... I. Additional Resources ... v. Oral and written communication needs ... vi. Learning needs assessment of each patient, which includes the patient's cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication (PC.022.03.01) ..."

1. Review of the closed medical record for Patient #5 on 12/17/2019 revealed a 22-year-old male presented to the emergency department (ED) on 07/11/2019 with complaints of "right side mid ABD (abdominal) pain x (for) today" and "not eating well x today". Review of the past medical history for Patient #5 revealed a history of Down Syndrome, Asthma, and tracheomalacia (the collapse of the airway when breathing), severe OSA (obstructive sleep apnea - temporary stoppage of breathing during sleep)(non-compliant with CPAP [continuous positive airway pressure]) and morbid obesity (100 pounds over ideal body weight and BMI [body mass index - identifies right weight for height of people] of 40 or above). Review of the "Neurological" flowsheet revealed when Patient #5 was intubated (had a tube through the mouth into the airway to allow assistance with breathing) (7/11/2019 through 7/21/2019) the section "Speech" was marked "non-verbal" and "unable to assess". When Patient #5 was not intubated (7/21/2018 through 7/25/2019) the "Speech" section was marked with "Sign language/hand gestures" or "Nods/gestures appropriately". Review of the "Plan of Care" for the period of 07/11/2019 through 07/25/2019 revealed there was no communication needs identified. Review of the "Physical Therapy " note dated 07/22/2019 at 1003 revealed, "... Patient in bed upon therapy arrivals; primarily nonverbal but uses gestures to communicate ..." Review of the "Speech Language Pathology" note dated 07/21/2019 at 1037 revealed, "... Oral Motor Evaluation: Vocal Quality: (aphonic) (without voice) ... " Review of the "Physical Therapy" note dated 07/24/2019 at 1004 revealed, "... Assessment: Patient pleasant and agreeable throughout session; nonverbal most of the session, using gestures to communicate or occasionally speaking with low voice ..." Review of the "Physician Progress Note" dated 07/24/2019 at 1445 revealed, "... Physical Examination: ... PSYCHIATRIC: Happy, nods and smiles, not very verbal ..."

Interview on 12/19/2019 at 1040 with MD (Medical Doctor) #3 revealed Patient #5 "did not communicate a normal way, he would grunt and nod. He could not talk a normal way."

Interview on 12/19/2019 at 1102 with RN (Registered Nurse) #7 revealed she remembered Patient #5. Interview revealed Patient #5 "would nod". Interview revealed RN #7 "looked for signs of grimaces" on Patient #5's face to help determine if he was in pain or uncomfortable. Interview revealed Patient #5 "would hit the bed" to get RN #7's attention while she was in the room. Interview revealed when RN #7 was not in Patient #5's room, Patient #5 would hit the bed and/or family would get the nurse.

Interveiw on 12/17/2019 at 1122 with RN #6 revealed "Patient did hand gestures for when he wanted something, like something to drink."

Interview on 12/18/2019 at 1345 with RN #8 revealed she remembered Patient #5. Interview revealed "he could tell me little words, point to things, nod his head, and answer yes/no questions. Interview revealed RN #8 could not remember if Patient #5 could use a call bell to call for assistance. Interview revealed RN #8 "sat outside his (Patient #5's) room all night".

Interview on 12/19/2019 at 1344 with NM #2 revealed she remembered Patient #5. Interview revealed NM #2 had minimal interaction with Patient #5. Interview revealed there was a communication board in the room that was used to communicate with Patient #5 and family. Interview revealed no one assessed if Patient #5 could read. Interview revealed Patient #5 used fragmented words and he would beat on the side of the bed. Interview revealed unsure if Patient #5 could use the call bell consistently to call for assistance. Interview revealed there was not anything on the plan of care for consistency in how Patient #5 communicated needs to staff or how staff knew of Patient #5's needs.

Based on policy review, medical record reviews and staff and physician interviews, the hospital discharge planning staff failed to arrange post-discharge services for physical therapy and durable medical equipment for 2 of 7 sampled patients (#9, #3).

Findings included:

Review of the facility's "Discharge Planning" policy effective 04/03/2018 revealed, "... Discharge planning (or transition planning) is a process that determines the most appropriate post-hospital discharge destination for a patient as well as the patient requirements for a smooth and safe transition from the hospital to that destination. ... If the patient, the patient's family or other informal caregivers are not able to address all of the patient's required care needs, the evaluation and plan will include the community-based services which will support the patient to continue living at home or with family/support person. Such services might include: ... Home Health RN, PT ... Durable Medical Equipment ... Once the determination is made that services will be needed post-discharge, the team will determine the availability of those services, or substitute services, and coordinate with payers. ... To implement post-hospital care, the Case Management team will arrange transfers to the following facilities or coordinate community referrals to facilitate a smooth transition for the patient: ... Referrals to home health ... Referrals for durable medical equipment ..."

1. Closed medical record review of Patient #9 revealed a 63 year-old male that was admitted on 12/06/2019 due to a fracture of the left tibia. Review revealed the patient had a surgical repair of the fracture on 12/06/2019. Review of discharge planning notes dated 12/09/2019 at 1100 recorded the patient lived alone in a boarding house and was independent with activities of daily living prior to admission. Review revealed Physical Therapy had recommended a rolling walker and that the patient was agreeable. Review revealed a plan to discharge home. Review of an Occupational Therapy (OT) note dated 12/09/2019 at 1209 revealed an assessment that documented the patient had decreased dynamic balance and decreased endurance impacting activities of dialing living and functional mobility. Review of the notes revealed the patient was not able to cross his lower extremities to dress his lower leg or bed it fully to his foot secondary to pain. Review revealed "Patient lives in a boarding house, housemates work outside home, will likely need short term rehab to maximize safety and I (independence) prior to return home." Review of discharge recommendations recorded a need for a rolling walker and bedside commode. Additional needs included intensive rehabilitation. Review of a Physical Therapy (PT) note dated 12/09/2019 at 1210 recorded the patient discharge needs included intensive rehabilitation greater than 3 hours per day and a rolling walker. Review revealed the patient ambulated 10 feet with a rolling walker. Review of PT notes dated 12/10/2019 at 1136 recorded the patient had increased in gait distance but he was not applying any weight to his left lower extremity when standing and he had difficulty touching his foot to the floor when sitting. Review of the notes recorded that the patient was below his baseline and would benefit from PT to progress. Review of the note revealed "Given limited assistance at home, recommend SNF (skilled nursing facility) initially prior to return home." Review revealed the patient reported he did not feel comfortable going home as no one would be there to assist him during the day. Review revealed the patient ambulated 15 feet with a rolling walker. Review of an OT note dated 12/11/2019 at 1143 recorded the patient continued to have significant pain with weight bearing and was anxious about returning home. Review revealed the patient needed moderate to maximum assistance with bathing, dressing and toileting. Review of the note recorded the patient was not safe or mobilizing well enough to return home alone. Discharge recommendations included intensive rehab and a bedside commode and rolling walker. Review of a physician's Discharge Summary dated 12/11/2019 at 0957 recorded the patient had progressed with physical therapy and was determined to be stable for discharge. Review of Discharge Planning notes revealed a walker and bedside commode were arranged. Review revealed no home health physical therapy services were arranged prior to discharge. Review revealed the patient was discharged home on 12/11/2019.

Review revealed Patient #9 was readmitted on 12/12/2019 due to increased pain and inability to take care of himself. Review of a physician's history and physical dated 12/12/209 at 1953 recorded "The patient returns to the (name of hospital) ED (emergency department) today after he reports that he was unable to pick up his pain medications on his way home after being discharged from the hospital. He has been in pain since that time. He also states that he is unable to take care of himself at home and requires rehab placement. ..." Review of a discharge planning note dated 12/12/2019 at 1920 recorded the patient reported he was unable to pay to go to short term rehab at the time of discharge. Review revealed the patient reported that he rents a room and has been alone and unable to take care of himself. He states he was having too much pain to ambulate or perform his activities of daily living. Review of a Discharge Planning note dated 12/13/2019 at 1149 revealed the patient had insufficient caregiver support after discharge. Review revealed the patient needed a referral to PT and OT and recommended a referral to SNF at discharge. Review revealed the patient was requesting a referral to SNF to get stronger before he goes home. Review revealed a choice list of SNF facilities was provided. Review of a PT note dated 12/13/2019 at 1150 revealed the patient presented below his baseline of moderate independence without an assist prior to his first admission. Review revealed the patient ambulated 25 feet with a rolling walker and supervision. Review revealed the patient required minimal to moderate assistance with transfers due to pain, impaired balance, and general deconditioning. Review of the note documented that patient would benefit from skilled acute PT to address strength, endurance and balance in order to increase the patient's independence with functional mobility and provide safety upon discharge. Review of discharge recommendation included intensive rehabilitation greater than 3 hours per day and a rolling walker. Review of a discharge planning note dated 12/16/2019 at 1356 revealed the social worker met with the patient to discuss a bed offer from SNF. Review revealed the patient had concerns regarding losing his room at the boarding house if he went to the SNF. Review revealed the patient wanted to go back to the boarding house and stated he would get assistance from a family member. Review of a discharge planning note dated 12/17/2019 at 1512 recorded the patient was being discharged home with physical therapy services arranged, and a rolling walker and bedside commode.

Interview on 12/18/2019 at 1520 with PT #2 revealed the therapist was involved with providing care to Patient #9 during his first admission. Interview revealed the patient needed to walk 100 feet which would be the average space for a rental room. The staff member stated the patient had no support at home. Interview revealed PT had recommended on 12/10/2019 that for the patient to discharge to a skilled facility due to a lack of assistance in the home setting unless the patient could ambulate 100 feet and transfer independently. Interview revealed the patient ambulated 10 feet on 12/10/2019 and 15 feet on 12/11/2019. PT #2 she saw the patient on 12/11/2019 and the physician discharged him on 12/12/2019. PT #2 stated her assessment revealed he was not safe for discharge home and she recommended short term placement in a skilled facility with physical therapy services. Interview revealed the patient should have had physical therapy arranged after discharge on his first visit.

Interview on 12/18/2019 at 1540 with RN #9 revealed she was a case manager that worked with Patient #9 regarding discharge planning. Interview revealed the nurse was unable to explain why physical therapy services were not arranged for the patient during the first hospital admission. The nurse stated PT should have been arranged and it was not done.

2. Closed medical record review of Patient #3 revealed a 70 year-old female that was admitted on 03/24/2019 with a hip fracture after a fall at home. Review revealed the patient had a surgical repair of the hip done on 03/25/2019. Record revealed revealed physical therapy and occupational therapy services were provided during the patient's hospitalization. Review of an OT note dated 03/26/2019 at 1430 recorded an initial evaluation for Occupational Therapy (OT) services that documented the patient was functioning below her level of baseline function and would benefit from continued OT services. Review revealed discharge recommendations included a need for a bedside commode. Review revealed a discharge planning note documented by a social worker on 03/26/2019 at 1608 that the patient lived with her husband and was independent with daily activities prior to admission. Review revealed the patient would likely need skilled nursing facility placement. Review of the note revealed skilled nursing lists of services available were provided. Review revealed the patient used no services or equipment prior to admission to the hospital. Review of a Physical Therapy (PT) note dated 03/26/2019 at 1620 recorded discharge recommendations included 24-hour assistance and a rolling walker. Review revealed a goal to ambulate 50 feet with least device and supervision. Review of a PT note dated 03/27/2019 at 1037 recorded a discharge recommendation of 24-hour assistance, home health services and a rolling walker. Review of an OT note dated 03/27/2019 at 1109 revealed a discharge plan that included 24-hour supervision, 24-hour assistance and equipment recommended for a bedside commode. Review of a PT note dated 03/27/2019 at 1451 revealed a recommendation at discharge for home health physical therapy verses skilled nursing facility. Review revealed the patient was "struggling with bed mobility" and needed a rolling walker. Review of a social worker discharge planning note documented on 03/27/2019 at 1522 recorded "Patient now leaning toward home with home health." Review revealed a choice list for home health and skilled nursing facilities (SNF) was provided. Review of an OT note dated 03/28/2019 at 1357 recorded discharge recommendations that included continued OT in a rehab setting, likely SNF prior to return home. Review revealed a need for a bedside commode. Review of a physician's progress note dated 03/28/2019 at 1406 revealed the patient would prefer to go home but acknowledged that she would need more than three times per week visits to rehab. The note recorded the patient recognized that her husband could not really manage her needs. Review of a discharge planning note dated 03/28/2019 at 1525 revealed the social worker met with the patient and her spouse to provide SNF bed offers and the patient selected a facility. Notes recorded bed placement would be initiated at the choice facility. Notes recorded by a social worker on 03/29/2019 at 1028 recorded the patient decided she wanted to pursue another inpatient rehab facility for placement. Notes recorded the social worker would initiate the referral. Review of OT notes dated 03/29/2019 at 1321 recorded a plan to continue OT services in a rehab setting and the need for a bedside commode. Review of PT notes dated 03/29/2019 at 1415 revealed discharge recommendations hat included the need for a rolling walker and home health PT versus SNF placement. Review revealed the patient was walking 40 feet with a rolling walker and contact guard assistance. Review of a PT note dated 03/30/2019 at 1230 recorded the patient was awaiting on decision to discharge to rehab or SNF. Review revealed the discharge recommendations included a rolling walker and home health PT verses SNF. Review of a discharge planning note dated 04/01/2019 at 502 revealed she was awaiting authorization from insurance for placement at the rehab facility. Review of an OT note dated 04/02/2019 at 0931 recorded the continued need for a bedside commode and to continue OT services in a rehab setting after discharge. Review of a PT note dated 04/02/2019 at 1230 revealed a continued recommendation for a rolling walker at discharge and home health PT verses SNF placement. Review of the note recorded the patient ambulated 80 feet with a rolling walker and stand by assistance and had met her progress toward goals. Review of a discharge planning note dated 04/02/2019 at 1532 recorded the insurance company denied rehab placement and the patient was notified. Review of a physician's progress note dated 04/03/2019 at 1842 recorded the patient and family were still hoping that the patient could go to an SNF. Review of the note revealed the insurance denied her request for SNF placement. Review revealed " ... I've spoken with their peer-to-peer advisor and I was successful in achieving approval of SNF. I've notified SW (social worker) to begin work on HHPT (home health physical therapy) with patient and family. ..." Review revealed a plan to discharge the patient home with physician therapy services. Review of a discharge planning note dated 04/04/2019 at 0832 recorded the social worker discussed home health services with the patient and husband. Review of the note revealed the patient "has needed DME (durable medical equipment). Review revealed the patient chose home health and requested wheelchair transport home. Review revealed arrangements for transport were made. Review of a physician's Discharge Summary dated 04/04/2019 at 1145 recorded " ... She worked with PT and OT. Arrangements were made for rehab at SNF; however, she improved quickly, and her insurance company guided patient to home health with PT. Patient is agreeable with that at this point, day 11. ..." Review revealed the patient discharged home on 04/04/2019. Record review revealed no evidence that the patient had a rolling walker or bedside commode available at admission and no evidence that arrangements were made to ensure the patient had the equipment available at discharge.

Telephone interview on 12/17/2019 at 1425 with the patient's Hospitalists (MD #5) revealed the patient's recovery was "fairly routine." Interview revealed the patient mobilized well to the bathroom and out of bed to a chair. The physician stated he called the insurance physician to verify that they had correct information and discuss the patient's desire to go to a SNF. Interview revealed the insurance physician felt the patient could do enough to go home based on the PT notes. MD #5 stated the patient disagreed with the decision. MD #5 stated he was working off the PT and nursing notes and all agreed that the patient was safe to go home with physical therapy.

Interview on 12/17/2019 at 1500 with PT #1 revealed she remembered Patient #3. Interview revealed this therapist conducted the initial assessment on the patient and they were planning to discharge her to a SNF or rehab placement. Interview revealed the patient was struggling with getting in and out of bed and needed a rolling walker for ambulation. Interview revealed that the patient ambulated 40 - 50 feet initially and 80 feet prior to discharge with a rolling walker. Interview revealed the patient was safe for discharge home with the assistance of family and a rolling walker. PT #1 reviewed the record and reported the patient was independent with activity of daily living prior to admission and had no durable medical equipment prior to admission.

Telephone interview on 12/17/2019 at 1525 with the social worker (SW #1) that was involved with discharge planning for Patient #3 revealed she had some recall of Patient #3. Interview revealed the staff member no longer worked at the hospital and had relocated to another campus. The staff member was unable to provide evidence that arrangements were made for durable medical equipment that included a rolling walker and bedside commode.

Interview on 12/18/2019 at 1330 with the manager of Discharge Planning Services revealed he was familiar with Patient #3 because a complaint had been filed and he had investigated the concerns. Interview revealed the patient was discharged with home health physical therapy. Interview revealed the patient needed a rolling walker and bedside commode for home use after discharge. The staff member reviewed the medical record and stated that an assessment of equipment documented on 03/26/2019 recorded the patient had no equipment prior to arrival at the hospital. Interview revealed there was no evidence that the rolling walker and bedside commode were arranged for the patient to have available after discharge. Interview revealed the facility staff failed to follow hospital policy to arrange the needed equipment.

NC00156695; NC00154248; NC00155561