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Based on interview and the review of medical records, it was determined the facility failed to assure that for each patient in need of post-hospital care, a comprehensive care plan is developed with the involvement of health professionals whose services are medically needed. This finding was noted in 1 of 10 patients' records reviewed (Patient #1).

Findings include:

Patient #1 is an 80-year-old female with multiple medical conditions that include hypertension, cerebrovascular accident, and end-stage renal disease on dialysis three times weekly. The patient was admitted 1/28/15 with changes in mental status and found to have positive urine culture. Urine specimen obtained 1/28/15 and 1/31/15 both grew 20,000 colony forming unit/milliliter Escherichia coli (Bacteria) that were multi drug resistant. The patient was followed by infectious disease consultant and treated with multiple antibiotics including Meropenem (antibiotic) 500 milligram (mg) administered intravenously.

The patient was discharged on 2/5/15 with a written discharge medication list that included continued treatment with three more doses of Meropenem 500 mg intravenous to be administered post dialysis.

The discharge planning notes lacked information regarding the arrangement made by the facility to ensure the patient continues to receive her antibiotics post discharge. The patient was readmitted on 2/7/14 for treatment of sepsis (systemic reaction of the body to a bacterial infection). Physician notes on admission indicated that the patient's daughter stated the patient did not receive her antibiotics post hemodialysis on 2/6/15.

At interview with Staff #1 on 2/20/15 at 10:30 AM, she stated the patient's nephrologist should have communicated the treatment plan to the patient's outpatient hemodialysis center prior to discharge.

Based on interviews, the review of medical records and other documents, it was determined the facility failed to ensure that each patient discharged to a Skilled Nursing Facility is sent with necessary medical information. This finding was noted in 2 of 10 applicable patients' records reviewed (Patient #2 and #3).

Findings include:

1. Patient #2 is an 82-year-old female with multiple medical conditions including interstitial lung disease who was admitted on 10/10/14 for management of interstitial lung disease exacerbation, pulmonary hypertension, and congestive heart failure. The patient was discharged to a skilled nursing facility on 10/15/14 for short-term rehabilitation.

The patient had an advanced directive that was acknowledged by the facility on 10/11/14. The document titled "Advanced Health Care Directive Living Will, Health Care Proxy and Designation of Proxy... " signed by the patient on 3/26/09 notes, "I do not want my life to be prolonged and I do not want life - sustaining treatment or procedures if (a) I have a condition that is incurable or irreversible which, without the administration of life-sustaining treatment would be expected to result in death within a relatively short period of time. The patient included cardiac resuscitation amongst a list of procedures that may be withheld or withdrawn under the above conditions".

In a document titled Patient Notification Record of Advance Directive signed by patient's daughter on 10/10/14, she refused additional information on advance directive. However, at discharge of the patient on 10/15/14, the facility failed to send a copy of the patient's advance directive with the patient to the skilled nursing facility.

On 10/16/14 at about 10:20 AM, the patient was brought to the Emergency Department unresponsive and cardiopulmonary resuscitation (CPR) in progress by paramedics. The Ambulance Call Report indicated that on arrival at the skilled nursing facility, the patient was found lying supine in bed with CPR in progress. In the ED, resuscitation effort continued until family arrived and requested resuscitation to be terminated. The patient was pronounced dead at 10:24 AM.

The facility's policy titled "Discharge Planning" last revised 3/1/14 notes, "if the patient is being transferred to a skilled nursing facility, subacute rehabilitation or acute rehabilitation facility, applicable documents such as discharge plan or transfer summary are sent with the patient at the time of discharge ... " The policy however, did not indicate what are the applicable documents.

At interview with Staff #1 on 2/20/15 at 10:15 AM, she stated that a copy of the patient's living will should have been sent to the skilled nursing facility at discharge.


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2. Patient #3 was admitted to the facility on 1/22/15 with a diagnosis of Radicular pain (Pain involving a nerve root) of right lower back and pain of left shoulder. He was discharged on 2/11/15. During the admission period, the patient had several procedures performed. On 1/28/15, it was documented that the patient developed a sizeable "Iliopsoas" hematoma (rare complication that occurs in patients receiving anticoagulant therapy). An inferior vena cava (IVC) filter was placed on 1/28/15 due to the patient's Deep Vein Thrombosis (DVT - formation of a blood clot within a deep vein). Lovenox, an anticoagulant therapy, had been discontinued on 1/24/15 for the same clinical reason. On 2/6/15, the cardiologist documented that the patient has DVT, pulmonary embolism (blood clot in the lung), liver cancer, status post IVC filter, and was not a candidate for Coumadin (blood thinner) therapy due to liver coagulopathy (coagulation disorders in liver disease).

On 2/8/15 at 8:00 AM, the medical resident documented that the patient will need a "Peripherally Inserted Central Catheter" for 6 weeks of antibiotics. However, at discharge (on 2/11/15) the patient's medication list did not include an antibiotic prescription.

On 2/11/15, at discharge, the patient's medication list included Lovenox 60 milligram/0.6milliliter subcutaneously every 12 hours, the medication that had been discontinued on 1/24/15.

Although the patient was on pain medication therapy with Fentanyl patch 25 microgram/hour every 72 hours, with the most recent dose having been administered on 2/10/15 at 3:52 PM, the patient was discharged on 2/11/15 without a prescription for continued pain management.

On 2/11/15, the patient was discharged with the same exact medication list as the one that existed on his admission. During interview with Staff #2 on 2/19/15 at 3:30 PM, it was verified that the patient was transferred to the Nursing Home on 2/11/15 with the same medication list that he had when he was admitted on 1/22/15.

The facility staff failed to ensure that necessary and accurate medical information was included in the discharge information given to the patient on discharge. Staff failed to review the patient's medication regimen at discharge to ensure that discontinued medications were not included on the patient's medication list, and that medications necessary for the continued care of the patient were included on his medication list.

It was not until the patient's family called the facility from the Nursing Home and notified the facility's medical staff of the medication error, that the error was corrected, via the phone by the Medicine Department Resident.

Based on interview, review of medical record and other documents, it was determined the facility failed to ensure that each patient presenting to the Emergency Department (ED) and determined to have an Emergency Medical Condition receives stabilizing treatment prior to discharge. This finding was noted in 1 of 29 applicable records (Patient #4).

Findings include:

Patient #4 is a 43-year-old male who presented to the ED on 8/29/14 at 7:57 PM with complaint of abdominal pain. Labs revealed an elevated WBC at 12.33 thymus-helper cells/millimeter cubed (t-h/mm3). Surgical consult was obtained after an abdominal sonogram revealed cholelithiasis (presence of gallstones) and gallbladder sludge with wall thickening and edema. The radiologist recommended clinical and laboratory correlations and a Hepatobiliary Iminodiacetic Acid Scan (HIDA - a scan that creates pictures of the liver, gallbladder, biliary tract and small intestine) to be obtained for further evaluation.

Although the clinical impression of the surgical consultant was, "questionable biliary colic versus acute cholecystitis (inflammation of the gallbladder)" and a plan was proposed to admit patient, start intravenous fluids, and intravenous antibiotics, the patient was discharged home on 8/30/14 at 05:59 AM. The patient did not receive antibiotic treatment in the ED and HIDA scan was not obtained as recommended by the radiologist. The patient's discharge instruction included prescriptions for Pepcid (an acid reducer) and Nulev (an anti-spasmodic indicated for cramping pain caused by kidney stones). The patient was instructed to follow-up next week with a surgeon for reevaluation and further treatment. During the ED course, the patient was medicated five times with intravenous Morphine sulfate and Hydromorphone (opioid analgesics).

At interview with Staff #3, surgical consultant, on 2/20/15 at 10:45 AM, she stated she saw the patient in the Emergency Department on 8/30/14 and determined patient required admission for treatment of an infectious process related to what she thought could be biliary colic versus acute cholecystitis. She stated that she later authorized the patient's discharge because the patient was pain free and wanted to go home. She added that the patient was given a referral for follow up care and management of his medical condition. She admitted that no antibiotic was ordered for the treatment of the infectious process.

The patient returned to the ED on 8/30/14 at 10:09 AM, four hours after discharge, with complaint of increasing abdominal pain. Labs revealed elevated WBC at 16.5 t-h/mm3. CT scan of the abdomen and pelvis revealed distended gallbladder with stones and surrounding inflammatory changes. These findings, when correlated with abnormal ultrasound, were highly suspicious for acute cholecystitis.

The patient was admitted for acute abdomen, peritonitis (inflammation of the membrane which lines the inside of the abdomen), and sepsis (systemic inflammatory response caused by infection). He underwent laparoscopic subtotal cholecystectomy (removal of the gallbladder by laparoscopy) on 8/30/14. Intraoperative findings included cholecystitis, with peritonitis, and gallbladder wall gangrene.