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Based on record review and interview the facility failed to complete a discharge planning evaluation for 2 of 11 patients (Patient #1 and Patient 7); failed to provide a handoff between the surgeon and the hospitalist completing the discharge for 1 of 11 patients (Patient #1); failed to follow and implement physician orders prior to discharge for 1 of 11 patients (Patient #1); failed to identify those patients likely to suffer adverse health consequences and provide a follow up phone call and transitional care management appointment per policy for 1 of 11 patients (Patient #1); and failed to provide correct and effective discharge instructions for 2 of 11 patients discharged (Pt. #1 and Pt. #7) out of 11 medical records reviewed.

Findings Include:

The facility failed to identify those patients likely to suffer adverse health consequences upon discharge and provide a follow up phone call and transitional care management appointment per policy. See tag C 1404

The facility failed to complete a discharge planning evaluation for Pt. #1 and Pt. #7. See tag C 1406

The facility failed to assess its discharge planning process and implement an action plan based on findings. See tag C 1422

The facility failed to follow physician orders at discharge; failed to provide a handoff between the surgeon and the hospitalist completing the discharge; and failed to provide patients with the necessary medical information for post-surgical care at the time of discharge. See tag C 1430

Based on record review and interview the facility failed to follow it's discharge planning policies and procedures to identify those patients likely to suffer adverse health consequences upon discharge and failed to provide a follow up phone call and transitional care management appointment per policy for 1 patient (Pt. #1) out of a total of 11 discharge records reviewed.

Findings Include:

Review of facility document, dated 08/23/2023 titled, "[Facility Name] Transitional Care Management (TCM) flow diagram," revealed, "Patient ready for discharge---was the patient discharged after hours/wkend---yes--Charge nurse contacts ER (Emergency Room) HUC (Health Unit Coordinator) to schedule patient appt (appointment) within 7 days---RN schedules appt as TCM appointment---RN enters information on patient's exit care----RN highlights date/time of TCM appointment and provides to patient along with Exit Care---RN provides patient education re: f/u (follow up) phone call with RN and TCM appointment with provider."

Review of facility policy last reviewed 01/18/2023 titled, "Assessment and Reassessment," revealed, "Each patient admitted to the institution shall receive a complete head-to-toe assessment...Discharge planning: Factors include discharge location, follow-up needs....Discharge planning shall be initiated at the time of admission and shall be reassessed continuously throughout the patient's hospital stay."

Review of Facility Internal Investigation and Root Cause Analysis completed on 10/10/2023 as a result of Patient #1's event revealed, "A transitional care management (TCM) appointment should be made within 7 days of discharge, this was not done. No post discharge phone call follow ups were done by nursing staff- the process is to call patients within 48 business hours following discharge."

Pt. #1 was admitted to the hospital on 09/22/2023 (Friday) following surgery for a total abdominal hysterectomy and discharged home on 09/24/2023 (Sunday).

Review of Pt. #1's medical record revealed no evidence of a 48 hour post discharge phone call, no evidence of a TCM appointment scheduled and no evidence of a completed discharge planning evaluation pre-discharge. This was confirmed during an interview with Manager B on 11/02/2023 at 1:05 PM.

Review of Pt. #1's Emergency Department (ED) Medical Record revealed Pt. #1 returned to the ED on 10/2/2023 at 12:04 AM with increased weakness. Family reported patient has become increasingly weak over the last week, being unable to walk or stand, decreased appetite, increased pain at incision site. Sepsis screen was positive, signs of organ dysfunction present and subtle mental status changes. Skin on lower abdomen/pelvic region is hot to touch, firm, and red. Several purple blister-like areas noted to lower abdomen. Foul, yeasty odor and white/yellow discharge noted from incision site. Pt. was transferred by air to a higher level of care and died of MRSA (staph infection resistant to antibiotics) and necrotizing fasciitis (flesh eating bacteria infection) on 10/04/2023, 12 days after their surgical procedure.

On 11/02/2023 at 11:40 AM in an interview with Social Services Manager I, I stated, "The doctors and or nurses screen the patient and then we get a referral, we don't have an automatic referral to social services...we try to plan on Friday for the weekend discharges, if there is a need then we would call that following Monday."

On 11/02/2023 at 1:05 PM in an interview with Manager B, when asked how Pt. #1's discharge needs were addressed- when they were admitted on 09/22/23 (Friday) and discharged 09/24/23 (Sunday), B stated, "They were discharged before social services or UR (Utilization Review) came back on Monday."

Based on record review and interview the facility failed to provide a discharge planning evaluation for 2 patients (Pt. #1 and Pt. #7) out of a total of 11 discharge records reviewed.

Findings Include:

Review of facility policy last reviewed 02/04/2022 titled, "Patient Rights and Responsibilities," revealed, "Every patient...shall receive...information about the patient's illness, course of treatment, and prognosis for recovery in terms the patient can understand...Every patient shall have the opportunity to participate to the fullest extent in planning for his or her care and treatment."

Review of Pt. #1's medical record revealed no evidence of a discharge planning evaluation being completed. This was confirmed during interview with Manager B on 11/02/2023 at 1:05 PM.

Review of Pt. #7's medical record revealed no evidence of a discharge planning evaluation being completed. This was confirmed during interview with CNO (Chief Nursing Officer) M on 11/21/2023 at 2:00 PM.

On 11/02/2023 at 1:05 PM in an interview with Nurse Manager B, B stated, "We don't have a specific policy for the discharge planning evaluation."

On 11/02/2023 at 3:59 PM in an interview with Nurse Manager B, when asked if there was a discharge needs assessment completed for Pt. #1, Manager B stated, "(She/He) didn't have one, you are correct."

Based on record review and interview the facility failed to assess it's discharge planning process in 1 of 1 discharge processes reviewed and failed to implement appropriate interventions upon recognition of deficient practices, in 1 (Pt. #1) of 1 Sentinel Events reviewed. This deficient practice has the potential to impact all patients receiving care at this facility.

Findings Include:

Review of facility policy last reviewed 03/26/2022 titled, "Sentinel Events Policy & Procedure," revealed, "It is the policy of [Name] Medical Center to identify and respond appropriately to all sentinel events...Once identified, each sentinel event will be followed by a thorough and credible root cause analysis, development of an action plan designed to implement improvements to reduce risk, implementation of the improvements, and monitoring the effectiveness of those improvements....Action Plan: The action plan is the product of the root cause analysis and identifies the strategies that [Facility] intends to implement in order to reduce the risk of similar events occurring in the future. It will address responsibility for implementation, oversight, pilot testing as appropriate, time lines and strategies for measuring the effectiveness of the actions."

Patient #1 was a 68 year old admitted to the hospital on 09/22/2023 (Friday) following surgery for a total abdominal hysterectomy (removal of the reproductive organs) and discharged home on 09/24/2023 (Sunday). On 10/02/2023 at 12:04 AM (10 days after surgery) Pt. #1 presented to the ED (Emergency Department) with severe abdominal pain and was diagnosed with sepsis (life threatening complication of infection). Pt. #1 was transferred to a higher level of care and died on 10/04/23.

On 11/02/2023 at 12:05 PM in an interview with Compliance and Medical Practice Staff C, C stated, "This is the only adverse event we've had in the last 6 months and we are treating it like a sentinel event. We are working through the RCA (Root Cause Analysis)." When asked what has changed, Staff C stated, "We are still working through this, it isn't closed, we discussed this with medical staff on 10/31/2023 and what we can safely do here, we are looking at our systems and processes, this case is also being reviewed externally and we have a phone call scheduled with external peer review and our surgeon on 11/06/2023. Our next multidisciplinary meeting regarding this event is scheduled for 11/6/2023 at 12:30 PM."

On 11/21/2023 at 2:05 PM in an interview with RN O, when asked what processes have changed or education provided, O stated, "I haven't been told much except that state was here because [Pt. #1] passed away, I don't know any specifics or what happened, just what I've heard from other nurses, not anything from my manager."

During an interview on 11/21/2023 at 3:30 PM with Compliance Officer C, when asked what action steps have been implemented following the 11/06/2023 Root Cause Analysis Meeting, C stated, "Nothing additional, we are still working through action steps, it's been busy with the EPIC (Electronic Health Record) conversion."

On 11/21/2023 a review of the facility action plan document last updated 11/06/2023 revealed action steps were identified and nothing further has been implemented, no dates have been assigned for completion of interventions or monitoring of changes made.

On 11/22/2023 at 2:45 PM in an interview with CNO N when asked what the last review of the discharge planning process revealed, CNO N stated, "We couldn't find any documentation of a discharge planning assessment being completed, I know we've done them, but don't remember when."

Based on record review and interview the facility failed to follow and implement physician orders upon discharge and failed to provide a handoff between the surgeon and the discharging hospitalist for 1 of 11 patient records reviewed (Patient #1), and failed to provide 2 of 11 patients (Pt. #1 and Pt. #7) with the necessary medical information for post-surgical care upon discharge out of a total 11 discharged records reviewed.

Findings Include:

Review of facility policy last reviewed 01/08/2023 titled, "Discharge a Patient," revealed, "The patient...shall be involved in the discharge process. A physician's order shall be required prior to discharge...Discharge instructions ordered by the physician shall be completed...Preparation: Verify the patient's discharge orders..Complete home care form and/or discharge instructions..collect medications and prescriptions for instruction in self-administration...Teach procedures, medications....Explain and write activity restrictions, diet, and when to call the physician...Review the discharge instructions, including medications to be taken at discharge, to the patient and or family."

Review of facility document titled, "[Facility] Medical Staff Rules and Regulations for acute care," no effective date, revealed, "C. A qualified Practitioner shall be responsible for the general medical condition, care and treatment of each patient in the Medical Center. This shall include the responsibility for prompt completion and accuracy of the medical record, necessary special instruction, and the condition of the patient to referring Practioners...Whenever these responsibilities are transferred to another Practitioner, a note covering the transfer of responsibilities shall be entered into the medical record."

Pt. #1 was admitted to the hospital on 09/22/2023 (Friday) following surgery for a total abdominal hysterectomy (removal of the reproductive organs) and discharged home on 09/24/2023 (Sunday).

Not following Physician Orders:

Review of Pt. #1's post op (after surgery) orders on 09/22/2023 revealed, "Post Op Antibiotic...Cephalexin 500 mg QID (4X a day) X 7 days (urine was cloudy) suspect UTI (urinary tract infection). Start date of 9/22/23 and end date of 9/29/23. UA (Urine Analysis) + Urine for culture tomorrow AM."

Review of Pt. #1's discharge instructions on 09/24/2023 revealed Pt. #1 was not discharged home on an oral antibiotic.

Further review of the medical record revealed no evidence of the urine culture being obtained prior to discharge per order, and no evidence that Pt. #1 was discharged with the ordered oral antibiotics.

On 11/02/2023 at 4:20 PM, when Manager B was asked if the order for the urine culture was missed, Staff B stated, "Correct."

On 11/21/2023 at 11:30 AM in an interview with Hospitalist M when asked why wasn't the antibiotic that was ordered post op continued at discharge, M stated, "I didn't think the antibiotic was warranted, but was considered. In hindsight it was the wrong decision. I'm not sure the antibiotic chosen would have made a difference."

No handoff between the surgeon and the Hospitalist who completed the discharge for Patient #1:

Further review of the medical record revealed no instructions for post op wound care were ordered by Surgeon H and no documentation of a handoff being completed between Surgeon H and Hospitalist M.

When asked how the handoff from surgery to the inpatient unit happens, Hospitalist M stated, "Historically surgery refers to family medicine, they report off to us usually, but not always...we have a good working relationship. I don't remember getting a handoff from the surgeon on this patient. We've worked together for 25 years...if I had known the history, in hindsight I should have had [Pt. #1] use a cotton towel under [their] pannus [stomach fold], to keep the air on it. They really should call us with the incision into the pannus if we need to treat it differently."

On 11/21/2023 at 1:00 PM in an interview with Surgeon H, when asked about the process for handing off a patient from surgery to hospital service, Surgeon H stated, "The process is to work with family physicians....I give PO [Phone orders] and relinquish care to family medicine. My usual practice is to call the Doctor assuming care, not sure what my reason was not to. I usually call, but can't remember in this case. Typically the hospitalist discharges the patient, but I'm available on Saturday and Sunday by phone if needed." When asked if there has been any further discussion about this event, H stated, "We had a meeting with a lot of physicians, it was critiqued with peer review, I'm pretty sure we will do things from that."

Post-surgical discharge instructions not provided:

Patient #1:
A review of Pt #1's discharge instructions dated 9/24/2023 revealed that there were no discharge instructions present indicating what wound/incision care should be completed after discharge, activity/lifting restrictions, diet or what signs and symptoms of infection to report or when to call the physician. This was confirmed in an interview during record review with Nurse Manager B on 11/02/2023 at 1:05 PM.

On 11/21/2023 at 11:30 AM in an interview with Hospitalist M when asked why Pt. #1 didn't receive specific discharge instructions, Hospitalist M stated, "I don't trust checklists...I don't remember getting a handoff from the surgeon on this patient...If I had know the history....I didn't give specific instructions or anything on signs/symptoms of infection." When asked who is responsible for giving the discharge instructions to patients at discharge, M stated, "Typically nursing gives the discharge instructions, We are a small hospital, we didn't see it coming, it surprised us and we feel terrible."

Patient #7:
Pt. #7 was admitted to the hospital on 09/05/2023 (Tuesday) for a total abdominal hysterectomy and discharged home on 09/07/2023 (Thursday).

Review of Pt. #7's discharge instructions revealed Pt. #7 had the same procedure as Pt. #1 and received the same discharge instructions as Pt. #1. Pt. #7's discharge instructions did not include instructions for wound care or for signs and symptoms of infection or when to seek medical attention. This was confirmed in an interview during record review on 11/21/2023 at 2:00 PM with CNO O.

On 11/21/2023 at 1:45 PM in an interview with Charge Nurse P, when asked who is responsible for ensuring the patient has the right discharge instructions, P stated, "Not sure who is responsible, but typically it's laid out in the discharge instructions and when to call the provider if symptoms get worse and it is dependent case by case."

On 11/21/2023 at 2:05 PM in an interview with RN O (Discharging RN for Pt. #1) when asked why there were not discharge instructions provided to Pt. #1 for incision care and signs and symptoms of infection, RN O stated, "There should be. We provided diet, activity and discharge instructions to the patient, a copy is in the chart." When O was asked why the oral discharge instructions given to Pt. #1 weren't documented, O stated, "It's hard when we're busy to get the charting done with phones, call lights, and we're busy with hands on care...could be a lot better if we had more time."

A review of discharge instructions given to other patients with same/similar surgery (Patient #11) revealed that there were detailed discharge instructions available that list instructions and signs and symptoms of infection and when to seek medical attention.