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Based on medical record review, review of policies, and staff interviews, it was determined the hospital failed to have complete medical records to monitor patients' status and provide appropriate medical care, including pain assessment, for 1 of 5 patients (Patient #10) whose records were reviewed and were seen in the ED and discharged to home. This resulted in the lack of pain assessment for patients presenting to the ED, and had the potential for patient needs to go unadressed. Findings include:

A facility policy titled "Adult and Pediatric Pain Assessment and Management" with approved date of 02/15/2022 stated, " All patients, as appropriate, will be assessed for pain upon admission with a pain goal set for their stay." This policy was not followed as evidenced by the following example:

Patient #10 was a 24 year old female who presented to the ED with abdominal pain 8/09/22 and was discharged 6 hours later on 8/10/22.

Patient #10's medical record documented an abnormal CT scan and ultrasound noting ovarian cysts on left and right ovaries as well as endometriosis. There was no documentation of a pain evaluation of the patient. There was no documentation of pain medication being offered or delivered to Patient #10.

There was no documentation of Patient #10's pain being assessed or addressed during her ED visit.

Staff C was interviewed on 11/07/24 at 1:15 PM. Staff C was asked if pain was normally assessed, and stated, "there is usually a pain scale .. and I would think their pain should be addressed."

The incomplete record of Patient #10 led her chief complaint of pain to not be asssessed or addressed.

Based on policy review, medical record review, and staff interview, it was determined the hospital failed to ensure patient discharges were safe and addressed all concerns. This had the potential to negatively affect the outcome of all patients discharged from the hospital. Findings included:

Refer to A-0802 as it relates to the failure of the hospital to ensure patients were discharged in a safe manner.

The cummulative effects of these negative systemic practices impeded the hospital's ability to ensure the discharge of patients was comprehensive and appropriate to patient needs.

Based on medical record review, hospital policy review, website review, and staff interviews, it was determined the hospital failed to ensure a safe discharge was completed for 2 of 7 patients ( Patients #3 and Patient #12) whose records were reviewed as inpatients and were discharged to their homes. This had the potential to cause serious harm for patients discharged and had the potential to affect all patients receiving care at the hospital. Findings include:

A hospital policy titled "Discharge Planning - SAHS," approved 10/15/21 stated, "Assessment and documentation related to discharge planning needs to begin at time of admission and continue throughout the hospital stay." This policy was not followed. Examples include:

1. Patient #3 was a 58 year old female admitted on 8/22/22 for surgery for a 10 centimeter left adnexal mass with ascites and left lower quadrant pain. The patient underwent an open bilateral salpingo-oophorectomy (surgery to remove both ovaries and fallopian tubes) with 3 liters of fluid drained from the abdomen. Past medical history documented in Patient #3's chart stated,"asthma, depression, GERD (gastroesophageal reflux disease) and hypertension."

Patient #3's medical record included a note from Provider A documented on 8/24/22 at 9:51 AM. It included, "patient had an episode of vomiting attributed to continued abdominal pain." The plan of "home after lunch today" was not changed.

Patient #3's medical record indicated that her WBC (White Bloodcell Count) was trending upwards. Provider A's note did not address the upward trending WBC of 17.2 (17,200 cells per microliter) on the day of discharge. The previous WBC was noted on 8/23/22, collected at 5:57 AM to be 14.1 (14,200 cells per microliter), indicating a rise in the number of white blood cell count for Patient #3.

Clevelandclinic.org (https://my.clevelandclinic.org/health/body/21871-white-blood-cells), states "The normal white blood cell count ranges between 4,000 and 11,000 cells per microliter." Additionally it states, "If your white blood cell count is too high (leukocytosis), you may have an infection or an underlying medical condition"

Patient #3's medical record included a discharge planning note that did not document any risk factors or address the rising WBC from the day of discharge.

Patient #3's medical record included a note from Provider #B on 8/24/22 at 2:43 PM. It included that Patient #3 "was advanced to regular diet which she tolerated without nausea or vomiting."

Patient #3 was discharged from hospital on 8/24/22 at 5:40 PM to home via taxi.

A request for a copy of discharge instructions sent with patient were requested. A discharge summary was provided but staff were unable to confirm what instructions were sent home with patient.

An interview with the practice manager for gynecology/oncology was conducted on 11/07/24 at 1:45 PM. He was asked if he would expect surgical wound care instructions to be included upon discharge for Patient #3. He confirmed this would be typical and also confirmed there were none documented in the record for Patient #3.

An interview was conducted with Patient #3's Surgeon on 11/7/24 at 3:00 PM. He confirmed Patient #3 was discharged on 8/24/22 although he would have preferred to have her remain inpatient. The surgeon further reported that Patient #3 had multiple risk factors, including alcohol and tobacco use, immunocompromised, low body weight, and minimal if any support in home. The surgeon stated Patient #3 wanted to go home so, considering his concerns that she might leave Against Medical Adviceif he did not discharge her, he gave her a protein supplement and hibiclens (antimicrobial soap) and let her discharge to home.

When asked if he was aware of Patient #3's death, the Surgeon stated he was and he was not surprised. He thought she had likely suffered a pulmonary embolism although he learned later from the autopsy the cause of death was sepsis. He stated Patient #3 was very sick and was not a good surgical candidate, but she was in a great deal of pain so he agreed to the surgery to relieve her pain.

An interview with the discharge planner was conducted on 11/7/24 at 11:40 AM regarding the discharge plan of Patient #3. Discharge planning did not identify concerns regarding the discharge, the aftercare, lack of help at home, or any surgical follow up of Patient #3. There was no mention of Patient #3's risk factors, including alcohol use and low body weight, mentioned by the surgeon. When the discharge planner was asked if she was aware Patient #3 had expired 2 days after discharge, she stated she was not.

An ambulance was called to Patient #3's home on the morning of 8/27/22 after roommate found patient unresponsive. Emergency Medical personnel performed lifesaving measures. These efforts were terminated and Patient #3 was pronounced dead in the home at 12:45 PM on 8/27/22.

The autopsy report, dated 8/29/22, stated, "Cause of Death: sepsis due to peritonitis following recent surgery for adnexal mass."

Discharge planning was not sufficient to ensure a safe discharge for Patient #3.

2. Patient #12 was a 51 year old male admitted on 11/24/22 and discharged 11/26/2022 with a primary diagnoses of acute upper GI bleed, peptic ulcer, Nissen fundoplication (a surgical procedure to treat gastroesophaheal reflux disease) and chronic NSAID use. Per Patient #12's record, he had blood loss and cause of bleeding was not found during admission.

Patient #12's medical record included a discharge summary dated 11/26/22. It stated "He ... passed a little bit of dark blood the day of discharge." Hemoglobin was also documented in Patient #12's medical record. The levels were recorded as follows:

- 10.2 on11/24/22 at 21:47
- 11.1 on 11/25/22 at 04:30
- 11.3 on 11/25/22 at 06:06
- 10.9 on 11/25/22 at 12:22
- 11.1 on 11/25/22 at 17:37
- 10.2 on 11/25/22 at 23:53
- 10.6 on 11/26/22 at 05:53

Abnormal hemoglobin is documented as below is 11.2 g/dL. There was no documentation in Patient #12's discharge summary on 11/26/22, less than 48 hours after admission, providing for continued monitoring of low hemoglobin with lab follow up or follow up with a GI provider. The source of the bleed was not found during admission.

Patient #12 was readmitted 3 days later on 11/29/22 with the same complaint with diagnoses including "suspected upper GI bleed and hemorrhagic anemia." Patient was discharged from this admission 5 days later on 12/4/22. Discharge summary included lab and GI follow up guidance.

A grievance was filed on the day of readmission, 11/29/22, by Patient #12 and wife. In the grievance, the patient's wife was recorded as "they feel like they weren't prepared for what happened. They said that they felt like they were not given any information when they left the hospital."

The Patient Relations Manager was interviewed on 11/7/24 at 12:10 PM. The manager reported they investigate all grievances and speak with concerning parties on a specific timeline and then send findings to the complainant. The letter sent to Patient #12 reported that "discharge timing and instructions were appropriate."

The discharge plan failed to properly evaluate and make accommodations for post discharge including follow up monitoring and specialty appointements had the possibility to lead to readmission and patient deterioration.

The hospital failed to ensure patients had a sufficient discharge plan prior to discharge.