HospitalInspections.org

Based on review of documents and staff interviews, it was determined the hospital did not consistently comply with regulations which require the provision of the advanced written notice of hospital discharge rights to be delivered to Medicare beneficiaries (IM's, "Important Message from Medicare About Your Rights").

Findings include:

Review of medical records on all dates of the survey found that the hospital did not consistently adhere to federal regulations and hospital procedures for the provision of required notices. This notice advises patients of the right to file a discharge appeal which must be distributed within two days of admission and also requires a follow up notice to be administered to applicable inpatients within 48 hours in advance of discharge.

Interview of the nursing staff on unit D7North on 2/14/2012 found that staff was unclear regarding which staff is responsible for issuance of the notice on admission and again at discharge.
One staff member reported that 24 hour discharge notification is given by the MD on the unit. Another nursing staff member stated that the initial form is provided by ED nursing staff but was unsure and would check. Other staff reported the notice is given by admitting staff but that the nurse is to follow upon admission.
The policy for the Discharge Review program, PC 4.01.03, indicates both Admitting and Nursing are responsible for the initial IM and that Nursing will re-issue the discharge notice before discharge following physician notification.

The copy of the discharge notice provided to the surveyor found that it was the incorrect notice and targeted to non-Medicare patients. This form was not the standardized CMS-R -193 formatted notice as required.

Review of six of eight applicable medical records found that either the initial or second IM notice was not issued in accordance with the hospital's procedures:
Refer to MR #s: 2, 3, 4, 5, 6, 7.

Based on review of records, the hospital did not clearly document the designated patient representative authorized to provide consent in instances where the patient condition renders the patient incapable of decision making for informed consent or other medically related decisions.

Findings include:

Review of three applicable concurrent inpatient medical records on 2/14/12 and 2/15/12 found that these records did not clearly document surrogates with authority to provide informed consent for patients whose decision making ability was presumed to be compromised.

MR # 3: Concurrent record reviewed on 2/14/12 for an 85 year old female with advanced dementia found a cousin signed a consent in the record. However, interview with the caseworker on the floor found that a daughter deferred all decisions to another relative who was identified elsewhere in the record as the niece. It was stated that the daughter is the person who deferred all decision making to the person later found to be a cousin. However, this decision making arrangement was not recorded and the correct relationships of the relatives involved was not accurately noted in the medical record on 2/14/12.

MR # 6: Concurrent record reviewed on 2/15/12 for a 74 year old female on a ventilator found multiple consents and required forms were signed by different persons, including a grandson.
The patient lived with a daughter prior to hospitalization who signed a patient rights acknowledgement form. The record did not clearly delineate authority of the parties authorized to sign consent or document a reason why consent would be deferred to another relative.

Review of MR # 15 on 2/15/12 for a 44 year old female with lung cancer and on ventilator noted that her sister was listed as her next of kin and gave consent on 2/2/12 for bronchoscopy and tracheotomy and for transfusion on 2/6/12. On 2/9/12 consent for CT scan with intravenous contrast was signed by someone other than the sister and did not indicate the person's relationship to the patient. There is no evidence in the medical record that this individual was authorized to sign consent for the patient or reason why consent would be deferred to her.


Review of procedures for Patient Consent and operating procedure 180-06 for Surrogate Health Care Decision Making found a specific procedure in place for surrogate identification and designation of another surrogate by the main surrogate. This must be documented in the record.
The hospital did not adhere to the process as defined.



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Based on record review there was no evidence that the facility assessed patients as well as the caregiver's skills to safely manage the procedures required to be done at home.

Findings include:

Review of MR # 1 found that the nursing discharge summary and progress notes did not document return demonstration to assess the patient's and family member's ability to manage the T -tube, the JP drain, and dressing changes.

Based on review of medical records, it was determined that the hospital did not provide complete assessments that met discharge planning requirements in that plans did not address pertinent patient risk factors and post discharge care needs.

Findings include:

Three of nineteen concurrent and closed inpatient medical records reviewed on all dates of the survey did not reflect inclusion of complete assessments or plans for evident post-discharge care needs.

Examples include:


MR # 8:
Record reviewed for an active 54 year old female inpatient on 2/15/2012 found there was no social work/discharge planning assessment despite evident needs. The patient was admitted on 1/14/12 to the hospital for SOB and placed in respiratory isolation for positive AFB in sputum.
On 1/18/12, the physician ordered social work consultation and noted the patient was TB positive and recommended family members be tested. A referral was made to Department of Health to get family members tested and the patient was seen by DOT (Directly Observed Treatment) clinic staff on 1/20/12. However, as of 2/15/2012, no social work assessment was evident.

There is evidence in the record that the patient had chronic alcoholism and on 2/7/12, nursing noted that the patient appeared sad and stated she wanted to be discharged to home.
Follow up interview with the Assistant Director of Social Work on 2/16/2012 found the patient had been assessed by him following the surveyor's visit to the unit and it was also confirmed by this staff that the family members had been tested.

MR # 9:
Record reviewed on 2/16/2012 for a 16 year old male in police custody did not demonstrate evidence of a complete discharge planning assessment for identified injuries. Discharge plans were not implemented for rehabilitation needs.
This 16 year old was brought in on 11/23/11 and admitted as a trauma patient; the patient was struck in a motor vehicle accident while riding a moped with no helmet, and was reportedly evading Police. The patient had sustained serious injuries including: open fracture to the right distal tibia, right humerus non displaced fracture, multiple facial fractures, medial wall right orbital fracture, right nasal bone fracture, and closed skull fracture.

The patient was assessed on 11/29/11 for discharge planning needs on only one occasion by a Caseworker, whose interventions were focused on obtaining a wheelchair for discharge so that the patient could be discharged into Police custody. The assessment was incomplete and did not consider the need for an assessment of the circumstances of the accident, arrest, and home situation, in order to determine if a referral to the Agency for Children's Services was warranted to rule out inadequate guardianship.

The child was discharged into Police custody on 12/5/11. There was no validated assessment of the post-discharge care needs as the patient was non-ambulatory and non-weight bearing. It was noted that a rehabilitation assessment had recommended need for discharge for subacute rehabilitation placement as referenced in the 11/28/11 and 11/29/11 medical notes. Physical Therapy notes dated 11/29/11 noted recommended need for subacute rehabilitation. Despite this recommendation, the patient was discharged into police custody without implementation of a plan for evident rehabilitation needs.

The patient received inadequate follow up. A follow up clinic visit on 12/14/11 noted that the patient had missed two orthopedics appointments. The patient did return to the ED for assessment during 12/21/11 with a damaged cast, and he was noted to be walking with a cane. The patient walked out. He had been called three times with no response. The patient returned to the ED on 1/14/12 for pain and suture removal. It was noted that the patient removed his own cast and was ambulating well. The patient did not keep his 1/20/12 pediatric orthopedic appointment. There was no documented referral to follow up on evident psychosocial and rehabilitation needs.

MR # 3:
Review of the record for this concurrent patient on unit D7N on 2/14/2012 found that the discharge planning assessment for this patient was incomplete and inaccurate. In addition the patient was scheduled for discharge on 2/14/12 but was postponed until 2/15/12 because the plan did not fully address the patient's needs.

This patient, an 85 year old female with advanced dementia and other medical comorbidities, was admitted on 2/5/12 for Altered mental status and hypoxemia. The patient was treated for pneumonia and sepsis.
Assessment by the caseworker noted on 2/14/12 that the patient resided with her daughter and that information was given by the niece. It was noted the patient had a 7 x 8 hour home attendant and had been referred for hospice care as well. It was noted at 1141am that the patient was going home and that the hospice nurse would visit later that day. The home attendant services would resume the next day. The hospice referral paperwork in the medical record was only partially completed.

The assessment was incomplete and did not address all of the post discharge safety needs. The assessment contained contradictory information where in one section it was noted that the patient was ambulatory, yet in another section it was recorded that she was ADL dependent.

Observation of the patient by the surveyor and follow up confirmation with nursing staff on the unit at approximately 1 PM found that the patient was completely bedbound and dependent in all activities of daily living (ADL's). At the time of the observation a woman was visiting with the patient who identified herself as the patient's cousin (this woman was identified as the niece in the psychosocial assessment). This cousin reported that she had just arrived and did not receive a copy of the Medicare IM discharge notice or a discharge plan. Furthermore, she stated that the patient lived with her mother, who is the patient's niece and reported the patient actually received 12 hours of home attendant services, not the eight hours as noted in the medical record. She did not know how they would manage caring for the patient at home without 24 hour assistance.

The medical record inaccurately identified the woman interviewed as the patient's niece, yet review of one signed consent in the record found the woman signed off as the cousin.
The plan lacked evidence of safety assessment. Physical Therapy assessment dated 2/14/2012 recommended referral to subacute rehabilitation and noted the patient as non ambulatory on that date. There was no indication if this option had been discussed with the next of kin and no assessment of the capacity of the kin to provide assistance if home care could not be approved for round the clock care.

Follow-up discussion was held with administrative SW staff on 2/14/12, and at that time it was stated that the discharge plan was deferred and reassessment provided.
Additional follow up interview with the administrator on 2/15/12 found that the caseworker was in the process of documenting discharge arrangements on 2/14/12 but did not document that necessary equipment had been ordered including a bed and commode.
Follow up visit to the unit found that the record had been corrected to identify the relationship of the family members . It was also confirmed that additional hours of care had been confirmed, along with delivery of medical equipment. The assessment also included affirmation by the family that they would assume responsibility for the patient when the aide leaves.

Based on review of records and staff interviews, it was determined that the hospital did not provide patients or their representatives with lists of available options for certified Home Health Care Agencies (CHHA's) and skilled nursing facilities (SNF's).
This finding was noted in 9 of 10 applicable medical records reviewed.
Findings include:
1. The hospital has no current process in place that requires the provision of lists to patients which contain information about options for available certified home health care agencies or skilled nursing facilities.
Review of the policy titled, "Patient /Family Education, PC.2.03.01", finds that education about available community resources is provided by nurses and social workers, but lacks description of the need for inclusion of required resource listings in accordance with federal regulations. The policy titled, "Discharge Planning", PC.04.01.01- 04.01.03" found a reference attached dated June 2011, that described a rotation schedule for on-site Community Home Care Agencies (CHHA's) for specific units covered.

2. At interview with the Administrative staff from the Department of Social Work on 2/16/2012, it was acknowledged that a list of available home care agencies and skilled nursing residential facilities is in the process of being developed for distribution to patients and families. It was stated this will include information about options for agency or facility selection.
It was also stated that at present, no listing is distributed routinely to applicable patients or their representatives to advise of choice of selection from among available home health agencies and skilled nursing facilities.
At present, if patients or their representatives request resource listings, the staff will photocopy pages containing the names of agencies and facilities from a resource booklet used by department staff.
The facility has six home health agencies on site for the purpose of intake and it was stated by staff that referrals to each agency are rotated.

3. Nine of ten applicable medical records reviewed lacked documentation that lists, containing options, for available home care agency or residential facilities were provided to patients to ensure choice.
Examples include:
MR # 2: Elderly female patient with Parkinson's Disease and Alzheimer's dementia was admitted on 2/9/12 for failure to thrive. The patient underwent placement of a PEG feeding tube and reinstatement of pre-existing 24-hour home attendant services . Referral was made for Visiting Nurse services through VNAB on 2/10/12 but there was no documentation that the patient's representative, in this case the patient's son, was provided with a written listing of available certified home health care agency options. On 2/14/12, the discharge was held due to need for delivery of PEG supplies, and it was also noted that VNAB could not accept the case. There was no documented reason for this agency's declination in the record. The record noted SW administration directed the patient be referred to VNS instead, and the case was accepted.

MR # 7: Record reviewed on 2/15/12 for a 64 year old patient admitted for altered mental status found no documentation of options offered to the family for placement or home care. Initial social work assessment dated 1/23/12 found there was a dual plan in place for home care or rehabilitation referrals, but there was no evidence a list was provided to the patient or the representative with options. The patient had been accepted for short term rehabilitation at a sub-acute rehabilitation facility on 2/10/12 and the spouse was noted to have given consent.
Refer to MR #s :1, 2, 6, 7, 10, 11, 12, 13, 14.

Based on record review and interview it was determined that a surgical patient who sustained an intraoperative complication was not followed up in a manner to ensure that she received timely and appropriate interventions.

Findings include

Review of MR #1 found that on 1/11/11 the patient sustained a common bile duct injury while undergoing a cholecystectomy. Laparascopic approach was justifiably converted to an open procedure and the surgeon identified a structure that appeared like the cystic artery and it was ligated between clamps. This was then found to be the common bile duct.

The patient required a repair and the facility acknowledged that it was unable to provide the type of hepatobiliary surgery required and an attending surgeon from Downstate Medical Center was consulted.

The patient was discharged 1/28/11. On 1/30/11 based on review of the medical record of another facility the patient was admitted to the ICU and had corrective surgery on 2/11/11 which included exploratory laparotomy, extensive lysis of adhesions, small bowel resection and Roux-en-Y hepaticojejunostomy. The wound was infected and there was dishescience.

There is no evidence that an organized post operative plan was implemented that took in consideration that the patient was discharged with the need for corrective surgery and that the patient would require surgery done at LICH-Downstate. Further review finds that even intraoparative cholangiograms as well as observations made in the OR did not clearly confirm the structures and the locations of the injury. Furthermore, there was no evidence that the facility assessed whether the patient was at sooner risk of a post-operative complication given the anatomic anamolies found during surgery. .

Review of the Nursing Disharge Summary dated 1/28/11 found that she was given an appointment with the surgical clinic 1/31/11. She was also advised to follow up with a hepatobiliary surgeon at Downstate LICH on 2/8/11 and to call for an appointment.

At interview with the Director of Surgery 2/16/12 it was acknowledged that he did not know if the arrangements with LICH Downstate were formalized or if a consult note was on file. A progress note 1/15/11 makes reference to the hepatobilary surgeon planning to perform a biliary - enteric reconstruction.

Review of the social work progress notes found that there was a delay in implementation of home care where the patient was discharged on 1/28/11. The report is specific in that due to patient insurance VNAB continued to seek authorization and that both the social worker and the surgeon were informed that a nurse for VNAB would visit the patient 1/31/11. (3 days following discharge ).