HospitalInspections.org

Based on interview and document review the facility failed to protect the rights of one ( #1) of two patients reviewed for abuse out of a total sample of 10, resulting in the potential for emotional and physical injury to the patient concerned. Findings include:

Findings include:
---the facility failed to ensure that a patient was discharged to a safe environment (See A-145)

Based on interview and record review, the facility failed to ensure that a patient was not discharged home to an unsafe environment with an alleged perpetrator, for one (#1) of two patients reviewed for abuse/neglect allegations out of a total sample of 10, resulting in potential/possible emotional and physical injuries from abuse. Findings include:

On 3/6/18 at 1400, Patient #1's clinical record from the facility of concern (Facility #1) was reviewed and revealed the following information:

Patient #1 was a 67 year-old female who was admitted into the facility on 12/7/17 for chest pain. Diagnoses included Diabetes Mellitus, Coronary Artery Heart Disease, and history of coronary artery stent placement. The patient arrived alone at the facility by ambulance on 12/7/17 at 0500. Review of the original (non-edited) facesheet for that admission, revealed that Patient #1 was her own responsible party and signed her admission paperwork.

An order for a Social Work (SW) Consult for Patient #1, dated 12/7/17 at 1447 noted the reason for SW consult as, "Adult Neglect/Domestic Violence."

A SW note dated 12/7/17 at 1522, written by SW Staff G documented, "SW received referral for adult abuse/neglect. Chart reviewed. SW met with patient at bedside. Patient reports that she has been living with her son for 2 years. She states that since 9/17, (son) has been threatening her, telling her to die, making threats to kill her. She stays mostly in her room to avoid him. She states that she called (local city) police on him about three weeks ago, but all they did was give him a warning. Patient states that she has nowhere else to live. Patient states that in the past (son) pushed and shoved her. She uses a walker. Referral made with APS (Adult Protective Services) intake (name) and she states she will forward the information to her supervisor who will decide if case meets criteria for investigation. If it does, an APS worker will contact SW. SW will receive a letter in the mail informing if case is being investigated or not within two weeks."

On 3/6/18 at 1615, the SW, Staff G was interviewed regarding Patient #1. Staff G was unable to provide any documentation of follow up or communication with APS following the referral. There was no documentation to indicate that SW attempted to follow up with APS prior to patient discharge. When asked, Staff G was unable to provide documentation that Patient #1's physician, Case Management, or the Multidisciplinary Care team, or the 5th floor Nursing management was notified of the abuse allegation, the APS referral, or that concerns related to discharge to a safe environment were discussed. When asked about this, Staff G reported, "APS never got back to me. We can't hold a patient in a bed indefinitely if we don't hear from them (APS)."

There were no Nursing notes, or Interdisciplinary Team notes for Patient #1's entire admission at Facility #1 that documented any knowledge or awareness of abuse/neglect allegations, any knowledge or awareness of APS referral or follow-up. There was no documentation of Interdisciplinary Care Team discussions or interventions to protect Patient #1 from abuse or to assess whether she was safe to return home after discharge.

An order for a Case Management Consult was written on 12/10/17 (Sunday) at 0011 AM. There was no documentation that Case Management ever performed this consultation, or assessed whether Patient #1 could be safely discharged home. There is no documentation to indicate that Case Management was aware that there was a current APS investigation into whether Patient #1 lived in an abusive home situation.

There was no documentation that the Multidisciplinary team was aware of the APS referral for an allegedly abusive home environment. There was no documentation to indicate that the attending physician (Staff I) was aware of the APS referral for an allegedly abusive home environment.

There was no documentation to indicate that Patient #1 was evaluated to see if she was competent to make her own decisions on where to go after discharge from the facility.

A Neurology Consultation, for evaluation of "altered mental status", dated 12/11/17 (no time noted), documented that the patient was delirious and confused, and had an abnormal CT (computerized axial tomography) scan of the head.

A Psychiatric Consultation Report for Patient #1, dated 12/10/17 at 1421 contained no assessment of the patient's mental competency, and did not document that current abuse/neglect or safety of the patient's home environment were assessed or discussed. The report documented that the referral was for assessment of "confusion" and the psychiatrist noted that she was confused, and unaware of her location, time and current medical issues, and had poor judgement and insight.

On 3/7/18 at approximately 1025, Patient #1's EMR (electronic medial record) from the sister facility (Facility #2), for an admission dated 12/14/17 was reviewed and revealed the patient had symptoms of abuse and neglect upon admission and a referral was made to APS by the facility SW for suspicion of Abuse/Neglect.:

Patient #1 presented to Facility #2's ED (Emergency Department) by ambulance on 12/14/17 at 0320. The ED Physician assessment dated 12/14/17 at 0334 documented the patient's chief complaints as "Fall, Chest pain". The report noted that the patient reported no current chest pain. The physician documented that the patient stated she "fell over silverware" and then "fell in the yard", "days ago",and noted, "The fall occurred in unknown circumstances. She fell from an unknown height. Patient unable to provide reliable (?) at this time due to mental status changes."

A Nursing Admission Assessment from Facility #2, dated 12/14/17 at 1430 noted excessive bruising in multiple stages of healing.

A Social Work Note from Facility #2, dated 12/15/17 at 0339 documented concerns for physical abuse and neglect. The Note documented, "SW received a consult regarding adult neglect/abuse. The following was reported in the order, Multiple bruises in different stages of healing. Pressure Dressing still applied to catheterization site (catheterization done seven days earlier at Facility #1 on 12/7/17). It was also noted that patient had not taken any of the medications she was discharged with. Patient presented confused at admission. SW placed a telephone call to APS and reported the allegations." The SW note also documented that the son (next of kin) had not responded to facility attempts to contact him.

Subsequent Facility #2 SW notes revealed that the APS case worker telephoned her on 12/17/17 (48 hours after referral), and called her again on 12/18/17 for follow-up.

A Facility #2 SW note dated 12/18/17 at 0958 contained allegations made by the APS caseworker that Facility #1 had failed to protect Patient #1 from suspected abuse. The SW note documented that a court hearing was scheduled for 12/18/17 for emergency guardianship. The note also documented, "Due to the serious nature of the case (APS caseworker) is requesting that the patient not be moved from the unit until after the hearing. Patient was apparently discharged from (Facility #1) back home with her son who is the alleged perpetrator, and APS was unable to locate patient until the new referral was placed on Friday. SW will continue to follow up."

A letter dated 12/15/17 from the APS caseworker to SW at Facility #2 alleged that Facility #1 had failed to follow his requests for abuse follow-up and protection for Patient #1. The APS letter documented that the Caseworker interviewed the Patient #1 on 12/8/17 (at Facility #1), "in the presence of her attending nurse (not named or identified)." The letter documented that Patient #1 reported to the APS caseworker that her son was "physically abusive and hit/kicked her during altercations and threatened to assault her", but that she wanted to return home because her step son and daughter in law help her. The letter noted that Patient #1 was confused and at times incoherent, raising the question of whether she was competent to make decisions. The APS letter noted, "subsequent to the interview (at Facility #1, no date or time noted), I made the following requests as protective measures to the tending nurse (not identified): a request was made for a competency exam to determine the extent of the client's capacity to make decisions, and the nurse was advised that (Patient #1) should not be discharged home until a competency exam took place and it was determined that she is capable of making her own decisions." The report went on to document, "The nurse advised that she would most likely be discharged to Rehab (a skilled care and rehabilitation facility)."

Neurology and Psychiatric consultations were ordered on 12/10/17 at Facility #1 due to Patient#1's fluctuating mental status (periodic confusion), but neither consultant evaluated her competency to make decisions, or documented any assessment or discussion of her abuse allegations.

A Facility #2 SW note dated 1/4/18 at 1649 documented that APS had contacted her and expressed, "concerns regarding the discharge planning and social work services this patient received at (Facility #1)." The SW note went on to document that, "(APS caseworker) reported that he was there on 12/7/17, the same day that complaint was made, he did not have contact with SW as requested, and no one contacted him after he had left a request for follow-up. Also, he expressed concern that this patient was sent home as opposed to sub-acute rehab (skilled care/rehabilitation facility)."

A Facility #2 SW note dated 1/5/18 at 1345 documented that (APS Caseworker) states that the patient's sister has not seen her in three years and only communicated with her on social media as the patient has been kept isolated by her son (alleged abuser).

On 3/6/18, The Facility #1 Case Manager assigned to Patient #1's unit, Staff K was interviewed and stated that she couldn't remember the patient, but probably did not do daily interdisciplinary rounds on Patient #1 during her stay, and did not comply with the order for Case Management Consult, "because the nurse probably told me that she had no discharge planning needs." Staff K was unable to provide documentation of this when asked.

On 3/6/18 at approximately 1130, Staff C, the 5th floor unit manager at Facility #1 was interviewed and stated that if a patient reported that they had an abusive living situation, the charge nurse would put an alert in the chart, call the Social Worker (SW), and a (Consult) Order for Case Management would be made. Staff C stated that the SW would call Adult Protective Services (APS) to report the abuse allegation, and would be responsible for the follow-up. Staff C stated that this should have been discussed with Case Management, the Attending Physician and the Multidisciplinary Team, and Patient #1 should not have been discharged home to a potentially unsafe environment.

On 3/6/18 at 1135, the 5th floor Social Worker (SW) at Facility #1, Staff G, was interviewed and reported that she was responsible for abuse allegation reporting and followup to APS. Staff G stated that the standard language from APS acknowledging the referral stated that APS would send a written notification of investigation progress to the SW within two weeks. Staff G stated that if APS felt that an allegation was serious, the APS case worker would telephone her within 48 to 72 hours to let her know that the patient should not return to the suspected unsafe living situation until APS completed it's investigation. Staff G reported that she did not remember Patient #1, and stated, "I don't follow patients for discharge planning." Staff G was unable to provide any documentation of any facility communication or follow-up with APS for Patient #1 after the initial referral was made.

On 3/6/18 at 1625, Staff H, the nurse who documented Patient #1's discharge from Facility #1 on 12/11/17 at 1904 was interviewed. Staff H read her nursing documentation and her documentation on the shift assessment flowsheet and stated, "I think I remember who she was. She was kind of leery about going home. I think there were some issues with family dynamics for her." Staff H denied knowledge of any APS abuse referral for Patient #1, or of any discussion of whether Patient #1 was safe to be discharged back home with her son, her alleged abuser.

On 3/7/18 at 1000, Patient #1's attending physician, Staff I, was interviewed. Staff I stated that as a cardiologist, he was usually a consultant, and not usually an attending physician. Staff I stated that Patient #1 was admitted directly into his service as the attending physician, as she was admitted for cardiac problems and was a prior patient of his. Staff I stated, "There was some issue raised about her family support. She wasn't taking her medications at home. I discharged her because there was no reason medically or psychologically to keep her in house. Her level of cognition fluctuated." When asked if Social Work or Case Management had discussed this patient with him, or if he was aware at the time that an APS referral was made, Staff I stated, "Not to my knowledge. If APS told the SW that they would contact her in two weeks, that means to me that it wasn't urgent."

On 3/7/18 at approximately 1100, the Director of Nursing, Staff A, was interviewed and reported that the facility should have followed up to make sure that Patient #1 wasn't discharged home to a potentially unsafe environment. Staff A stated that if APS didn't get back to the facility for two weeks after an abuse referral, then the facility had to make sure that they had a process in place to make sure that a patient wasn't sent home with an alleged abuser. Staff A stated that there was no facility documentation to prove that APS followed up with the facility or visited Patient #1 prior to discharge. Staff A noted that the APS caseworker did not report back to the SW (Staff G), did not identify the staff nurse he allegedly talked to, and failed to follow up with written documentation prior to the patient's discharge.

On 3/7/18 at approximately 1110, the Director of Quality and Case Management, Staff E, was interviewed. Staff E reported that Patient #1's home environment safety and family support should have been assessed prior to discharge, especially as there was an allegation was of abuse. Staff E said that the Case Manager should have followed up for assessed discharge needs and home environment safety, but that this may not have happened because Patient #1 was discharged on a Monday (12/11/17 at 1908), and Case Management staff only work Monday through Friday. The Case Management Supervisor, Staff F, declined to comment at this time.

On 3/9/18 at 1600 review of the facility policy entitled, "Abuse/neglect/assault: identification and intervention", revised 3/7/05 revealed the following statements, "It is the policy that patients are assessed and identified for, to the extent possible, protected from possible abuse, neglect or exploitation from family members, visitors, other patients, staff, students or volunteers. If there is reason to suspect that abuse or neglect may have occurred, appropriate diagnostic and care procedures, internal and external resources, and reporting procedures are implemented to coordinate the care and protection of the suspected victim."

Based on interview and record review, the facility failed to fully implement it's discharge planning process to ensure that discharge needs were accurately assessed, updated as necessary and discharge needs met for one (#1) of seven patients reviewed for discharge planning, out of a total sample of 10, resulting in unmet care needs, readmission within 3 days of discharge, and discharge to an allegedly unsafe environment. See specific tags:

A 0821 - Failure to perform a comprehensive discharge assessment and update discharge care plan

Based on observation, interview and record review, the facility failed to reassess discharge needs, and update the discharge plan after a cognitive decline, nursing assessed needs for Home Care and Rehabilitation referrals, consultant physician evaluations and a reported abusive living situation for one (#1) of two patients reviewed for abuse/neglect allegation followup, out of a total sample of 10, resulting in unmet care needs, hospital readmission three days after discharge, and discharge home with a potential abuser for the patient concerned. Findings include:

On 3/6/18 at 1030, the 5th floor Case Management team was observed during daily patient rounds on the unit. The team consisted of two unit nurses, the Care Management Coordinator, Staff K, and the Case Management Supervisor, Staff F. The Case Management team members were interviewed at this time. Staff F reported that Case Management rounds were done daily from Monday to Friday, and was the time Case Managers, Unit Nursing Staff and patients talked about discharge planning and what the patient would need after discharge.

On 3/6/11 at approximately 1105, attending physician, Staff P and the team Case Manager, Staff Q were observed and interviewed during daily Multidisciplinary Team patient rounds. Staff P and Staff Q were observed to ask each patient regarding services and medical equipment they would need after discharge, and confirming the patient's choice to return home or go to a skilled care (rehabilitation) facility. Staff Q was interviewed at this time regarding the discharge planning process, and reported that discharge needs were discussed with the Multidisciplinary team while they saw patients together during daily rounds, and then discussed afterwards with the staff nurse and Case Management to make a Discharge Plan. Staff Q stated that the Discharge Plan would be updated as needed with information gathered during daily rounds.

On 3/6/18 at approximately 1130, Staff P was interviewed regarding Case Management's role in the discharge Planning process and stated that the Case Manager and the Social Worker would be given daily updates on patients due to be discharged, and on any patients with new discharge planning needs. When asked, Staff P stated that if a patient reported an abusive home situation, Case Management would "turn everything over to Social Work (SW) for follow-up."

On 3/6/18 at 1400, Patient #1's clinical record from the facility of concern (Facility #1) was reviewed and revealed the following information:

Patient #1 was a 67 year-old female who was admitted into the facility on 12/7/17 for chest pain. Diagnoses included Diabetes Mellitus, Coronary Artery Heart Disease, and history of coronary artery stent placement. The patient arrived alone at the facility by ambulance on 12/7/17 at 0500. Review of the original (non-edited) facesheet for that admission, revealed that Patient #1 was her own responsible party and signed her admission paperwork herself.

Review of Nursing Care Plans for Patient #1 revealed a Discharge Care plan (no date initiated, documented as discontinued- for discharge on 12/11/17), included the following interventions:

"Initiate Discharge Referral consults"
"Set up Outpatient Services"
"Evaluate need for possible Medical Equipment at Discharge"
"Evaluate Patient's ability to fill prescriptions"
"Identify potential discharge barriers on admission"
"Assess potential discharge needs"
"Patient will be returned to a safe environment"
"Assess safety of discharge environment prior to discharge"

There was no documentation to indicate that this discharge care plan was implemented, or updated with new interventions to reflect changes in the patient's condition.

A SW note dated 12/7/17 at 1522, written by Staff G documented, "SW received referral for adult abuse/neglect. Patient reports that she has been living with her son for 2 years. She states that since 9/17, (son) has been threatening her, telling her to die, making threats to kill her. Patient states that she has nowhere else to live. Patient states that in the past (son) pushed and shoved her. She uses a walker. Referral made with APS (Adult Protective Services). "

There was no documentation on the discharge plan to indicate this allegation of an abusive home environment was noted, or that this was assessed, or discharge needs related to this addressed. There was no documentation that Case Management was notified of possible discharge needs for assuring a safe environment. There was no documentation of a discharge planning assessment of the safety or supportiveness of Patient #1's home environment. There was no documentation of assessment for possible alternative living situations or of any planning for keeping Patient #1 safe after discharge.

There were no Nursing notes, or Interdisciplinary Team notes for Patient #1's entire admission at Facility #1 (facility of concern) that documented any knowledge or awareness of abuse/neglect allegations, or the APS referral or follow-up. There was no documentation of Interdisciplinary Care Team discussions or interventions to protect the patient or ensure a safe environment after discharge.

An Admission Discharge Complexity/Readmit Risk Scale did not document when it was originally done. This form was updated on 12/10/17 at 0090 (original assessment prior to update not available) to note that Patient #1 was at "medium risk" for readmission and "requires home care."

There was an order dated 12/10/17 at 0010, for Case Management to consult for Patient #1. The order 's comments noted, "Patient has a score of medium or high within the Discharge Complexity Scale", and, "Acute Rehabilitation (physical or occupational therapy) assessment requires a Physiatry (Physical and Occupational Therapy specialist) Physician consultation."

There was no documentation that a Physiatry Physician Consultation order was ever written, or that Patient#1's needs for Physical or Occupational Therapy were ever assessed. There is no documentation that this was added to the discharge care plan, or that this was discussed with the attending physician or Multidisciplinary Team.

The order for a Case Management Consult for Patient #1 was noted on 12/11/17 at 0837 by Case Manager, Staff K, but there is no documentation that this was added to the Discharge Care Plan, or that this consultation was ever done.

There was no documentation of Case Management evaluation, or discussion with the Multidisciplinary Team. There was no documentation that Case Management evaluated Patient #1's discharge needs.

The only Case Management documentation for Patient #1 was dated 12/8/17 at 0946, and noted, "Attempted to meet with patient, and patient was sleeping. Will try to meet with patient later." The facility was unable to provide documentation that this was done.

A Neurology Consultation, for evaluation of "altered mental status", dated 12/11/17 (no time noted), documented that the patient was delirious and confused, and had an abnormal CT (computerized axial tomography) scan of the head, indicating brain abnormalities and a possible stroke.

A Psychiatric Consultation Report for Patient #1, dated 12/10/17 at 1421 contained no assessment of the patient's mental competency, and did not document that current abuse/neglect or safety of the patient's home environment were assessed or discussed. The report documented that the referral was for assessment of "confusion". The psychiatrist documented that Patient #1 was confused, and unaware of her location, time and current medical issues, and had poor judgement and insight.

Patient #1's decline in mental status, and documented confusion and memory impairment were not noted in the patient's discharge plan as possible barriers to discharge, or as triggering the need to reassess family supportiveness, or the need to reassess Patient #1 for possible needed services and/or alternative placement after discharge.

Review of Multidisciplinary Team Progress notes for Patient #1 revealed no documentation of assessment of the safety and supportiveness of her home environment, assessment for rehabilitation therapy needs, or of any assessment of Patient #1's ability to take her medications and change the dressing on her incision (from cardiac catheterization) after discharge.

The last Multidisciplinary Team note documenting daily rounds or team discussion for Patient #1 was dated 12/8/17 (three days before discharge). Case Management was not documented as attending any of the Multidisciplinary Team rounds for Patient #1 during her admission.

On 3/7/18 at approximately 1025, Review of Patient #1's EMR from the sister facility (Facility #2), for an admission dated 12/14/17 revealed that Patient #1 was readmitted to hospital three days after discharge from the facility (Facility #1), with symptoms suspicious for abuse and neglect. A referral was made to APS by Facility #2 for suspected abuse and neglect.

The ED Physician assessment dated 12/14/17 at 0334 documented the patient reported no current chest pain. The physician documented that the patient stated she "fell over silverware" and then "fell in the yard", "days ago". The physician documented, "The fall occurred in unknown circumstances. She fell from an unknown height. Patient unable to provide reliable (?) at this time due to mental status changes."

A Social Work Note from Facility #2, dated 12/15/17 at 0339 documented concerns for physical abuse and neglect. The Note documented, "SW received a consult regarding adult neglect/abuse. The following was reported, Multiple bruises in different stages of healing. Pressure Dressing still applied to catheterization site (catheterization done seven days earlier at Facility #1 on 1/7/17). It was also noted that patient had not taken any of the medications she was discharged with. Patient presented confused at admission. SW placed a telephone call to APS and reported the allegations."

A letter dated 12/15/17 from the APS caseworker to the SW at Facility #2 documented APS allegations that Facility #1 had failed to follow requests for abuse follow-up and protection for Patient #1. The APS letter noted that Patient #1 was confused and at times incoherent, raising the question of whether she was competent to make decisions. The letter documented, "subsequent to the interview (of Patient #1, at Facility #1, no date or time noted), I made the following requests as protective measures to the tending nurse (not identified): a request was made for a competency exam to determine the extent of the client's capacity to make decisions, and the nurse was advised that (Patient #1) should not be discharged home until a competency exam took place and it was determined that she is capable of making her own decisions. The nurse advised that she would most likely be discharged to Rehab (a skilled care and rehabilitation facility)."

A Facility #2 SW note dated 1/4/18 at 1649 documented that APS contacted her and expressed, "concerns regarding the discharge planning and social work services this patient (Patient #1) received at (Facility #1)." The note documented that APS was concerned that Patient #1 was sent home as opposed to sub-acute rehab (skilled care/rehabilitation facility).

On 3/6/18 at approximately 1530 the Director of Nursing, Staff A , was asked when Patient #1's Discharge Complexity/Readmit Risk Scale was done originally, and the date the Nursing Care Plan for Discharge Planning was initiated. Staff A stated that the Discharge Complexity/Readmit Risk Scale assessment was done within 24 hours of admission, and the Nursing Discharge Care Plan should be done immediately afterwards. When asked why there was no documentation to indicate when these documents were originally created, Staff A stated that the Electronic Medical Record (EMR) software program was a "living program" and documents were continuously updated to reflect the latest data. The original initial Care Plans and Admission Discharge Complexity/Readmit Risk Scale for Patient #1, with the dates they were created, were requested but not provided by exit.

On 3/6/18 at 1615, the SW, Staff G was interviewed regarding Patient #1. When asked, Staff G was unable to provide documentation that Patient #1's physician, Case Management, or the Multidisciplinary Care team, or the 5th floor Nursing management were notified of the abuse allegation, the APS referral, or that concerns related to discharge to a safe environment were discussed, or the Discharge Care Plan updated to reflect concerns with a potentially unsafe home environment, or the need to assess for discharge to an alternate living situation. Staff G stated, "I don't remember this patient," and stated , "I don't follow patients for discharge planning."

On 3/7/18 at approximately 1030, The Case Manager assigned to Patient #1's unit, Staff K was interviewed and stated that she couldn't remember the patient. When asked, Staff K reported that she did not do daily interdisciplinary rounds on Patient #1 during her stay, and did not comply with the order for Case Management Consult, "because the nurse probably told me that she had no discharge planning needs."

On 3/6/18 at 1625, Staff H, the nurse who documented Patient #1's discharge on 12/11/17 at 1904 was interviewed. Staff H read her nursing documentation and her documentation on the shift assessment flowsheet and stated, "I think I remember who she was. She was kind of leery about going home. I think there were some issues with family dynamics for her."

On 3/7/18 at 1000, Patient #1's attending physician, Staff I was interviewed. Staff I stated that as a cardiologist, he was usually a consultant, and not an attending physician for patients admitted into the facility. Staff I stated that Patient #1 was admitted directly into his service as the attending physician, as she was admitted for cardiac problems and was a prior patient of his. Staff I stated, "There was some issue raised about her family support. She wasn't taking her medications at home. I discharged her because there was no reason medically or psychologically to keep her in house. Her level of cognition fluctuated." When asked if Social Work or Case Management had discussed this patient with him, or if he was aware at the time that an APS referral was made or that nursing had assessed a need for a Physiatrist assessment and a Home Care referral, Staff I stated, "Not to my Knowledge."

On 3/7/18 at approximately 1100, the Director of Nursing, Staff A stated that the facility should have followed up to make sure that Patient #1 wasn't discharged home to a potentially unsafe environment. Staff A said that if APS took two weeks to get back to them, then the facility had to make sure that they had a process in place to make sure that a patient wasn't sent home with an alleged abuser.

On 3/7/18 at approximately 1110, The Director of Quality and Case Management, Staff E also was interviewed and reported that Patient #1's discharge plan should have been updated to include the concerns about home environment safety. Staff E stated that the Case Manager should have followed up for discharge needs assessed on the Discharge Complexity/Readmit Risk Scale, and should have responded to the Case Management referral order. Staff E stated that Patient #1's home support and home environment safety should have been assessed due to her confusion and mental impairment as well as due to the the allegations of physical and mental abuse.

On 3/7/18 at approximately 1115, the Case Management Supervisor, Staff F was interviewed regarding discharge planning. Staff F stated that if the Discharge Complexity/Readmit Risk Scale score for a patient was moderate or high, the EMR automatically triggered a notification for Case Management to assess the patient for discharge planning needs. When asked why this was not done for Patient #1, Staff F said, "Case Management did see her, on 12/8/17." When asked how the Case Manager assessed Patient #1's discharge needs while she was asleep, Staff F declined to comment. Staff F was requested at this time to provide documentation that Case Management assessed Patient #1's discharge needs or participated in Multidisciplinary Care Team discussions of Patient#1's care and needs after discharge, but was unable to provide any additional information.

On 3/9/18 at 1600 review of the facility policy entitled, "Indicators for Care Management Referrals", dated 12/13, revealed the following statements,

"Assessment will be completed within 24 hours or the next business day."

"The Progression Care Coordinator PCC), Social Worker (SW) and Case Manager (CM) will continue to follow the case and communicate with the attending physician on the initial discharge plan and any changes that may occur throughout the hospital stay."

"The PC/SW/CM will continue to review the discharge plan and barriers to transfer/discharge every 24-48 hours and will document as needed."

"Nurse Screen Referrals - Care Management assessment will be completed during the admission assessment. Discharge readiness is assessed by the nurse during progression rounds. Nursing Staff, PC/SW/CM will follow the case with daily discussions of progress toward discharge and continue to follow up and have discussions with the attending physician regarding the discharge plan."

"Indicators for Care Management Referrals: Questionable functional/cognitive status, family dysfunction, new onset of decline in functional status during hospitalization, rehabilitation placement."