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Based on interview, review of documentation in 8 of 8 medical records of patients who received hospital services (Patients 1 through 8), and review of policies and procedures and other documents it was determined that the governing body failed to ensure that the provision of care and services were conducted in a manner that promoted and protected patients' rights to:
* Safe care;
* Freedom from abuse and neglect;
* Response to and investigation of complaints and grievances; and
* Required notifications.

This Condition-level deficiency substantially limits the capacity of the facility to furnish services of an adequate level of quality.

Findings include:

Refer to the Condition-level deficiency cited at Tag 0115, CFR 482.13 Patient's Rights. Those findings include, but are not limited to:
* A patient's lung was perforated during a naso-gastric tube insertion and the hospital failed to conduct an investigation;
* Patients with cognitive and functional limitations were discharged by themselves, without assistance, to unsafe situations;
* The hospital failed to investigate allegations of physical and sexual abuse;
* The hospital failed to respond to and investigate complaints and grievances;
* The hospital failed to provide the "Important Message from Medicare", which contains patient's rights to appeal early discharge and procedures for the appeal, to patients or their representatives as required.

Refer to the deficiency cited at Tag 0057, CFR 482.12(b), Chief Executive Officer, that reflects the failure of the CEO to protect and promote patients' rights.

Based on interview, review of documentation in 8 of 8 medical records of patients who received hospital services (Patients 1 through 8), and review of policies and procedures and other documents it was determined that the CEO failed to ensure that the provision of care and services were conducted in a manner that promoted and protected patients' rights to:
* Safe care;
* Freedom from abuse and neglect;
* Response to and investigation of complaints and grievances; and
* Required notifications.

Findings include:

Refer to the Condition-level deficiency cited at Tag 0115, CFR 482.13 Patient's Rights. Those findings include, but are not limited to:
* A patient's lung was perforated during a naso-gastric tube insertion and the hospital failed to conduct an investigation;
* Patients with cognitive and functional limitations were discharged by themselves, without assistance, to unsafe situations; and
* The hospital failed to investigate allegations of physical and sexual abuse;
* The hospital failed to respond to and investigate complaints and grievances;
* The hospital failed to provide the "Important Message from Medicare", which contains patient's rights to appeal early discharge and procedures for the appeal, to patients or their representatives as required.

29708

Based on interview, review of documentation in 8 of 8 medical records of patients who received hospital services (Patients 1 through 8), and review of policies and procedures and other documents, it was determined that the hospital failed to fully develop and implement policies and procedures to ensure that the provision of care and services were conducted in a manner that promoted and protected patient's rights to:
* Safe care;
* Freedom from abuse and neglect;
* Investigation of and responses to complaints and grievances; and
* Required notifications.

This Condition-level deficiency substantially limits the capacity of the facility to furnish services of an adequate level of quality.

Findings include:

1. Refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects the hospital's failure to ensure the patient's right to receive care in a safe setting:
* A patient's lung was perforated during a naso-gastric tube insertion and the hospital failed to conduct an investigation;
* Patients with cognitive and functional limitations were discharged by themselves, without assistance, to unsafe situations; and
* The hospital failed to investigate allegations of abuse, including physical and sexual abuse.

2. Refer to the deficiency cited at Tag 145, CFR 482.13(c)(3) Patient's Rights - Free from Abuse/Harassment. That deficiency reflects the hospital's failure to investigate allegations of abuse, including verbal, physical, and sexual abuse.

3. Refer to the deficiency cited at Tag 123, CFR 482.13(a)(2)(iii) Patient's Rights - Notice of Grievance Decision. That deficiency reflects the hospital's failure to provide written notice of follow-up investigation and resolution that contained the required elements, including but not limited to: the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

4. Refer to the deficiency cited at Tag 117, CFR 482.13(a)(1) Patient's Rights - Notice of Rights. That deficiency reflects the hospital's failure to ensure the provision of the "Important Message from Medicare", which contains patient's rights to appeal early discharge and procedures for the appeal, to patients or their representatives as required.

Based on interview, review of documentation in 6 of 6 medical records of patients who were Medicare beneficiaries (Patients 1, 3, 4, 5, 6 and 7 ), and review of policies and procedures it was determined that the hospital failed to fully develop and implement its policies and procedures to ensure the provision of the "Important Message from Medicare", which contains patient's rights to appeal early discharge and procedures for the appeal, to patients or their representatives as required. CFR 489.27(a) and CFR 405.1205 require that an IM be provided to each Medicare beneficiary within 2 days of hospital admission. The CFRs also require that if the hospital stay is more than 2 days, a signed copy of the IM must be provided in advance of discharge, but not more than 2 days before discharge. The IM must be signed and dated by the patient or patient's representative to acknowledge receipt.

Findings include:

1. The medical record of Patient 1 reflected he/she was admitted on 10/06/2015 at 1137 and was discharged on 10/11/2014 at 1500. The patient was 94 years old and was a Medicare beneficiary. The record contained a scanned copy of an "Important Message from Medicare." The form was signed by the patient on 10/08/2014 at 1240. There were no other IM forms in the medical record to reflect that the patient received a second IM notice before discharge as required. This was confirmed with Quality Management Coordinator on 11/02/2015 at 1500.

2. The medical record of Patient 3 reflected he/she was admitted on 11/18/2014 at 1400 and was discharged on 11/26/2014 at 1730. The patient was 86 years old and was a Medicare beneficiary. The record contained a scanned copy of an "Important Message from Medicare." The form was signed by a patient representative on 04/19/2014 at 1135 which was 7 months prior to the admission date. There were no other IM forms in the medical record to reflect that the patient received a second IM notice before discharge as required. This was confirmed with Quality Management Coordinator on 11/03/2015 at 1110.

3. The medical record of Patient 4 reflected he/she was admitted on 11/28/2014 at 1245 and was discharged on 02/17/2015 at 1542. The patient was 86 years old and was a Medicare beneficiary. An entry in the medical record reflected "CMS IM for Patient Signature...[Registered] letter came back return to sender." The record contained a scanned copy of an envelope post marked 12/03/2014 addressed to the patient's family member, and a Social Worker note dated 02/17/2015 at 0845 which reflected that the IM was emailed to the patient's family member. There was no documentation reflecting the patient or patient representative received and signed the required "Important Message from Medicare" notice.

4. The medical record of Patient 5 reflected he/she was admitted on 02/20/2015 at 2231 and was discharged on 03/07/2015 at 1815. The patient was 87 years old and was a Medicare beneficiary. The record contained a scanned copy of an "Important Message from Medicare." The form was signed by a patient representative on 02/22/2015 at 1618. There were no other IM forms in the medical record to reflect that the patient received a second IM notice before discharge.

5. The medical record of Patient 6 reflected he/she was admitted on 03/28/2015 at 1029 and was discharged on 04/07/2015 at 1348. The patient was 87 years old and was a Medicare beneficiary. The record contained a scanned copy of an "Important Message from Medicare." The form was signed by the patient on 03/29/2015. There were no other IM forms in the medical record to reflect that the patient received a second IM notice before discharge as required. This was confirmed with the Quality Management Coordinator on 04/23/2015 at 1615.

6. The medical record of Patient 7 reflected he/she was admitted on 07/25/2015 at 2037 and was discharged on 07/28/2015 at 1448. The patient was 96 years old and was a Medicare beneficiary. The record contained a scanned copy of an "Important Message from Medicare." The form was signed by one of the patient's representatives, was dated 07/26/2015, and was untimed. A second handwritten notation at the bottom of the form reflected the following: "left by pt bedsite (sic) 7/28/15 1127." The author of the entry was not identified. There was no evidence in the medical record to confirm that the form that was "left by pt bedsite (sic)" had been received by the patient or the patient's representatives as required.

7. The policy and procedure titled "Discharge Planning Process" dated last revised "03/2015" was reviewed and reflected "...For Traditional Medicare beneficiaries and Medicare Advantage plan enrollees who are inpatients, Providence Health and Services will deliver the Important Message (IM) from Medicare on admission and again prior to discharge. The Important Message from Medicare informs beneficiaries and Medicare and Advantage plan enrollees of their hospital discharge appeal rights." The policy did not include the required timeframes for providing the notice and the requirement that the notice be signed and dated by the patient or patient's representative to acknowledge receipt.























29708

29708

Based on interview, documentation in 3 of 3 medical records reviewed about whom complaints/grievances were expressed or filed (Patients 2, 4 and 7), and review of hospital policies and procedures and other documentation, it was determined that the hospital failed to provide written notice of follow-up investigation and resolution that contained the required elements, including but not limited to: the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. Refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects the hospital's failure to investigate and provide a written response to Patient's 2 and 4, or their representatives, in response to numerous complaints/grievances, including but not limited to: allegations of abuse; and an incident of patient care resulting in harm.

2. The medical record of Patient 7 reflected that the 96 year old patient was admitted on 07/25/2015 at 2037 and was discharged on 07/28/2015 at 1446.

Refer to the findings for Patient 7 under the following Tags that reflect the hospital's deficient practice in the provision of care and services:
* Tag A117, CFR 482.13(a), Patient Rights;
* Tag A395, CFR 482.23(b), Nursing Services;
* Tag A450, CFR 482.24(c), Medical Records;
* Tags A806 and A823, CFR 482.43(b)(c), Discharge Planning.

An "ORQMD Record Summary" dated 07/30/2015 related to Patient 7's hospitalization was reviewed. The document reflected that a complaint about the patient's hospitalization had been received two days after the patient's discharge through the HHA. A "Comment" on the summary recorded on 07/30/2015 at 1449 reflected that "When HH called to arrange visit, AFH informed them that patient had been taken to another hospital ER as they were unable to care for patient. The patients [family member] was called, [he/she] was very dissatisfied with care, did not understand why patient had been discharged from PPMC and [he/she] stated that [he/she] has to report this as 'elder abuse' per [his/her] job requirements. The [family member] was provided with PPMC QM phone number although [he/she] stated [he/she] did not wish to speak to QM. Patient record reviewed. All RN and [RN Care Manager] documentation very thorough and match RNs story. Will await call from patient/family if they have concerns." The next and final entry on the summary was recorded on 07/30/2015 at 1449 and read "No further action needed at this time." There was no evidence of follow-up or further communication, verbal or written, with the patient's representative.

During interview with the Quality Management Coordinator on 09/30/2015 at 1130 he/she confirmed that the summary was the only documentation related to the concerns about care and discharge voiced by Patient 7's representative.

29708


Based on interview, review of documentation in 5 of 8 medical records of patients who received hospital services (Patients 1, 2, 4, 7 and 8), and review of policies and procedures and other documents, it was determined that the hospital failed to ensure the patient's right to receive care in a safe setting:
* A patient's lung was perforated during a naso-gastric tube insertion and the hospital failed to conduct an investigation;
* Patients with cognitive and functional limitations were discharged by themselves, without assistance, to unsafe situations; and
* The hospital failed to investigate allegations of abuse, including physical and sexual abuse.

This deficiency substantially limits the capacity of the facility to furnish services of an adequate level of quality.

Findings include:

1. The medical record of Patient 4 reflected he/she was admitted to the hospital on 11/28/2014 at 1400 with a diagnosis of dehydration.

The History & Physical electronically signed by the physician and dated 11/28/2014 at 1753 reflected "...[Patient] with history of stroke, dementia, [hypertension], postoperative atrial fibrillation...presented with increased confusion, abdominal pain and left knee pain...admitted with severe sepsis concerning for an abdominal source..."

A physician order electronically signed by the physician on 12/03/2014 at 1318 reflected "Verification of tube placement (Naso/Oro tubes only)...Comments...Clinical: Aspiration, instillation & auscultation of air...Radiographic Confirmation: X-ray abdomen...Frequency...Until discontinued 12/03/2014 1318 - Until Specified." The order was discontinued on 12/19/2014 at 0135.

The record reflected an order for a feeding tube that was electronically signed by an RN on 12/03/2014 at 1700. The order was authorized by a physician but did not reflect the date and time it was authorized. The order reflected the following: Tube Feeding W/ STYLT 12FR 43 [inch]...Frequency...1 Time 12/03/2014 1700 1 Occurrences (sic)...Questions: Quantity 1 Need STAT? Yes"

The RN notes dated 12/03/2014 at 1900 reflected "...went to bedside to place [naso-gastric tube]. Measured and preped (sic) for procedure. Pulled the NG out, (sic) patient was very agitated by this. Had CNA...and [family member] at bedside to assist with placement. Patient was combative and agitated while placing tube, unable to follow commands. Got tube placed at projected 65cm, secured with paper tape until able to confirm with x-ray. Did a set of [vital signs] after placement. [Oxygen saturation] 96% on room air. Patient showing to (sic) signs of distress. Stat portable x-ray ordered...report given to RN at change of shift."

There was no documentation to reflect the RN determined that the naso-gastric tube was placed in the patient's stomach; the documentation related to the patient's tolerance to the procedure was unclear with respect to the patient's "agitation" and "signs of distress"; and there was no documentation reflecting the time the naso-gastric tube was inserted, the insertion site, the condition of the patient's skin at his/her nares and areas taped in accordance with hospital policies and procedures.

An order electronically signed by a "Tech" on 12/03/2014 at 1813 and authorized by a physician reflected an order for an abdomen x-ray. The reason for the examination was "check [naso-gastric tube] placement."

A physician order electronically signed by the physician on 12/03/2014 at 2145 reflected an order for a chest x-ray. The reason for the examination was "[respiratory] failure, rule out pneumothorax."

The next RN notes dated 12/03/2014 at 2200 reflected "...Radiologist called...about Xray report at 2130. Rapid Response Team called also at this time...Patient was promptly transferred to ICU at 2140..."

The "Progress Notes" electronically signed by the physician and dated 12/03/2014 at 2326 reflected "Patient...had a feeding tube placed. Post feeding tube placement [he/she] had a [x-ray] which demonstrated a feeding tube in the right thorax...[He/she] was coughing and having some discomfort. Patient was prepped and emergently (sic) to the ICU...chest x-ray demonstrating pneumothorax following feeding tube removal...chest tube was placed...then sutured in place...the patient will remain in the ICU with a chest tube on suction..."

The RN notes dated 12/04/2014 at 0636 reflected "[Naso-gastric tube] removed by MD upon arrival to ICU..."

The physician notes electronically signed by the physician on 12/04/2014 at 1229 reflected "[Chest x-ray] from yesterday shows a large [pneumothorax] on the right side after an attempted [naso-gastric tube] placement. There is resolution of the [pneumothorax] after a small catheter placement with only a trace apical [pneumothorax]. Today's [chest x-ray] shows stable, small, apical [pneumothorax]. [Chest x-ray] is stable after a catheter was placed to waterseal...Recommend continue catheter and clamp trial prior to removing pleural catheter."

The RN notes dated 12/07/2014 at 1842 reflected "Family at bedside throughout the day...Family has many concerns regarding patient's care; they state 'many mistakes have been made.'"

The RN notes dated 12/13/2014 at 2001 reflected "Order to remove [telemetry] post blood transfusion - [physician] spoke with family at length about this today, family very upset and wanting to continue [telemetry], day (sic) and noc charge nurse in patients (sic) room at change of shift discussing this matter. Oncoming RN aware of need to remove [telemetry]. [Family member] was very upset and angry most of the day despite explanation of care."

The nurse practitioner notes dated 12/21/2014 at 1630 reflected "[Family member] is extremely distrustful of staff. [He/she] spoke with me for half an hour and gave me example after example of [his/her] dis-satisfaction."

The "Progress Notes" electronically signed by the physician and dated 12/30/2014 at 0808 reflected "Met with [family member]...who had multiple complaints including but not limited to...no explanation for rash...Poor nursing care...reports that [patient] is neglected...[his/her] sleep is interrupted to (sic) frequently during night...Pain control...Nutrition...[he/she] claims last [naso-gastric tube] was done by untrained personnel which led to pneumothorax..."

The "Plan of Care" notes electronically signed by the physician and dated 01/03/2015 at 1737 reflected "Updated [family members] at bedside...[Family member] had many complaints about issues that occurred previously during the hospitalization and had to be redirected several times to focus on plan for nutrition."

The LCSW notes dated 01/15/2015 at 1636 reflected that the patient's family member "...accused staff of abusing patient and protocols not being followed."

The "Progress Notes" electronically signed by the physician and dated 01/15/2015 at 1739 reflected "[Family member] said '...Do you know that there is a nurse on this floor who physically and verbally abuses patients and no one does anything about it. (sic)'"

The RN notes dated 01/15/2015 at 1950 reflected that Patient 4's family member "...began to talk about other nurses and how they 'were abusing and ignoring patient'."

The RN notes dated 01/15/2015 at 2014 reflected that Patient 4's family member "...called 911 with claims of elder abuse."

The Discharge Summary electronically signed by the physician on 02/12/2015 at 0910 with a "Filed" date of 02/17/2015 at 1458 reflected "[Patient]...admitted to ICU with severe sepsis [secondary to] an intraabdominal abscess/peritonitis...pneumothorax post [naso-gastric feeding tube] placement 12/3 requiring chest tube...now with prolonged hospital stay with severe malnutrition and poor oral intake requiring ongoing tube feeds...

The record reflected the patient was discharged to a SNF on 02/17/2015 at 1542.

A UOR report for Patient 4 with an "Event" date/time 01/09/2015 at 0250 was reviewed. The report reflected "Patient recovering...status post...Nasogastric Feeding tube placement. Patient started to rouse and became more and more agitated...Patient yelling out and screaming...[Family member] at [patient's] bedside...accusing staff of...neglect of and abuse toward patient." The "Possible Causes" section reflected "Dissatisfaction with Treatment, Altered Mental Status." The "Patient Affected" section reflected "Yes" however there was no information about how the patient was affected. The "Outcome" section reflected "Resulted in need for treatment or intervention. Temporary harm" but did not reflect any other information about the treatment and interventions needed or the the nature of the harm that occurred. The "How this incident could have been prevented?" section reflected only "Potentially restrain patient - have a care conference involving patients (sic) family members and all care providers" and reflected no other information. The "Action" section dated 01/12/2015 at 1354 reflected "No further action." The "Quality Comments/Conclusion", "Physician Name", and "Please indicate if any changes to this UOR are needed" areas on the report were not completed and were blank. The "Actions/Conclusions/Contact Log" area was time stamped 01/12/2015 at 1354 and reflected "No further Action." There was no documentation on the report reflecting that it had been investigated, actions taken, and follow-up with applicable staff taken in accordance with hospital policies and procedures.

An "ORQMD Record Summary" dated 12/03/2014 related to Patient 4's hospitalization was reviewed. The "Result Summary" sections of the summary reflected the following:
* On 12/04/2015 at 1201 "Call from intensivist who describes...[naso-gastric] feeding tube placement resulted in accessing lung and caused [perforation]. Chest tube placed and patient returned to ICU..."
* On 12/10/2014 at 1517 "12/8/14, 0730: Call from [RN Supervisor] yesterday to express dissatisfaction with care by [family members]...Met with [family members] in [Patient 4's] room...this morning. Quite a bit of hostility as conversation started...feeding tube placement this afternoon, into LUNG, pneumothorax noted post-placement...[Family members] have questions about first discharge, readmission, nursing competency on the [naso-gastric tube] placement, etc..."
* On 12/10/2014 at 1518 "...It will be difficult to satisfy [family member] with all [his/her] issues..."
* The summary contained no documentation reflecting an investigation of the feeding tube placement or any of the other complaints and grievances voiced by the patient's family members.

A security services incident report with an "approved" dated of 01/17/2015 and a "Date Reported" of 01/15/2015 at 1745 was reviewed. The "Summary" section reflected "A visitor became disruptive...[he/she] called the [police department] to file a report about [his/her] suspicions of patient abuse by staff." The "Case Info" section reflected "...[Patient 4's family member] was making claims that the staff members were physically and emotionally abusing [Patient 4]...Manager...said that [nurse] and [he/she] had gone into [room], where [Patient 4's family member] had shown them that the patient had red marks on [his/her] left upper arm. They told us that [Patient 4's family member] also accused nurse...of verbally abusing the patient...[Manager] said that [he/she] would follow up with quality management in the morning. There was no documentation reflecting the hospital conducted an investigation of the reported abuse and red marks on the patient's arm.

An interview was conducted on 11/04/2015 beginning at 1010 with the Quality Management Coordinator. In relation to the 12/03/2014 incident involving Patient 4's naso-gastric tube, the Quality Management Coordinator stated the hospital had no assessment of the RN's competency to insert the naso-gastric tube prior to the 12/03/2014 incident and has received no follow up training or a competency assessment since the hospital learned of the naso-gastric tube incident. He/she stated "It's part of RN scope of practice." The Quality Management Coordinator stated no UOR was completed related to the naso-gastric tube incident and no investigation was conducted until after the onset of this investigation on 04/01/2015.

During the interview, the Quality Management Coordinator also acknowledged that the hospital provided no written notice to Patient 4's family members in response to any of their voiced complaints as required by the hospital's grievance policy.

During interview on 11/04/2015 at 1215, the Quality Management Coordinator provided an untitled handwritten document dated 01/08/2015 related to Patient 4. The Quality Management Coordinator stated the document was an "investigation" conducted by a manager after the hospital received an allegation of verbal abuse pertaining to the patient. He/she indicated the document was the only "investigation" documented related to any of the allegations of abuse reported by the patient's family members. The document was not signed and contained no information reflecting who the author of the document was. The document reflected "...[Family member] very angry - c/o [nurse] calling [patient derogatory name]...I told [family member] I needed to investigate...I told [patient] that [nurse] was going off duty now (I pulled [nurse] from the assignment)... " The document had information related to interviews with 2 hospital individuals and an interview with the patient and contained no documentation indicating the outcome of the "investigation."

An interview was conducted on 11/05/2014 at 1545 with an RN Manager. The RN Manager acknowledged he/she was the manager of the unit where the incident occurred involving Patient 4's naso-gastric tube. The RN Manager stated he/she had no assessment of the RN's competency to insert a naso-gastric tube. The RN Manager stated "That's not one of our competencies because they learn that in nursing school." The RN Manager indicated that he/she did not check the RN's experience or competency related to the naso-gastric tube insertion before the RN was assigned to care for Patient 4. The RN Manager stated the RN "floated" to his/her unit and therefore he/she did not know if the RN routinely performed a naso-gastric tube insertion. The RN Manager stated if a nurse has never inserted a naso-gastric tube before then they would need to get someone to help them, and stated "Its up to the nurse to approach the charge nurse if they're uncomfortable with the procedure." In relation to whether the hospital provided training for the RN after learning of the incident involving Patient 4, the RN Manager stated "I wouldn't be able to answer that."

2. The ED record for Patient 8 was reviewed. The record reflected the patient presented to the ED by ambulance from a SNF on 09/18/2015 at 1425.

The triage notes documented by the ED RN at 1431 reflected "[Patient] lives at [SNF]. [Patient]...tripped and fell over [his/her] walker; [patient] fell on right side. Reports neck and back pain. c-collar on arrival by [EMS]...Reports 'pain all over.'

The ED RN notes documented at 1442 reflected "...reports 'pain all over my body...Site: Neck; Upper Back (care facility reports [patient] fell onto right side)...reports c-spine tenderness...Cognitive/Perceptual/Neuro...(per care facility pt at baseline)...Orientation: disoriented to; time..."

The "Emergency Department Encounter" notes electronically signed by the physician and dated 09/18/2015 at 1456 reflected "[Patient]...presents with back pain after a ground-level fall this afternoon. Patient was outside...at [his/her] facility with a walker when [he/she] tripped and fell. [He/she] was brought in by ambulance for evaluation of neck pain and back pain. The "Final Impression" section of the physician notes reflected "Fall...Cervical strain, acute..." The "Plan" section of the physician notes reflected the patient was discharged home but did not reflect where "home" was and contained no documentation reflecting that the patient was to be discharged back to his/her SNF.

The ED RN notes at 1602 reflected "...[patient] lying on right side on bed, states [he/she] feels horrible with pain from falling today..."

The "Departure Condition" notes documented by the ED RN at 1616 reflected "...Mobility at Departure: Wheelchair...Patient Teaching: Discharge Instructions reviewed; Patient verbalized understanding (sic) Patient Observations...Patient sleeping. Vitals - Pulse: 85; [blood pressure] 90/40...Number Scale - Pain Rating: Rest (numeric): 4."

The ED RN notes documented at 1618 reflected "...[Physician] aware of pt's [blood pressure] and is ok with [discharge]. Pt asymptomatic."

The untimed "After Visit Summary" with "Date of Discharge: 09/18/2015" was reviewed. The summary reflected "...In this packet you will find information about...Diagnosis, Discharge Instructions and Follow-up...Medication Instructions...Emergency Department Stay Summary...Your care plan at home." The "Discharge References/Attachments" section reflected "Fall, Mechanical (English)". However, no "Fall" references or attachments were included in the record. The "Follow-up Information" section was unclear and reflected only "Follow up with Unknown pcp No." The summary included information about how to get help with quitting smoking and how to access health information online but included no information related to transportation arrangements for the patient or where the patient was discharged to.

The "Patient discharged" section documented by the ED RN was the last entry by the ED RN and reflected only that the patient was discharged at 1621 and no other information, including where the patient was discharged to.

The record contained no documentation reflecting the RN conducted an assessment of the patient's discharge plan and on-going care needs including coordination and communication with the patient's SNF; there was no documentation reflecting the RN assessed the patient's ability to make his/her own transportation arrangements and no documentation that assistance with transportation was provided; and there was no documentation to reflect where the patient was discharged to.

A medical record for Patient 8 from another hospital was reviewed. The record reflected the patient was admitted to that hospital on 09/19/2015 at 1433, less than 24 hours after the patient was discharged from the ED on 09/18/2015 at 1621.

The record reflected that the patient had fallen and "...was taken to [PPMC] for assessment. [He/she] was sent home...via taxi, and asked to be dropped off downtown...and fell again..."

The record reflected "[patient]...was found at a park with blood on [his/her] face...admitted...for evaluation of [his/her] falls, lacerations and presumed cancer in the setting of [his/her] lack of capacity." The record reflected the patient was not discharged until 4 days later on 09/23/2015.

An interview was conducted with an individual from Patient 8's SNF on 11/10/2015 at 0900. He/she stated that Patient 8 who had a mental illness diagnosis and was on "blood thinners," had fallen at the SNF and hit his/her head on 09/18/2015. He/she stated the patient was transported by ambulance from the SNF to the hospital. The individual stated that staff at the SNF called the hospital on 09/19/2015 and were told by hospital staff that the patient was discharged from the ED by taxi to an unknown address on 09/18/2015. The individual indicated that on 09/19/2015 he/she got a call from another hospital in the area, and found out that the patient had fallen in the "community" and was "picked up by 9-1-1" and transported to that hospital.

During an interview on 11/02/2015 at 1220 the ED manager stated that he/she did not know about the incident involving Patient 8's discharge from the ED. During the interview, the ED Manager reviewed Patient 8's ED record and confirmed that the patient came to the ED from a SNF. The ED Manager stated that the process for discharging a SNF patient was that the RN should provide a hand off report to the SNF, provide discharge instructions to be sent with the patient to the SNF, and arrange transportation for the patient's return to the SNF. The ED Manager confirmed the record contained no documentation of the stated process. The ED Manager stated "The RN should've documented that and [he/she] did not."

An interview was conducted on 11/03/2015 at 1000 with an ED RN. The ED RN stated he/she was the RN who discharged Patient 8 from the ED on 09/18/2015. The ED RN stated the patient asked for a wheelchair and needed assistance getting dressed because he/she had a neck brace. The ED RN stated the patient said he/she was "going home" and he/she would make his/her own taxi arrangements to get there. The ED RN stated he/she "floated" to the ED and was not the patient's primary nurse and therefore he/she did not know the patient was a SNF patient. The ED RN stated he/she did not know where the patient's stated "home" was and acknowledged he/she did not assist the patient with making transportation arrangements. The ED RN stated that the last time he/she saw the patient, he/she was sitting in a wheelchair at a telephone in the lobby. The ED RN stated he/she found out later that the patient's SNF called the hospital the next morning and reported that the patient never returned to the SNF after being discharged from the ED on 09/18/2015.

Review of email documentation from the Quality Management Coordinator dated 11/19/2015 reflected that the hospital became aware of the incident involving Patient 8 on the day after the incident, on 09/19/2015. The email documentation reflected the hospital conducted no investigation after learning of the incident.

3. The medical record of Patient 2 reflected he/she was admitted to the hospital on 10/20/2014 and had a diagnosis of traumatic quadriplegia. Documentation on the physician Discharge Summary dated 12/12/2014 at 1211 reflected "...mental status is much improved although [he/she] remains intermittently upset in the evenings ...including delusion that [he/she] was raped over last 2 nights 12/10 and 12/11. QM spoke with pt who reported it happened 1 month ago. QM will continue to follow up on this..." The record reflected the patient was discharged to another hospital on 12/12/2014 at 1411.

There was no documentation in the medical record of an investigation conducted in relation to the patient's allegation of sexual abuse.

A "ORQMD Record Summary" dated 12/12/2014 related to Patient 2's hospitalization was reviewed with the Director of Medical Staff/Quality/Risk on 04/22/2015 at 1445. The "Result Summary" section dated 12/15/2015 at 1630 reflected "12/12/14...Call to [department] with allegation that came through Nursing Supervisor's office Wednesday evening to Nurse Manager on Friday. Patient alleges sexual misconduct by a staff member. Discussed with hospitalist...and psychiatrist...Patient has been in hospital for 2 months....[Physicians] agree with plan to address allegation and continue with plans for move to [another hospital]...Visited [Patient 2]accompanied by Nurse Manager...and RT...Patient described being approached by a 'male, long beard about a month (sic) when asking for a mouth-swab.' Describes 'being violated and raped...by the male, who [Patient 2] thinks is a nurse because 'he was wearing a blue T-shift (sic)' Describes [he/she] is okay now because 'the man got fired from the lady from the 3rd floor.' There was no documentation reflecting that the allegation of abuse was investigated or how the allegation was "addressed." An interview was conducted at the time of the review with the Director of Medical Staff/Quality/Risk. He/she stated the hospital had no further documentation related to Patient 2's allegation of sexual abuse. The Director of Medical Staff/Quality/Risk stated "This has been a learning for us."

During an interview on 04/16/2015 at 1600 the Senior Clinical Project Manager indicated that after Patient 2 reported the allegation of sexual abuse he/she spoke to the patient. The Senior Clinical Project Manager confirmed that the patient reported being violated and raped by an individual at the hospital that the patient thought was a nurse. The Senior Clinical Project Manager stated he/she did not consider the allegation to be a grievance and therefore no written response was provided to the patient or patient's representative as required by the hospital's grievance policy.

An interview was conducted on 04/22/2015 at 1430 with an RN Manager for Patient 2. RN Manager stated that Patient 2 reported an allegation of sexual abuse on 12/11/2014 in the evening. The RN Manager stated he/she spoke with the patient on 12/12/2014 and confirmed the allegation of sexual abuse. However, the RN Manager stated he/she conducted no investigation of the allegation and stated "I've searched everywhere."

An interview was conducted with an evening shift House Supervisor on 04/22/2015 at 1530. The supervisor stated he/she received a report from a charge nurse who reported that Patient 2 "made a sexual allegation about one of the nurses." The supervisor could not remember the date or time of the allegation. The supervisor stated he/she had no documentation of what was reported to him/her by the charge nurse and stated he/she conducted no interviews of staff on duty at the time he/she received the allegation. The supervisor stated he/she told the charge nurse to call his/her manager and risk management and that "they would deal with it in the morning."

During an interview with the Quality Management Coordinator on 04/23/2015 at 1620, he/she confirmed no UOR was completed in relation to Patient 2's allegation of sexual abuse as required by the hospital's policy.

4. Refer to the deficiency cited at Tag 145, CFR 482.13(c)(3) Patient's Rights - Free from Abuse/Harassment. That deficiency reflects the hospital's failure to investigate allegations of elder abuse for Patient 7.

5. Refer to the deficiency cited at Tag 806, CFR 482.43(b)(1)(3)(4) Discharge Planning Needs Assessment. That deficiency reflects the hospital's failure to ensure Patient 1 was discharged to a safe setting.

6. Policies and procedures reviewed:
* The policy and procedure titled "Flexible Feeding Tube: Insertion, Care & Removal" dated last revised "07/2011" reflected "Correct placement of flexible feeding tube needs to be verified by x-ray." The "Directions" section of the policy reflected "...Explain procedure to the patient (include that mouth breathing, panting and swallowing will help in passing the tube)...Tilt the patient's head back (in a sniffing position) and gently pass tube into the posterior nasopharynx directing downward and backward toward the ear. If obstruction appears to prevent tube from passing, do not use force. Rotating tube gently may help. If unsuccessful, remove tube and try other nostril...When tube reaches the pharynx, the patient may gag; allow patient to rest for a few moments...Have the patient tilt head forward (chin to chest). Offer several sips of water through a straw, unless contraindicated. Advance tube as patient swallows...If there are signs of distress such as gasping, coughing, or cyanosis, immediately remove the tube. These are indications that the tube has entered the trachea...Determine that the tube is placed in the stomach...Ask the patient to talk...Use the tongue blade and penlight to examine the patient's mouth...Aspirate contents of stomach with a large catheter tip syringe. If stomach contents cannot be aspirated, place the patient on the left side and advance the tube 2.5-5 cm (2 inches) and try again...Attach a catheter tip syringe to the end of the feeding tube. Place a stethoscope over the left upper quadrant of the abdomen and inject 10-20cc of air while auscultating the abdomen for the 'gurgle' of air insertion...Leave stylet in place until x-ray verification of correct placement...X-rays must be done to confirm tube placement...Document date, time, placement verification, patient tolerance, and condition of skin at nares & areas taped."

* A Lippincott Procedures document provided titled "Enteral feeding tube insertion, gastric and duodenal" dated last revised "10/03/2014" reflected "For enteral feeding tube insertion, record the date, time, tube type and size, insertion site, area of placement, and confirmation of proper placement. Document the patient's tolerance of the procedure, any patient teaching provided, and the patient's understanding of your teaching."

* The policy and procedure titled "Unusual Occurrence Reporting", dated last revised "02/2013" was reviewed. The policy reflected "...An unusual occurrence is any event, which is not consistent with routine operation of the hospital or routine care/service of a particular patient/visitor/staff member. An unusual occurrence can also be defined as an event, or a process which places patients and/or others in an unplanned risk situation for harm or possible harm...Each hospital has a Quality Council, which is a joint medical staff and hospital committee with responsibility for the review and coordination of quality assessment and improvement activities undertaken by the Medical Staff and hospital. This committee assesses the trended data, prioritizes identified opportunities for improvement, facilitates problem resolution...and monitors to determine the effectiveness of action taken...When an unusual occurrence is discovered, the individual involved in the event and/or the individual discovering the event will complete an Unusual Occurrence Report as soon as possible so that details will not be forgotten. It is expected that anytime an event of serious consequences occurs, the person who becomes aware of the event will notify their supervisor/manager immediately to provide assistance and take actions, if appropriate. The supervisor/manager should contact Quality Management as soon as possible. Action will be taken as appropriate to reduce any immediate danger to patients...the facts of the event should be documented in the medical record if it has an impact on patient care...The Unusual Occurrence Report (UOR) will be reviewed by the unit manager or department head (or designee) who is responsible to investigate the situation, take actions as indicated, follow-up with applicable staff, and document their findings on the UOR. This individual also reviews the UOR for completeness and accuracy, and submits the completed UOR within 14 days. The Quality Management Department has access to any electronically submitted UOR immediately after initial submission. The UOR is also automatically or manually submitted to identified departments through secondary routing...The information contained on the UORs is aggregated by the Quality Management Department and analyzed for trends, patterns, opportunities for improvement, prevention and proactive process redesign. Reports on trends, patterns, opportunities for improvement, prevention and proactive process redesign...Managers are responsible for reviewing the data applicable to the areas that they are responsible."

* The policy and procedure titled "Sentinel Events Management Plan" last revised 04/2015 reflected "...A sentinel event is a patient safety event not primarily related to the natural course of the patient's illness or underlying condition that reaches a patient and results in one of the following...Death...Permanent harm...Severe temporary harm (Defined as critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition.)...Reviewable events may include...Criminal event...Fall...Inappropriate discharge...Injury-related event...Medical equipment-related...Other care management...Other procedural......Surgical/invasive procedure event...Wrong procedure...An event is also considered sentinel if it is one of the following...Rape, assault...or homicide of any patient receiving care, treatment, and services while on site at the ministry...Invasive procedure, including surgery, on the wrong patient, wrong site, or wrong (unintended) procedure...Sentinel events will be thoroughly reviewed to gain understanding of the circumstances surrounding the occurrence and to decrease the likelihood of a same or similar incident occurring in the future...A root cause analysis and subsequent action plan will be conducted on any patient related sentinel event that meets the defin

29708

Based on interview, review of documentation in 3 of 3 medical records of patients about who the hospital received allegations of abuse (Patients 2, 4 and 7), and review of policies and procedures and other documents, it was determined that the hospital failed to ensure the patient's right to be free of abuse. The hospital failed to investigate allegations of abuse, including verbal, physical, and sexual abuse, in accordance with hospital policies and procedures.

Findings include:

1. Refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects the hospital's failure to investigate allegations of verbal, physical, or sexual abuse for Patients 2 and 4.

2. The medical record of Patient 7 reflected that the 96 year old patient was admitted on 07/25/2015 at 2037 and was discharged on 07/28/2015 at 1446.

An "ORQMD Record Summary" dated 07/30/2015 related to Patient 7's hospitalization was reviewed. The document reflected that a complaint about the patient's hospitalization had been received two days after the patient's discharge through the HHA. A "Comment" on the summary recorded on 07/30/2015 at 1449 reflected that "When HH called to arrange visit, AFH informed them that patient had been taken to another hospital ER as they were unable to care for patient. The patients [family member] was called, [he/she] was very dissatisfied with care, did not understand why patient had been discharged from PPMC and [he/she] stated that [he/she] has to report this as 'elder abuse' per [his/her] job requirements. The [family member] was provided with PPMC QM phone number although [he/she] stated [he/she] did not wish to speak to QM. Patient record reviewed. All RN and [RN Care Manager] documentation very thorough and match RNs story. Will await call from patient/family if they have concerns." The next and final entry on the summary was recorded on 07/30/2015 at 1449 and read "No further action needed at this time." There was no evidence of follow-up or further investigation related to the allegation of "elder abuse".

During interview with the Quality Management Coordinator on 09/30/2015 at 1130 he/she confirmed that the summary was the only documentation related to the concerns and allegations voiced by Patient 7's representative.

Based on interview, review of documentation in 4 of 8 medical records of patients who received hospital services (Patients 2, 4, 7 and 8), and review of policies and procedures and other documents it determined that the hospital failed to ensure an investigation was conducted of a serious adverse event; failed to investigate complaints and grievances; and failed to ensure corrective actions were planned, implemented and tracked in accordance with hospital policies and procedures.

Findings include:

1. Refer to the Condition-level deficiency cited at Tag 0115, CFR 482.13 Patient's Rights. That deficiency reflected the hospital failed to ensure an investigation of serious adverse events and complaints/grievances; and failed to ensure corrective actions were planned, implemented and tracked.

Based on interview, review of documentation in 4 of 8 medical records of patients who received nursing services (Patients 1, 4, 7 and 8 ), and review of policies and procedures and other documents it was determined that the RN failed to supervise and evaluate the nursing services for each patient to ensure the provision of safe and appropriate care in the areas of:
* Naso-gastric feeding tube insertion;
* Conformance with physician's orders;
* Monitoring of patient condition;
* Management of constipation; and
* Discharge needs.

Findings include:

1. The medical record of Patient 4 reflected the patient was admitted on 11/28/2014 with a diagnosis of dehydration and required tube feeding for nutritional support. The record reflected the patient was at high risk for weight loss and fluid maintenance deficits including but not limited to the following:
* A RD nutrition assessment dated 12/03/2014 at 1405 reflected "Presents with severe, protein-calorie malnutrition...consuming less than 50% of energy needs...significant weight loss...severe edema in bilateral arms, hands and legs."
* A RD nutrition summary dated 12/26/2014 at 1342 reflected "[Patient] continues to have very poor oral intake, taking bites of food here & there when offered by...Pain, agitation & delirium are all contributing to [patient's] inadequate intake. [Tube feeding] was discontinued on 12/16 now with 10 days of inadequate nutritional intake. Current weight reflects a 16 lb weight loss since admission...continues at moderate risk for aspiration..."
* A RN note dated 01/17/2015 at 2045 reflected "Attempted to assist [patient] w/ feeding...[Patient] refused any PO intake stating, "I don't want any food! Every time I think about eating I want to throw up...[Patient] continues to be confused by feeding tube and grabs at it..."
* A RD nutrition note dated 01/28/2015 at 1142 reflected "...Inadequate intake...with underlying dementia at high risk for aspiration, poor appetite, advanced age as evidenced by failed Calorie count x 3 since admission, significant weight loss, muscle wasting, need for [tube feeding] to support nutritional needs".
* A RD nutrition note dated 02/09/2015 at 1441 reflected "...[Patient] remains [tube feeding] dependent...continues to refuse PO intake or take a couple of bites at most on a modified texture diet. [Patient] with worsening diarrhea...Current weight drastically lower than weight recorded 2 days ago."
* A RN note dated 02/13/2015 at 1829 reflected "...Took a few bites of applesauce and sips of water this AM, otherwise has continued to refuse all PO intake..."

The record reflected a physician order for daily weights dated 12/08/2014. The record reflected the order was discontinued on 02/17/2015.
The record reflected the physician orders for the daily weights were not carried out on 20 of the 71 days the order was in effect. There were no weights recorded on the following dates:
12/14/2014, 12/16/2014, 12/20/2014, 12/23/2014, 12/24/2014, 12/25/2014, 12/30/2014, 01/05/2015, 01/09/2015, 01/10/2015, 01/15/2015, 01/17/2015 through 01/20/2015, 01/23/2015, 01/25/2015, 02/04/2015, 02/10/2015, and 02/13/2015. The record reflected the patient was discharged on 02/17/2015.

These findings were confirmed during a review of the medical record with the Quality Management Coordinator on 11/04/2015 at 1400.

Refer also to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects that the RN inserted a naso-gastric tube and Patient 4 sustained a lung injury.

2. The medical record of Patient 7 reflected that the 96 year old patient was admitted on 07/25/2015 at 2037 with constipation, confusion, hip and back pain, and was found to have a UTI for which he/she was treated with IV antibiotics.

The patient's Plan of Care and Problem List did not include constipation as a problem.

The only narrative notes in the medical record that related to constipation were the following:
* An ED RN note dated 07/25/2015 at 2037 reflected that the patient had arrived on 07/25/2015 at 2031 with constipation and confusion.
* An ED RN note dated 07/25/2015 at 2053 reflected that the "Caregiver called 911 stating that pt hasn't had a BM for 3 days and seems more weak and confused than normal...Unsure if anything has been administered at home for constipation."
* An RN note dated 07/28/2015 at 1147 reflected Pt refusing to take anything for [his/her] no bowel movement for 7 days. Facility will not take her back until pt has a bm. Will ask for a suppository and attempt to give."
* An RN note dated 07/28/2015 at 1316 reflected "Foster home refusing patient until after having a bm. Hasn't had a bm for 7 days. Given suppository, Colace, and senna, with prune juice and peaches. Had a large bm."
* The last RN note dated 07/28/2015 at 1548 reflected "Had another large bm on the commode."

The "Flowsheet Data...Intake/Output" record reflected that the only documentation related to the patient's bowel status was recorded on the day of discharge. The first entry was on 07/28/2015 at 1300 and was "Incontinent Stool 1 large bm after suppository." The second and last entry was on 07/28/2015 at 1500 and was "Stool Occurrence 1."

The MAR reflected the following physician's orders for laxatives and stool softeners:
* 07/26/2015 at 0121 - Dulcolax suppository 10 mg. PRN for constipation;
* 07/26/2015 at 0121 - Colace capsule 100 mg 2 times daily PRN constipation;
* 07/26/2015 at 0121 - Miralax powder 17 g daily PRN constipation;
* 07/26/2015 at 0121 - Senokot tablet 8.6 mg 2 times daily PRN constipation; and
* 07/28/2015 at 1143 - Dulcolax suppository 10 mg. PRN for constipation.

The MAR reflected that none of the physician's orders for constipation were carried out on 07/26/2015 or 07/27/2015. There was no documentation on the MAR or in the nurse's notes to reflect that attempts were made to administer those medications or that the patient was offered and refused those medications. The MAR reflected that a Dulcolax suppository was administered on 07/28/2015 at 1150; that a Colace capsule was administered on 07/28/2015 at 1218; and that a Senokot tablet was administered on 07/28/2015 at 1218.

The "After Visit Summary" provided to the patient upon discharge to the AFH on 07/28/2015 included a note that reflected the patient "refused all laxatives and other treatments while here and hasn't had a BM for many days."

Although the Intake/Output record reflected that the patient had a BM while in the hospital on 07/28/2015 at 1500 and the nurses notes reflected the patient had a BM on 07/28/2015 at 1548, the demographic information record reflected that Patient 7 was discharged prior to those BMs on 07/28/2015 at 1448.

Although one of Patient 7's presenting problems was identified as constipation on 07/25/2015 and physician's orders for constipation were provided, the documentation in the record reflected that the nursing staff failed to assess and monitor the patient's constipation and bowel status. The record further reflected that the nursing staff failed to implement nursing interventions and physician's orders for constipation until the day of discharge and only as a result of the AFH refusal to take the patient back. Additionally, nursing staff failed to provide accurate written information about the patient's constipation and bowel status on the discharge instructions to the AFH, and failed to accurately document either the times of the patient's BMs or the time of the patient's discharge.

3. Refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects the RN failed to provide appropriate discharge for Patient 8, a SNF patient who was discharged from the ED to an unknown address, was found in the community with multiple injuries, and was admitted to another hospital.

4. Refer to the deficiency cited at Tag 806, CFR 482.43(b)(1)(3)(4) Discharge Planning Needs Assessment. That deficiency reflects the RN failed to evaluate and supervise the discharge needs of Patient 1, who had physical and cognitive deficits, was discharged to a hotel, was unable to care for him/herself, and was re-admitted.













29708

Based on interview, review of documentation in 1 of 1 medical record of a patient who sustained a lung injury during a naso-gastric tube insertion(Patient 4), and review of policies and procedures, and other documentation, it was determined that the hospital failed to ensure the RN had the appropriate competency and experience to perform the procedure.

Findings included:

1. Refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects Patient 4's lung was perforated when the RN inserted a naso-gastric tube. The RN's competency and experience to perform the procedure had not been evaluated.

2. The policy and procedure titled "Competency Assessment and Verification" last revised 05/2013 was reviewed and reflected "The ministry is responsible to demonstrate clinical nursing staffs (sic) are competent to perform their job duties...Staff competence is initially assessed and documented as part of orientation...Staff competence is assessed and documented at least every 3 years or more frequently as required by ministry policy or in accordance with law and regulation...The ministry takes action when a staff member's competence does not meet expectations. Providence Health & Services, Oregon Region, clinical nursing employees will be assessed on their ability to satisfy the competency standards within the first 6 months after hire. The competency assessment plan is evaluated on an annual basis. The plan is based upon changes or initiatives affecting the department population/work requirements, work processes, high risk-low volume procedures, risk management issues and goals...The Manager is accountable to assure that the employee's competency has been validated and that the employee has successfully completed this process by the end of the competency/orientation period. Records of the documentation of the employee's competency will be maintained within the individual's department by the manager or designee...Department/Unit Competencies: Expected observable and measurable behaviors/skills which may be specific to a department/unit and which all clinical nursing employees within the department/unit must meet for employment upon hire or on an on-going basis...All clinical nursing staff within a given department/unit should be able to perform ongoing department/unit competencies...Reviewed annually and revised as needed...Department/unit competencies include both new hire and on-going competencies...The department/unit manager will be accountable for the evaluation of each employee's competency to meet the job requirements...Competency will be documented as part of the orientation process, at the 6-month/new hire performance appraisal, and the annual performance appraisal...Documentation of verified competencies will be maintained by the department manager or designee."

Based on interview and review of documentation in 7 of 8 medical records reviewed (Patients 1, 2, 3, 4, 5, 7 and 8) it was determined that the hospital failed to ensure the medical records were legible, complete, dated, timed, and authenticated, and clearly and accurately reflected the course of the patients' hospitalizations and the results of care, treatment, and services.

Findings include:

1. The medical record of Patient 7 reflected that the 96 year old patient was admitted on 07/25/2015 at 2037 and was discharged on 07/28/2015 at 1446. The medical record contained the following omissions and inaccuracies:
* The "Important Message from Medicare" document contained a space to record the "Time" of the patient or patient's representative signature. The "Time" space for the signature dated 07/26/2015 was blank.
* The "Important Message from Medicare" document included a handwritten entry that read "left by pt bedsite (sic) 7/28/15 1127". That entry was not authenticated by its author.
* The "After Visit Summary" dated 07/28/2015 inaccurately reflected that the patient "refused all laxatives and other treatment while here and hasn't had a BM for many days." Further, the "Care Plan Once You Return Home" section of the form lacked reference to, or information about, the HHA services ordered and arranged to be provided after discharge. During interview with the Quality Management Coordinator on 09/30/2015 at 1545 he/she confirmed that the "After Visit Summary" printed on 07/28/2015 been sent with the patient to the AFH.
* An "After Visit Summary" acknowledgement and signature page contained the statement "I have received a copy of my After Visit Summary and discharge instructions from Providence Portland Medical Center." In the space for "Patient/Responsible Signature" was a handwritten entry that read: "Telephone call to care giver [person's name]." In the space for "Date/Time" was written only the date 07/28/2015. There was no reference to what information was conveyed or discussed during the telephone call, who made the telephone call, and who the "care giver" was associated with. In addition, the entries were not authenticated by the author.
* Flowsheet and narrative notes throughout the record referred to "caregiver" and "[family member]" in primarily generic terms. Although there were multiple caregivers and family members involved the entries did not consistently specify who those individuals were by name or other clear and accurate identifier.
* Refer also to the findings for Patient 7 under Tag A395, CFR 482.23 (b)(3), Nursing Services, that reflects additional omissions and inaccuracies related to the lack of care and services to address the patient's bowel care needs.
* Refer also to the findings for Patient 7 under Tag A806, CFR 482.43(b), Discharge Planning, that reflects additional omissions in documentation, and inaccuracies related to the times of care and services in relation to the time of discharge on the patient's last hospital day.

2. The medical record of Patient 4 reflected that the patient was admitted on 11/28/2014 and was discharged on 02/17/2015. The medical record contained the following omissions and inaccuracies:
* An undated "Consent to Operation Administration of Anesthetics and the Provision of Other Medical Services" form for a peripherally inserted central line was reviewed. The "1st Witness Signature" and "2nd Witness Signature" lines were signed but were not dated or timed.
* An undated "Consent to Operation Administration of Anesthetics and the Provision of Other Medical Services" form for "Exploratory laparotomy, bowel resection" was reviewed. The "Signature of Patient," "Date" and "Time" lines were not completed and were blank. The form reflected "If Patient is a minor or unable to sign, complete the following: Patient is a minor under the age of 15 and is [blank line], years of age, or is unable to sign because [blank line]. There was no documentation reflecting why the patient was unable to sign the form. The "Signature of Person Authorized to Consent for Patient" line was signed but the "Date" and "Time" lines below the signature had illegible entries. The "1st Witness Signature" line had a signature but was not dated or timed.
* Also refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects incomplete documentation in relation to the patient's naso-gastric feeding tube insertion for Patient 4..

3. The medical record of Patient 2 reflected that the patient was admitted on 10/20/2014 and was discharged on 12/12/2014. The medical record contained the following omissions and inaccuracies:
* An undated "Consent to Operation Administration of Anesthetics and the Provision of Other Medical Services" form for "Bronchoscopy, possible biopsy, possible C-arm fluoroscopy" procedure was reviewed. The "Signature of Patient" and "Signature of Person Authorized to Consent for Patient" lines were blank. The bottom of the form reflected "For Telephone Consent two witnesses needed." The "1st Witness Signature" line was not signed had a handwritten note that reflected "Spoke [with his/her family member] on phone." The bottom of the form had another handwritten note that reflected "consent over phone" and an illegible entry. The notes were not dated or timed and included no information related to who the author of the handwritten notes were. The "2nd Witness Signature" line was also not signed and was blank.
* A "Consent to Operation Administration of Anesthetics and the Provision of Other Medical Services" form for a "Bronchoscopy" procedure was reviewed. The "Signature of Patient" and the signature "Date" lines were not completed and were blank. However, the "Time" line following the patient signature line reflected "10.31.14." The "Signature of Person Authorized to Consent for Patient" was signed by the patient's representative but was not dated or timed.

4. The medical record of Patient 3 reflected that the patient was admitted on 11/18/2014 at 1400 and was discharged on 11/26/2014 at 1730. The medical record contained the following omissions and inaccuracies:
* A "Consent for Service - English Version" form was signed by the patient and dated 11/18/2014 but was not timed.
* Also refer to the deficiency cited at Tag A117, CFR 482.13(a)(1), Patient Rights: Notice of Rights, that reflects inaccuracies related to the date of the IM from Medicare notice for Patient 3.

5. The medical record of Patient 5 reflected that the patient was admitted on 02/20/2015 and was discharged on 03/07/2015. The medical record contained the following omissions:
* A visitation agreement form dated 03/06/2015 was reviewed. The lines following "Patient/Guardian Signature (if applicable)," "Security Officer Signature," "Charge Nurse Signature" and Nursing/House Supervisor Signature" were signed. However, none of the signatures were dated or timed.

6. Refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects unclear information on the After Visit Summary, and omissions related to the patient's discharge destination for Patient 8.

7. Refer to the deficiency cited at Tag A806, CFR 482.43(b)(1)(3)(4), Discharge Planning Needs Assessment. That deficiency reflects omissions and inaccuracies in documentation on the After Visit Summary for Patient 1.







29708

29708

Based on interview, review of documentation in 3 of 8 medical records of patients who were discharged from the hospital (Patients 1, 7 and 8), and review of policies and procedures and other documentation, it was determined that the hospital failed to implement its discharge planning policies and procedures to ensure an accurate and complete evaluation of the patient's post discharge needs in the following areas:
* Discharge transportation arrangements;
* Evaluation of the environment to which the patient was discharged;
* Physical functioning and adaptive equipment needs;
* Treatment of skin conditions;
* Provisions for weight monitoring; and
* Meal preparation.

Findings included:

1. The policy and procedure titled "Discharge Planning Process" dated last revised "03/2015" was reviewed. The "Screening Procedure" section reflected "The assessment process begins on admission or shortly thereafter in partnership with the patient and their family or representative. An interdisciplinary approach is taken to ensure all of the patient's post-discharge care needs are identified. The registered nurse, in collaboration with the care manager and attending physician and/or other providers screen patients...to determine the type of post-hospital care required. These criteria include, but are not limited to...functional capacity and cognitive status to determine ability to self-care post discharge...social, psychological, and financial factors that contribute to the ability to care for self...ability of family, support persons, and/or friends to provide follow-up care in the home or the need for other professionals to provide the care; and appropriateness to return home or to a care facility if accepted from one." The "Evaluation of Care Needs" section reflected "A comprehensive discharge plan is made, documented, and modified within the EMR, and implemented to avoid unnecessary delays in discharge but within a time frame that supports the patient's recovery and preference to return home or to previous living arrangements. The evaluation includes the likelihood of a patient needing post-hospital services and the availability of those services within their home community...Updated plans are made and documented and made available to all professionals within the EMR...every effort is made to honor the patient and their preference for continued card. Inclusion of family or representatives...Providence provides patients and/or their representatives with a choice of comparable facilities/agencies to best meet the patient's specific needs and preferences within the area the patient resides...When possible, the initial transition plan is implemented before discharge to improve the transition to the next level of care...The details of the transition plan are reviewed with the patient through-out the hospital stay and formally upon discharge in the After Visit Summary..."

2. Refer to the deficiency cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Care in a Safe Setting. That deficiency reflects the hospital's failure to implement its discharge planning policies and procedures for Patient 8. The patient was discharged from the hospital by taxi to an unknown address, was found in the community with multiple injuries and was transported by ambulance to another hospital.

3. The medical record of Patient 1 was reviewed. The record reflected the patient was 94 years old and was admitted to the hospital on 10/06/2014 at 1137.

The ED notes electronically signed and dated by the physician on 10/06/2014 at 1315 reflected "...[patient] presents to the ED for evaluation of generalized weakness for one month. Presently described as severe. Patient lives by [himself/herself] and can't ambulate...On assessment I did appreciate a chronically debilitated elderly [male/female]...At this point the patient is presenting with acute on chronic weakness. [He/she] is 94 years old and lives at home. I do not feel [he/she] can be discharged safely. Patient will be admitted to the hospital for acute weakness."

The RD nutrition notes dated 10/07/2014 at 1310 reflected "...Over the past 4-5 weeks, pt reports gradual worsening of appetite and fatigue...[He/she] estimates [he/she] has been eating [less than] 50% of [his/her] normal intake. Was struggling to prepare meals as usual given weakness. [He/she] does received help from [his/her] friend...occasionally; also gets Meals on Wheels..."

The occupational therapy notes dated 10/08/2014 at 1220 reflected the patient had increased blurriness in both eyes and "...repeated self at times. Sat [edge of bed] w/ [stand by assistance], donned socks and pants w/ [stand by assistance] and [verbal cues] for safe 4WW use and [stand by assistance to] walk short household distance w/ 4WW to standard toilet with [grab bar]...Equipment Recommendations: (May benefit from shower chair)." There were no further occupational therapy notes.

The record reflected the patient received physical therapy while at the hospital. The last physical therapy notes were dated 10/09/2014 at 0954 and reflected the following:
* "[Patient] is supervision] for all mobility including gait...[with] 4WW...cueing needed for 4WW safety. Treatment limited to in-room..." The "Physical Therapy Discharge Recommendations" reflected "...home independent (if goals are met)..."
* For bed mobility the patient needed supervision, set-up and "Assistive Device: Supine/Sit: [head of bed] elevated." The short term goal for bed mobility was "Independent." The notes also reflected "Impairments Contributing To Impaired Bed Mobility: decreased strength".
* For toileting the patient needed supervision, set up, verbal cues and "Assistive Device: 4WW: standard toilet with [grab bar]." The short term goal for toileting was "modified independent." The notes also reflected "Impaired Transfers: decreased strength".
* For gait the patient needed supervision, set-up and a 4WW. The short term goal for gait was "modified independent;" the short term goal for "Gait Device" was "4 wheeled walker;" and the short term goal for "Gait Distance" was "400 feet." The notes also reflected "Impairments contributing To Gait Deviations: decreased strength".
* Another section of the same physical notes pertaining to physical therapy goals was unclear and as it reflected only "Patient Status/Goals: Reflects last filed data of patient status; may be from multiple contributors."
The record contained no further physical therapy notes

The RN care management note dated 10/10/2014 at 1131 reflected "Discharge Services/Equipment...RN, PT, MSW...Home Equipment Needed at Discharge: None."

The RN care management note dated 10/10/2014 at 1549 reflected "Discharge plan: Pt will d/c to Expended Stay Hotel 10/11...1 week stay (with potential for longer pending time line of [apartment] cleanup (sic)..."

The last care management note dated 10/11/2014 at 0833 reflected "Plan: To hotel (Extended Stay America)..." The "Discharge Services/Equipment" section reflected "Metro West wheelchair transport scheduled [at] 1300...Friend...will purchase groceries for [patient] and drop them off at hotel today..." There was no evaluation of how the patient would prepare the food that was to be dropped off at the hotel and no information about the equipment reflected in the physical therapy notes. There were no further care management notes.

The RN notes dated 10/11/2014 at 0900 reflected that staff provided supervision and stand by assistance and a walker for ambulation in the patient's room.

The RN notes dated 10/11/2014 at 0935 reflected "Memory Deficit...forgetful..." and "Forgetful/Memory Loss Yes..."

The RN notes dated 10/11/2014 at 0935 also reflected "...Wound...moisture damage; ulceration...right buttocks with red, healing wound, starting to scab."

The RN notes dated 10/11/2014 at 1137 reflected that staff provided assistance with dressing and undressing.

The "After Visit Summary" was signed by the patient in the space following "Date/Time:" and was not dated and timed when it was signed. The space following "Patient/Responsible Signature:" was not completed and was blank. The summary reflected "...Weigh yourself at about the same time each day, using same scale; record your weight in a logbook, and call your doctor for weight gain of 3 pounds or more over one day, or 5 pounds in one week." The only information on the summary related to skin conditions and treatment was generic information related to bedbug bites and a note reflecting "Skin...Red, dried scab on lateral right ankle. Scattered Red and raised rash on upper extremities. And torso that has been there for almost a month..." The summary did not include the address of the hotel where the patient was discharged and no information about the home health agency services referenced in the care management notes.

The record reflected the patient was discharged to a hotel on 10/11/2015 at 1500.

* There was no documentation in the record to reflect that the 10/09/2014 physical therapy goals related to the patient's physical functioning were reevaluated and had been met prior to discharging the patient to the hotel.
* The documentation was unclear related to the date the HHA arrangements would be carried out;
* There was no documentation to reflect further evaluation or arrangements made at the hotel for a toilet with grab bars, a specialized bed (with elevated head of bed), and shower chair identified in physical therapy and occupational therapy notes.
* There was no physical therapy or other documentation to reflect an evaluation of the patient's ability to function in the hotel where he/she was discharged with respect to the patient's weakness, need for supervision and assistance, vision deficit, memory loss, and equipment needs.
* There was no documentation to reflect a plan for food preparation or an evaluation of the patient's ability to prepare food in the hotel. There was no documentation reflecting follow up to the patient's use of Meals on Wheels as reflected in nutrition notes.
* There was no documentation reflecting a discharge plan for treating the patient's coccyx and buttocks skin conditions.
* The record contained no evaluation or other information related to the patient's ability to access and use a scale to obtain daily weights while at the hotel as reflected on the After Visit Summary.

The medical record was were reviewed with the Quality Management Coordinator on 11/02/2015 at 1545. The Quality Management Coordinator confirmed the RN notes reflected that when the patient was discharged, he/she needed assistance with gait, bathing, dressing and toileting. The Quality Management Coordinator also confirmed there was no evaluation of the hotel the patient was discharged to in order to determine if it was a safe environment for the patient.

An interview was conducted on 11/20/2015 at 0820 with the individual who the hospital made arrangements with to take groceries to Patient 1 at the hotel. The individual stated that when he/she went to the hotel the patient was "all alone, overwhelmed and there was nobody there to help him/her." The individual stated "[Patient 1] didn't have the things [he/she] needed like a place to heat up food." He/she stated "The hospital expected that [Patient 1] could prepare [his/her] own meals and care for [himself/herself] and [he/she] could not. "The individual stated the patient was "very weak and really hurting" and "just getting in and out of bed was a challenge." He/she stated the patient didn't know where he/she was or when he/she would be able to return home. The individual stated [Patient 1] had to go back to the hospital because he/she could not take care of himself/herself at the hotel.

4. The medical record of Patient 7 reflected that the 96 year old patient was admitted on 07/25/2015 at 2037 with constipation, confusion, hip and back pain, and was found to have a UTI for which he/she was treated with IV antibiotics.

The History and Physical recorded by the physician on 07/26/2015 at 1615 reflected that the patient had "...some dementia at baseline...over the last 3 days [he/she] has been having increasing confusion at [his/her] adult foster home...Review of systems: Unobtainable due to the patient's confusion...a poor historian...can often get around [his/her] adult foster home with a walker, but for any significant distance needs a wheelchair...I anticipate the patient will be hospitalized for greater than 2 midnights and then discharged either to [his/her]adult foster home or [his/her] skilled nursing facility depending on the goals of care."

The "Flowsheet Data...Adult Patient Profile" documentation consisted of the following nursing entries related to the patient's ADL and functional abilities:
* 07/26/2015 at 0100 - "Functional level [before hospitalization]." The entries for ambulation, transferring, toileting, bathing, and dressing each reflected that patient required "assistive equipment and person." The entry for "Change in functional status since onset of current illness/injury" was recorded as "yes." The fields for "Functional level current...ambulation...transferring...toileting...bathing...dressing...current functional level comment" were all blank.
* 07/27/2015 at 1500 - "...recommend against mechanical lift use. Stedy (sic) (pull to stand) lift may work better for pt during transfers...facility resident foster care...Pt uses walker at baseline. has assist for all ADLs."

Narrative nursing notes contained the following entries related to the patient's ADL and functional abilities:
* 07/26/2015 at 0647 - "Pt in pain during shifts in bed possibly related to hx of falls and chronic back pain...Not successful standing with walker [and two person] assist for commode due to pain and hesitancy, so used bedpan."
* 07/26/2015 at 0655 - "Painful with repositioning..."
* 07/27/2015 at 0453 - "Pt screams out in fear with [every two hour] turns and incontinent pad changes."
* 07/27/2015 at 1432 - "[complains of] pain and fear with being repositioned in bed."
* 07/28/2015 at 1147 - "...suddenly started flaring around with arms waving in the air, legs moving rapidly back and forth, with head tilted backward in panic, yelling...[he/she] said [he/she] was falling. Pt extremely scared and afraid of failing. 2 max with Steady (sic) to get [him/her] back to bed..."
* 07/28/2015 at 1316 - "Foster home refusing patient until after having a bm. Hasn't had a bm for 7 days."
* 07/28/2015 at 1548 - "...caregiver, worried about patient's left hip pain, and inability to move as well as [he/she] had in the recent past. Also worried about [his/her] fear of falling, ever since...last Friday...After getting ready to be discharged...Helped to wheelchair, taking a few steps, but still needing help with balance. Slow, but able to walk to wheelchair with 2 person assist."

Physical Therapy documentation reflected the first note was recorded on 07/26/2015 at 1452 and read "Per RN, pt has been having significant pain [with] attempts to mobilize to commode as well as history of falls per pt's [family member]...Will defer PT at this time and attempt again tomorrow." The next note recorded by PT was the "Physical Therapy Plan of Care Initial Evaluation, Treatment Note" dated 07/27/2015 at 1554. It reflected "Pt presents with impaired strength, balance, and endurance...shortness of breath during session...quite fearful of being moved by others...requires frequent verbal and tactile cues...slow...required cues to stay on task...PT will follow...5 [times per week] until discharge from therapy or discharged from the hospital." The evaluation reflected that for bed mobility the patient required "moderate assist (50% patients effort)...1 person assist, verbal cues"; For transfers the patient required "2 persons...2 wheeled walker"; For ambulation the patient required "verbal cues, 2 persons...2 wheeled walker." The following fields on the evaluation were blank: Stairs; Wheelchair mobility; Balance; Posture; Activity Tolerance; and Range of Motion. There was no further PT documentation during the hospital stay.

The "Flowsheet Data...Discharge Planning" documentation consisted of the following case management entries:
* 07/26/2015 at 0100 - "Anticipate changes related to illness - none."
* 07/27/2015 at 1500 - "Equipment currently used at home - walker, rolling."
* 07/28/2015 at 1007 - "Community agency name - Providence HH...[start of care 07/29/2015 physical therapy]."
* 07/28/2015 at 1010 - "Assessment type - Admission"; "Transportation available - van, wheelchair accessible Metro West...at 1130"; "Case management plan - Return to AFH"; "Patient/family in agreement with plan - yes"; "Plan comments - spoke with MD [discharge nurse] and reviewed chart; contacted caregiver at AFH to verify pt baseline function and available assistance, pt only oriented to self requires assist with all adl's, transfers etc; confirmed pt can return to AFH today; will fax D/C instructions to AFH; advised H/H PT order however appears pt only seen by a nurse practionar (sic) who [HH] is not able to take orders from so not able to follow pt; arranged private pay transport as used in past per CG; [left message] for [family member] advising of pt transfer today."
* 07/28/2015 at 1017 - "HH referral canceled."
* 0728/2015 at 1600 - "Liaison set up referral with Providence HH...[start of care 07/30/2015 physical therapy]."

The only other case management documentation in the record was dated 07/28/2015 at 1031 and was titled "Care Management Initial Assessment And Discharge Note". It primarily contained the documentation found on the flowsheet above. In addition, it reflected "Per [discharge nurse] when report called AFH requested pt not return until [he/she] has a bowel movement, transport rescheduled to allow [discharge nurse] to work on this with pt."

There was not a discharge note written by nursing or case management staff. The only documentation of the time the patient left the hospital was on the demographic information sheet and reflected the patient was discharged on 07/28/2015 at 1446, which is prior to the time of the last narrative note by nursing staff.

An "ORQMD Record Summary" dated 07/30/2015 related to Patient 7's hospitalization was reviewed. A "Comment" dated 07/30/2015 at 1449 reflected that "When HH called to arrange visit, AFH informed them that patient had been taken to another hospital ER as they were unable to care for patient. The patients [family member] was called, [he/she] was very dissatisfied with care, did not understand why patient had been discharged from PPMC...Patient record reviewed. All RN and [RN Care Manager] documentation very thorough and match RNs story. Will await call from patient/family if they have concerns."

The discharge planning evaluation and activities for Patient 7 were not timely, appropriate, or effective. The initial or "admission" discharge planning assessment was not conducted until the third day of the patient's hospital stay, the day of discharge. Problems the patient experienced which led to the hospitalization had not been resolved, such as pain and constipation. The record reflected the patient had experienced a change in his/her ADL and functional abilities from prior to hospitalization. However, there was not thorough and appropriate assessment by the case manager, nursing, or PT during the hospital stay to objectively evaluate whether Patient 7's abilities had improved or worsened in order to make a determination as to the most appropriate post-hospital setting. Further, there was no documentation to reflect that the patient's representatives or the AFH provider were involved in the discharge planning process until hours before the discharge. Although the physician documented the possibility the patient may need SNF placement, there was no evidence in the record to reflect that was considered.

Refer also to Tag 395, CFR 482.23 (b)(3), Nursing Services, that reflects the RN's failure to ensure the patient's bowel care needs were met until the last day of the hospital stay and only after the AFH caregiver refused to take the patient back until the patient's 7 day constipation was resolved.

The RN Care Manager who had been assigned to Patient 7 was interviewed on 09/30/2015 at 1220. The Care Manager confirmed that he/she did not conduct the discharge planning evaluation until the day of discharge after the physician ordered the discharge. He/she stated in regards to the timeliness of the evaluation: "Ideal would be within 24 hours of admission but that doesn't always happen." The Care Manager stated that his/her assessment of Patient 7 at the time of discharge was that there was no change in function or abilities. He/she stated that he/she spoke with a AFH caregiver on the phone but did not remember which caregiver. He/she stated that he/she left a phone message for a family member of the patient about the discharge but did not remember which family member and did not remember the content of the message that he/she left.

Based on interview, review of documentation in 1 of 2 medical records of patients for whom HHA services were indicated for discharge (Patient 7), and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures to ensure that the list of Medicare participating HHAs or SNFs in the geographic area where the patients' resided was provided to the patient or the patient's representative(s).

Findings include:

1. The policy and procedure titled "Discharge Planning Process" dated last revised "03/2015" was reviewed. The only reference to a list of HHAs and SNFs in the document was as follows: "Providence provides patients and/or their representatives with a choice of comparable facilities/agencies to best meet the patient's specific needs and preferences within the area the patient resides."

2. A document titled "Providence Health System - Portland Service Area...Providence Portland Medical Center...Medicare Certified Home Health Agencies", dated as revised 08/24/2011 was reviewed. It contained a list of HHAs and the following statement: "In keeping with Federal requirements, we are providing you with information about Medicare Certified home care providers in the community. Providing this information does not constitute an endorsement, nor is this a complete listing. For additional listing, see 'Home Health Services' in the yellow pages."

3. The medical record of Patient 7 reflected that the 96 year old patient was admitted on 07/25/2015 at 2037 and was discharged on 07/28/2015 at 1446.

The "Flowsheet Data...Discharge Planning" documentation reflected that the discharge evaluation was conducted on the day of discharge and included plans for HHA services:
* 07/28/2015 at 1007 - "Community agency name - Providence HH...[start of care 07/29/2015 physical therapy]."
* 0728/2015 at 1600 - "Liaison set up referral with Providence HH...[start of care 07/30/2015 physical therapy]."

There was no documentation in the record to reflect that the required list of HHAs had been provided to the patient or the patient's representative for consideration in their choice of a HHA provider.

The RN Care Manager who had been assigned to Patient 7 and the Quality Management Coordinator were interviewed on 09/30/2015 at 1220. During the interview the process for documentation that the list of HHAs and SNFs was provided and reviewed with the patient or the patient's representative was described to be on the "Freedom of Choice" field on the discharge planning flowsheet.

Patient 7's record reflected that the "Flowsheet Data...Discharge Planning" fields included one labeled "Case Management Interventions...Freedom of Choice." The spaces for that field during the patient's entire hospitalization were blank.

During interview with the Quality Management Coordinator on 09/30/2015 at approximately 1400 he/she confirmed there was no documentation to reflect that the list had been provided.