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Based on medical record review, document review and staff interview, it was determined the facility failed to follow policy and procedure for completing an initial admission history and verifying home medications in one (1) out of ten (10) patients, patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A record review was conducted for patient #1. The patient presented to the facility's Emergency Department (ED) location in Ohio on 08/24/23 at 9:25 p.m. via Emergency Medical Services (EMS). The patient's home medication reconciliation was noted to be "In progress." The patient was transferred to the main facility in West Virginia on 08/25/23 at 5:00 a.m. and admitted to the Open-Heart Intensive Care Unit (OHICU). An admission assessment was conducted on 08/25/23 at 6:00 a.m. The patient was noted to be "Awake, follows commands/oriented to Person, Place, and Time" by employee (emp) #4. No admission history was obtained at this time. The patient signed the "Patient Leaving Against Medical Advice" paperwork on 08/31/23 at 10:37 a.m. witnessed by emp #12. The patient left the unit at 10:45 a.m.

May it be noted, there is no nursing admission history assessment or confirmation of home medication reconciliation.

A review was conducted of policy, titled "Assessment of Patient," last revised 08/23. The policy states in pertinent part, "... Procedure: ... II. Initial Admission Assessment A. The initial assessment of the patient's relevant physical, psychological, spiritual, cultural, educational, and sociological needs will be completed within eight (8) hours unless otherwise specified ... G. the need for discharge planning is addressed during the initial assessment ... K. all disciplines involved in the care of the patient have access to the initial assessment data ..."

A review was conducted of policy, titled "Medication Reconciliation," last reviewed 08/23. The policy states in part, "... Procedure: ... IV. Admission to Inpatient Units/Direct Admits A. For direct admits, a medication list will be obtained upon entry to the medical center. B. This list will be documented in the electronic medical record. C. Medication lists received from the ED are to be reviewed with a patient, and or family, during the admission process. D. The nurse will attempt to make the list as complete as possible by utilizing the following options: patient/family provides a list or are requested to bring in the medications, Emergency Medical Services (EMS) provides a list, or the referring facility provides a list. Additionally, the primary care provider or patients' family may be contacted. E. The attending provider will be responsible, during the admission process, for reconciling the medication orders with the home list and the electronic medical record. If additional home medication(s) are identified after reconciliation has occurred, the medication(s) are to be added to the electronic system and a call made to the provider to determine if the medication(s) are to be ordered."

An interview was conducted with emp #2 on 09/08/23 at 8:07 a.m. Emp #2 confirmed the patient did not have an initial admission history assessment completed except for the physical assessment part.

An interview was conducted with emp #17 on 09/08/23 at 9:34 a.m. Regarding patient #1, emp #17 states, "I normally don't look at the admission assessments. I remember I spoke with the nurse taking care of the patient the first day [patient #1] came in after the night shift. That nurse said when [Registered Nurse (RN)] received report [RN] was told all admission things had been completed but [RN] didn't check. Our policy states that the admission history needs to be completed within eight (8) hours. If for some reason they can't complete it due to patient condition or they can't get a hold of anyone on the patient's behalf, they can complete the portion they can and then leave it in progress. If the patient was alert and oriented, we would do the assessment based on what the patient is reporting. We wouldn't get the information from anywhere unless we had indication the patient was not alert and oriented. The home medication list is started and most of the time completed in the emergency department. The home medication list is assisted by Pharmacy. We only collect a list of medications, even if the patient comes from a facility, not when the medication was last given."

Based on medical record review, document review and staff interview, it was determined the facility failed to follow policy and procedure for completing a discharge planning assessment (See A-0805). This failure has the potential to negatively impact all patients receiving care at the facility.

Based on medical record review, document review and staff interview, it was determined the facility failed to follow policy and procedure for completing a discharge planning assessment in one (1) out of ten (10) patients, patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A record review was conducted for patient #1. The patient presented to the facility's Emergency Department (ED) location in Ohio on 08/24/23 at 9:25 p.m. via Emergency Medical Services (EMS). On 08/28/23 a "Addiction Services Note" timed at 10:58 p.m. by emp #7 states in part, "... Impression and Plan. 1. Alcohol abuse- [Patient #1] denies withdrawal symptoms or cravings ... patient confused at times today, unable to discuss treatment options. Will follow along and discuss when able. PRSS [Peer recovery support specialist] [emp #8] reports patient is from a group home in Ironton and is unable to return. May need SW [Social Worker] assistance in discharge planning." A "Care Management Progress Note" by emp #13 on 08/31/23 timed at 4:07 p.m. states, "SW received a call from charge nurse this morning stating this patient is trying to leave AMA. Nursing was concerned about patient's decision-making ability, however, there is no incapacity form on the chart. Patient is able to answer orientation questions appropriately, but [Patient #1] was fixated on being independent and not needing anyone to take care of [patient #1]. [Patient #1] repeatedly stated that God would take care of [patient #1] and [patient #1] didn't need any follow-up appointments with doctors. SW asked patient where [patient #1] was going to discharge to, and [patient #1] states [patient #1] not sure where [patient #1] is going but wants to leave. [Patient #1] states [patient #1] will go sit on the bench outside and figure it out. SW spoke with [Assistant Living Facility (ALF)], patients listed contact, and the nurse this SW spoke with was not aware where the information came from that patient was not allowed to return before going to substance use treatment. Patient stated [Patient #1] did not want to return to the ALF because [patient #1] is independent and can take care of herself. SW then received another call from the ALF stating patient's [patient #1's sibling] was asking where [Patient #1] was. SW called [patient #1's sibling] [phone number] and explained we were unable to keep patient against [patient #1] will, as [patient #1] was deemed to be alert and oriented this admission. [Patient #1's sibling] reports [patient #1] has called the cops to go find patient, and [patient #1's sibling] does not believe the patient should be making [patient #1] indecisions. SW did provide patient with a resource list prior to d/c [discharge] with information about the shelters, food banks, transportation, and substance use rehabs in the area."

The patient signed the "Patient Leaving Against Medical Advice" paperwork on 08/31/23 at 10:37 a.m. witnessed by emp #12. The patient left the unit at 10:45 a.m.

May it be noted, there is no initial discharge planning assessment in the patient's medical record.

A review of policy, titled "Community Collaborative Discharge Planning," last reviewed 05/19. The policy states in pertinent part, "... Procedure: ... B. St Mary's Care Management sees all patients for discharge planning. Each person has a discharge planning assessment and a uniquely created discharge plan. Each patient/surrogate is involved in creating their discharge plan and is educated to the options and choices available to them. 1. Additionally, referrals to Care Management for specific discharge needs may be initiated by any clinical team member, community service representative, patient, or family member. 2. Clinical nursing staff document potential patient discharge planning needs on the interdisciplinary initial assessment. Consults to Care Management are made via the electronic medical record ... C. Daily interdisciplinary flash meetings are held to discuss patient's needs, discharge plans and any potential/actual barriers to discharge. Communication regarding discharge planning is not limited to flash meetings, but rather occurs on an ongoing basis throughout the day among staff, patients, their families, and Post Acute Care providers ..."

An interview was conducted with emp #13 on 09/07/23 at 10:43 a.m. Regarding patient #1, emp #13 states, "I talked to [patient #1] in person. [Patient #1] was trying to leave AMA. Me and the unit clerk tried to encourage [patient #1] to stay but [Patient #1] wouldn't go back into [patient #1]'s room. I gave [patient #1] a list of resources and [patient #1] left. I tried to call [ALF] three (3) times while I was getting the resource packet. I finally got a hold of them after [patient #1] left. We had to Google another number and get the number directly to the nurse's station. They asked how [Patient #1] was doing and I told them [Patient #1] had left. They said that [patient #1] had a MPOA (medical power of attorney) but no guardian and no lack of capacity documentation. [ALF] said if [Patient #1] left AMA they wouldn't want [patient #1] back. They said they were going to give [patient #1's sibling] the information. [Patient #1's sibling] called, I explained the situation to [patient #1 sibling] and that [patient #1] had capacity. I reiterated that the doctor didn't incapacitate [patient #1] while [patient #1] was here. The patient knew everything that was going on and had no deficits. I did feel [patient #1] had capacity, [patient #1] knew why [patient #1] was here and [patient #1] was very specific that [patient #1] was going to sit on the bench and wait for a bus. I'm not sure if [patient #1] had money with [patient #1]. There was no initial social worker evaluation done. I tried to talk to [patient #1] the day before but [Patient #1] was sleeping. I was going to come back and see [patient #1] the day [Patient #1] left, we did not have any copy of a medical power of attorney in the documentation."

An interview was conducted with emp #14 on 09/08/23 at 9:00 a.m. Regarding patient #1, emp #14 explained that emp #14 sees patients based on orders and there were no orders for this patient.

An interview was conducted with emp #2 on 09/08/23 at 8:07 a.m. Emp #2 confirmed the patient did not have an initial admission history assessment completed except for the physical assessment part. This initial assessment would have included the initial discharge needs assessment.