HospitalInspections.org

Based on record review and staff interview, the hospital's staff failed to ensure that 1 (Patient # 2) of 1 patient was safely discharged from the hospital when Patient # 2 was discharged without access to necessary post-hospital services and care at discharge. The hospital staff failed to follow the "Care Management and Discharge Planning Policy".

(Cross Refer to Tag A0807)

Based on record review and staff interview, the hospital failed to ensure prompt resolution of complaints and grievances for 3 (Patient #'s 3, 5, and 6) of 9 sampled patients. The hospital failed to ensure:

A. grievances of patient mistreatment and care complaints were thoroughly investigated on 3 (Patient #'s 3, 5, and 6) of 9 patients.

B. a grievance involving patient care was properly identified as a complaint/grievance, logged in the complaint/grievance log and thoroughly investigated and resolved on Patient #6.

Findings include:

Patient # 3

Review of the Emergency department (ED) record on Patient #3 revealed she was a 61-year-old- female who was transferred from another hospital on 07/15/2024. Patient #3 had diagnoses which included respiratory failure and acute kidney injury.

Review of the hospital's grievance dated 12/19/2024 revealed Patient #3 said she was in the intensive care unit in July and was" abused by not one but two of the nursing staff." She stated that one male nurse had a really bad bedside manner the whole time but came in and startled her instead of calmly waking her up. Patient #3 reported that she coughed and instinctively went to put her hand over her mouth, and the nurse attacked her, grabbed her arms, and held her down until she stopped coughing and then looked at her "like he didn't know if he killed her or not" ...

Review of the investigation revealed no documentation about the allegations being investigated.

During an interview on 06/23/2025 after 12:32 p.m., Staff # 23 confirmed there was no documentation of the allegation being investigated.


Patient #5

Review of the Emergency department (ED) record on Patient # 5 revealed she was an 85-year-old- female who presented to the hospital on 01/28/2024 at 3:34 a.m. with right shoulder pain.

Review of a grievance dated 10/02/2024 revealed Patient # 5 reported that on discharge she was going to use a Lyft to transport home., as she did not have her car there, but states that someone in the lobby told her Lyft may not take her home since she was unstable on her feet. She states at this time she walked back into the hospital to "check herself into the hospital" and a hospital doctor pulled her aside into a "cubby" and began shouting at her stating nothing was wrong with her and she did not need to be in the hospital. She reported that at that time the doctor "slapped her back, pushed her down, kicked her and broke her hip."

During an interview on 06/23/2025 after 12:32 p.m., Staff #23 confirmed there was no documentation of the allegations being investigated.

During an interview on 06/24/2025 after 9:40 a.m., Physician # 28 revealed he had just found out today that Patient # 5 made the allegation against him. Physician # 28 said that he had not been talked to about the allegation prior to today.


Patient # 6

Review of Patient # 6's Emergency Department (ED) record revealed he was a 51-year-old- male who presented on 04/21/2025 at 3:45 p.m. with complaints of chest pain.

Review of the hospital's April complaint log revealed no complaints involving Patient # 6.

Review of a hospital call log revealed that Patient #'s 6 family complained on 04/22/2025 that staff did not give him a urinal for three hours and then put it out of reach. The family complained that staff were not being responsive, failing to give pain medication and they had poor attitudes.

During an interview on 06/24/2025 after 10:58 a.m., Staff #23 said she received a call from Patient # 6's sister on 04/22/2025. Staff # 23 said one of the concerns was that staff were going to assign Patient # 6 to a medical surgical floor instead of the heart hospital. Patient # 6's sister said that staff were not responding to him, staff had poor attitudes and were placing the urinal out of reach. Staff # 23 said she did not consider it a complaint and just verbally informed the assistant chief nursing officer of the unit about it, and she responded that she would take care of it. Staff # 23 said she had not gotten any communication about what happened, and she did never considered it to be a complaint. Staff # 23 said she was reading from her call log about the call, but it was not logged on the complaint and grievance log.

Review of a facility's policy named "Title: Management of Patient Grievance" dated 08/24 revealed the following:

"...IV.DEFINITIONS.
...COMPLAINT: An expression of dissatisfaction from patient or patient's representative regarding the patient's care or the services provided and is resolved at the point of service. This does NOT include allegations of abuse, neglect, or harm.
GRIEVANCE: A "patient grievance "is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present." ...
...V.PROCESS...
...2. Processing a Grievance
a. All formal and informal grievances will be investigated to determine if opportunities exist to improve processes and systems related to the issues reported..."

Based on observation, record review, and staff interview, the hospital's dialysis staff failed to ensure:

A. One (Patient # 7) of 4 patients' hemodialysis access was visible to dialysis staff at all times throughout hemodialysis treatment, in accordance with the hospital policy, "Arteriovenous Fistula or Graft Cannulation".

B.One (Patient # 7) of 4 patients' hemodialysis prescriptions was administered in accordance with the physician's order as required by the hospital policy, "Acute Hemodialysis Prescription".

C. Four (Machine # 47, 49, 77, and 78) of 4 Hemodialysis machines were cleaned and disinfected in accordance with the hospital policy, "Infection Control and Precautions for All Dialysis Patients".

D. The PM (preventative maintenance) sticker on hemodialysis machine #78 was current.

Findings include:

A.

During a tour of the hospital's hemodialysis unit on 06/23/2025 at 3:00 PM with Staff # 18, the surveyor observed Patient # 7 receiving hemodialysis treatment in room # 124. The patient's door was closed, and the curtain was pulled closed. The patient was not visible to the staff members. Upon looking into the patient's room further, it was discovered that the patient's hemodialysis access was covered and not visible to the hemodialysis staff.
Failure to ensure the patient's hemodialysis access was visible throughout treatment had the likelihood to result in the patient's needle becoming dislodged. A dislodged needle could result in the patient bleeding out without the hospital staff recognizing it.

A review of the hospital policy, "Arteriovenous Fistula or Graft Cannulation" with a date of 02/2022 revealed,

"OBJECTIVE: To ensure safe cannulation of the fistula or graft. POLICY STATEMENT: This guideline will provide guidance to ensure adherence to state and federal regulations as well as provide consistent, safe, high-quality hemodialysis to all patients who require therapy. This guideline reflects evidence-based practices derived from contemporary literature review as well as regulatory requirements. Individual patient assessment and other clinical situations may influence specific course of action ...
PROCEDURE: ...R. Document access site is visible and secure with treatment initiation and every 15 minutes throughout the duration of treatment ..."

An interview was conducted with Staff # 18 on 06/23/2025 at 3:15 PM, which confirmed Patient # 7 was not visible to dialysis staff. Staff # 18 stated, "I will make sure the nurse uncovers the patient's access".

B.

A review of Patient # 7's medical record was conducted with Staff # 18 on 06/23/2025 at 3:45 PM in the hemodialysis unit. A review of the patient's hemodialysis order revealed,
"2K/2.25Ca".

A review of the patient's dialysate prescription during treatment revealed the patient was receiving "2K/2.5Ca" during treatment on 06/23/2025.

The patient was receiving the incorrect prescription. Staff # 19 (Dialysis Registered Nurse) did not verify the prescription prior to the initiation of hemodialysis treatment to ensure the patient was receiving the correct dialysate composition according to the physician's orders.

A review of the hospital's policy, "Acute Hemodialysis Prescription" with a date of 02/2022 revealed,
"OBJECTIVE: This guideline will address the components of acute HD prescription that are necessary for an effective and safe treatment regimen that can be individualized for the heterogeneous population requiring acute HD. Therefore, this guideline will focus on important areas including choice of dialyzer, dialysate composition, blood and dialysate flow rates, length of treatment, amount and rate of ultrafiltration, choice of anticoagulation, and total dialysis dose ...GUIDELINE STATEMENT: Hemodialysis prescription is crucial for patients commencing HD, either as planned and unplanned new starters with end-stage renal disease (ESRD), or as patients suffering from acute kidney injury (AKI) requiring renal replacement therapy (RRT). Individualized HD prescriptions are required because of the varied indications for starting patients on HD and patient-specific variables that may affect delivery of HD in this heterogeneous population ...Accountability and reporting structures: All healthcare professionals involved in the prescribing and altering of HD prescriptions, as well as those assessing and monitoring the efficacy of the HD regimen, are expected to act in accordance with their professional standards and codes of conduct in relation to promoting patient safety. Although the HD prescription is written by the medical team, the regular assessment of its efficacy is made by the nurse. The nurse commencing the HD session is required to ensure that the appropriate HD components, such as dialyzer size, dialysate composition, blood and dialysate flow rate, and UFR, are used. The aim of nursing care pre-, intra-, and post-HD treatment is to monitor the treatment and prevent the occurrence of complications through comprehensive assessments and planning. Named nurses and team leaders are required to communicate with the unit consultants regarding HD prescription issues ..."

An interview was conducted with Staff # 19 on 06/23/2025 at 3:50 PM which confirmed Patient # 7 was receiving the incorrect dialysate composition. Staff # 19 stated, "I didn't reach out to the doctor to verify that he wanted 2K/2.5Ca instead of 2.25Ca. We don't even carry 2.25Ca here".


C.

During a tour of the hospital's hemodialysis unit on 06/23/2025 at 3:10 PM with Staff # 18, the surveyor observed 4 (Machine # 47, 49, 77, and 78) hemodialysis machines in the clean storage room. When the surveyor checked the back of the dialysis machines, there was a thick build-up of dust, dirt, and other unknown debris on the back of the machines.
A review of the hospital policy, "Infection Control and Prevention for All Dialysis Patients" with a date of 12/2020 revealed,

"OBJECTIVES: To educate staff on general guidelines in the prevention of infection while providing dialysis services in CHRISTUS health facilities. To reduce the transmission of pathogenic microorganisms and the incidence of healthcare-associated infections caused by these organisms ...POLICY STATEMENT: Christus Health endorses the current Centers for Disease Control and Prevention (CDC) guidelines to provide a 'sanitary environment' that meets the standard precautions for an inpatient hospital setting. 'Standard Precautions' apply to the care of all patients in any healthcare setting and include the use of gloves, gown, or mask whenever needed to prevent contact of the healthcare worker with blood, secretions, excretions, or contaminated items ...Process or Procedures: ...E. Clean areas should be clearly designated for the preparation, handling, and storage or medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled ....G. Clean and disinfect the dialysis station (chairs, beds, tables, keyboards, machines) between patients. H. Give special attention to cleaning control panels on the dialysis machine and other surfaces that are frequently touched and potentially contaminated with patients' blood ..."

An interview was conducted with Staff # 18 on 06/23/2025 at 3:10 PM, which confirmed the machines were considered "clean". Staff # 18 stated, "The staff are supposed to clean the entire machine after treatment."

D.

During a tour of the hospital's hemodialysis unit on 06/23/2025 at 3:10 PM with Staff # 18, the surveyor observed hemodialysis machine # 78 with a PM sticker dated "due 02/25". The preventive maintenance sticker was not changed when preventive maintenance was completed on the machine.

An interview was conducted with Staff # 18 on 06/23/2025 at 3:00 PM, which confirmed the PM sticker needed to be changed to indicate the correct and current PM date.

Based on record review and staff interview, the hospital nursing staff failed to develop and keep current care plans that met the patients' needs for pain assessment and reassessment in 2 (Patient # 2 and # 6) of 9 patients. The hospital staff failed to follow the policy, "Patient Assessment and Reassessment".

Findings include:

Patient # 2

A review of Patient # 2's medical record was conducted on 06/23/2025 at 11:00 AM with Staff # 3 and # 14 and revealed the patient was seen in the hospital's emergency room on 05/07/2025 and 05/22/2025.

05/07/2025 visit

Patient # 2 arrived at the hospital's emergency room with complaints of "seizure activity". The patient remained in the hospital's emergency room until 05/12/2025.

On 05/08/2025 at 7:41 PM, Staff # 39 documented that the patient complained of a pain score rated "8/10". The patient was given ibuprofen 800mg (milligrams) by mouth at 7:41 PM.

There was no reassessment of the patient's pain score after the nursing intervention was performed.

05/22/2025 visit

Patient # 2 arrived at the hospital's emergency room on 05/22/2025 at 7:06 PM with complaints of "chest pain".

A review of the triage nursing assessment completed on 05/22/2025 at 7:15 PM by Staff # 38 revealed the patient had a pain score rated "6/10".

The first nursing intervention was documented at 9:37 PM when the patient received 650 mg (milligrams) of Tylenol by mouth.

There was no reassessment of the patient's pain score until 1:31 AM on 05/23/2025, when the patient rated his pain as "4/10".

An interview was conducted with Staff # 15 on 06/23/2025 at 2:00 PM in the administrative board room. Staff # 15 confirmed that the nursing staff were not reassessing the patient's pain after a nursing intervention was performed.



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Patient # 6

Review of the Emergency Department (ED) record revealed Patient # 6 was a 51-year-old male who presented with complaints of chest pain on 04/21/2025 at 3:45 p.m.

At 4:19 p.m. (over 30 minutes after presenting), there was documentation that the triage was started. Patient # 6 had complaints of chest pain for two days and complained of dehydration.

At 4:21 p.m., Patient #6's vital signs were 82/50 blood pressure, 90 pulse, 16 respirations, 98.6 degrees Fahrenheit, and an oxygen saturation of 97 percent. There was no documentation of an assessment of what his pain level was from the chest pain.

At 4:25 p.m., Patient # 6 was given an emergency severity index level of 2 (meaning emergent).

At 4:30 p.m., 45 minutes after presenting, there was documentation that there were no complaints of pain.

At 5:38 p.m., the lab results for the Pro BNP was 3710 with reference ranges being 0-300. This is a marker for determining heart failure.

At 10:27 p.m., Patient # 6 complained of lower back pain and had a pain level of 7/10. Staff administered the pain medication Tramadol 50 mg (milligrams) by mouth. The physician's order called for Tramadol 50 milligrams every 6 hours prn (as needed) for mild pain rated 1-3/10.

At 11:21 p.m., Patient # 6 had a pain level of 8 and was given the pain medication Morphine 1 milligram intravenously. There was no documentation of the location of the pain.

At 11:27 p.m., Patient # 6 was documented as having a pain level of 4/10 without any documented pain location.

The next documented pain level on Patient #6 was almost 5 hours later at 4:22 a.m. on 04/22/2025. The pain level at this time was a 4/10, and there was no location documented. There was no continual documentation of a pain assessment after 4:22 a.m. On 04/22/2025 at 1:08 p.m. Patient # 6 was transferred from the emergency department to an inpatient unit.

Review of the hospital's policy titled, "Patient Assessment and Reassessment" dated 04/24 revealed the following:

" ...IV. PROCESS OR PROCEDURES:
B. Pain
1. Responsibilities
a. Health care providers will: ...
ii. Review and modify the plan of care for patients who have unrelieved pain ....
...d. Pain, as reported by the patient, will be assessed, documented, and addressed on admission, after each know pain-producing event, at each new report or pain or inadequate control of pain ...
...2. Guidelines for Care
a. Assessment:
i. Methods used to assess a patient's pain is consistent with the patient's age, condition, and ability to understand using an appropriate pain scale for the patient population including, but not limited to:
i.The Numeric Pain Rating Scale of 0-10 is used for adult patients able to verbalize pain intensity ...
...ii. Assessment includes a description of pain, intensity of pain, location, and frequency ...
b.Reassessment :
i. If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 60 minutes following treatment ...
3.Care Settings ...
b.Emergency Care Center (ECC)
i. Patients will be assessed in triage or initial assessment process to identify the presence of pain ...
iii. ECC patients shall receive treatment for acute pain relate to their chief complaint or presenting condition when intensity exceeds their acceptable level. ...
iv. If a treatment intervention for pain is provided, then the response to that intervention should be assessed within 60 minutes or at the time of discharge or transfer, whichever occurs first ..."

During an interview on 06/24/2025 after 9:50 a.m., Staff # 25 confirmed the lack of documentation of pain assessments and the administration of the pain medication on Patient # 6.

Based on record review and staff interview, the hospital's staff failed to ensure that 1 (Patient # 2) of 1 patient was safely discharged from the hospital when Patient # 2 was discharged without access to necessary post-hospital services and care at discharge. The hospital staff failed to follow the "Care Management and Discharge Planning Policy".

The hospital staff failed to ensure an effective transition of Patient # 2 from the hospital to post-discharge care and therefore failed to reduce the factors leading to a preventable hospital readmission.

Findings include:

A review of Patient # 2's medical record was conducted on 06/23/2025 at 11:00 AM with Staff # 3 and # 14.

Patient # 2

Patient # 2 arrived at the hospital's emergency room on 05/07/2025 at 8:42 PM via EMS from the Salvation Army with a chief complaint of "witnessed seizure".

The patient was a 49-year-old male with a past medical history of seizures, failure to thrive, polio, alcohol use, and homelessness.

The patient was in the hospital's emergency room from 05/07/2025 to 05/12/2025 pending placement to a skilled nursing facility or homeless shelter.

On 05/12/2025, the patient was admitted to the hospital as an inpatient due to the patient needing inpatient rehabilitation services. The patient was admitted to the hospital from 05/12/2025 to 05/22/2025.

A review of Physician # 33's History and Physical Note completed on 05/12/2025 revealed,

" ... A 49-year-old male who is homeless was at the Salvation Army shelter on Friday and had a seizure, so he was brought into the ED. He was supposed to have been taking Keppra twice a day, but he says he had not taken it for several months. He says his Medicaid would cover the medication, but he has no transport to get the medication from the pharmacy. He says he has not had alcohol in 3 months, typically had been admitted previously for alcohol abuse and withdrawal. He uses a four-wheel walker and a wheelchair and has difficulty walking due to debilitation and arthritis. Case management attempted to place him over the weekend but was unable for various reasons. We are being asked to admit him to work on therapy stabilization and placement ..."

On 05/12/2025, the patient was admitted to the hospital as an inpatient by Physician # 33 due to inability to walk, failure to thrive, gait instability, and seizures.

Physician # 33 placed an order for physical therapy and occupational therapy to evaluate and treat the patient as indicated.

The patient had physical therapy and occupational therapy evaluations and treatments while admitted to the hospital.

A review of Staff # 34's (Occupational Therapist) treatment evaluation on 05/21/2025 at 8:21 AM revealed,

"Patient is found in supine, agreeable to therapy today. Patient is making progress toward goals but remains functionally quite limited and requires greater assistance to complete simple ADLs than baseline due to increased generalized weakness, chronic contractures of the left upper extremity, limited use of both hands (loss of function in left hand is greater than right hand), unable to tolerate weight bearing through left lower extremity due to left heel ulcer, impaired balance, decreased endurance/activity tolerance. Today, patient was able to incorporate right upper extremity into wheelchair mobility, but still needs moderate assistance with wheelchair propulsion. Patient is homeless and is not safe to return home/to the streets. Highly recommend discharge to inpatient rehab post-acute when medically cleared. Continue skilled occupational therapy ..."

A review of the case management and social worker progress notes revealed the hospital staff had difficulty placing the patient in an inpatient rehab, skilled nursing facility, and homeless shelter due to a lack of funding, proper documentation, and a safe discharge plan. The patient had no familial or social support.

A review of Staff # 35's (Licensed Medical Social Worker) Clinical Note on 05/15/2025 revealed the patient did not pass the SLUMS exam. According to the patient's medical record, the patient's SLUM score was "18".

A SLUMS exam (Saint Louis University Mental Status Examination) is a screening test for Alzheimer's disease and other forms of dementia. SLUM scores are interpreted as follows:
27 to 30: Normal in a person with a high school education
21 to 26: Suggests a mild neurocognitive disorder
0 to 20: Indicates dementia

There was no documented psychiatric or neurological consultation made for the patient following the low SLUMS examination.

A review of the clinical note documented by Staff # 36 (Medical Social Worker) on 05/21/2025 at 3:15 PM revealed,

"Discussed with team lead, she advised having the bill presented to encourage the patient to leave. All discharge options have been exhausted. Patient unable to go to homeless shelter due to not having any form of ID. He also reportedly had a debit card to access his disability money but has lost it. He has no access to his income, which further complicates us finding any placement. Patient discharge plan to the street, homeless. Will have bill presented and encouraged to leave."

Physician # 12 placed an order for the patient's discharge on 05/22/2025 at 12:35 PM with the discharge disposition of "Rehab Facility".

A review of Physician # 12's Discharge Summary on 05/22/2025 at 12:36 PM revealed,

"This is a 49-year-old male with no significant past medical history other than seizures presented to the hospital with breakthrough seizures. Following admission to the hospital patient was placed on Keppra. Patient is homeless. PT OT evaluated the patient and recommended rehab but patient is unfunded and today patient is being discharged from the hospital in hemodynamically stable condition with oral Keppra ...Physical Exam: Constitutional: Appearance: Appears ill ...Disposition: Home. Patient screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. No needs were identified ..."

The patient was discharged to the community in a wheelchair on 05/22/2025 at 5:19 PM by Staff # 37 (Registered Nurse) without a safe discharge plan. The patient had significant cognitive impairment, was unable to walk, perform ADLs (activities of daily living) independently, and perform wound care for the wound on the left lower extremity. The patient did not have psychosocial support to assist with obtaining the prescriptions necessary to prevent seizures (Keppra), and did not have access to transportation, food, or housing.

The patient sat outside of the hospital for approximately 2 hours until he began to have chest pain. The patient was seen in the hospital's emergency room on 05/22/2025 at 7:06 PM for chest pain shortly after being discharged as an inpatient. The patient was transferred from the emergency room on 05/23/2025 at 1:54 PM to an inpatient rehabilitation facility.

A review of the hospital's policy, "Care Management and Discharge Planning Policy" with a revision date of 04/10/2025 revealed,

" ...Objectives: The purpose of the discharge planning process is to provide the patients with a safe, coordinated, comprehensive discharge plan that ensures transition from the hospital to an alternate care setting or home based on the patient's needs.Policy Statement: A hospital, as part of its effective Discharge Planning Process, must focus on the patient's goals and treatment preferences and include the patient (and/or the patient's representatives and caregivers) as active partners in the discharge planning for post-discharge care. The discharge plan must ensure an effective transition of the patient from the hospital to post-discharge care, and reduce factors leading to preventable hospital readmissions ...Process: A. Initial identification of patients with discharge needs may be identified, including but not limited to, the following ways: 1. Admission screening (nursing) 2. Interdisciplinary team meetings/rounds 3. Referrals from physicians, nursing staff or any member of the health care team. 4. Communication with patient, caregivers, or family members 5. Identified high-risk cases.
B. For patients identified as in need of a discharge planning evaluation CM will assess whether or not the patient's care needs can be met in the environment from which he/she entered the hospital. With consideration of impacts of SDOH, this should include: 1. Assessment of the patient's ability to perform activities of daily living and/or access to supports and services in the prior environment, 2. Assessment of access to, and the anticipated need for, specialized medical equipment, 3. Assessment of post-acute needs and available providers/services including but not limited to medical equipment, home health care, extended care services, hospice services, or other placement that may be required upon discharge, and 4. Documentation in the electronic medical record of these assessments.
C. This discharge planning evaluation must be developed by, or under the supervision of, a registered nurse or social worker. D. The discharge planning evaluation will be completed at an early stage of hospitalization to ensure that appropriate arrangements for post-hospital care can be made before discharge. E. The discharge planning evaluation, and all steps taken by the CM in the development of the discharge plan, will be documented in the electronic medical record and will be discussed with the patient and the patient's representative to prepare them for post-hospital care. F. The CM team will continually reassess the need for modifications to the discharge plan to ensure any changes in treatment or condition are considered and that the plan is adapted as needed. Reassessments and change to the discharge plan will be updated, as needed, will be documented in the electronic medical record ...."

An interview was conducted with Staff # 11 (Case Management Team Lead) and Staff # 22 (Case Management Director) on 06/24/2025 at 10:00 AM in the administrative board room. The surveyor asked the staff members if there was a process they were supposed to follow to escalate the discharge planning and placement concerns that arose for this patient. Both staff members agreed that this patient was difficult to find a safe and appropriate placement for, and there was room for improvement in the escalation of this case to a higher authority within the hospital for recommendations and additional support with discharge planning.