HospitalInspections.org

Based on document review and interview, it was determined that for for 1 of 3 patients' (Pt. #1) clinical records reviewed for allegation of abuse, the Hospital failed to follow the reporting process to ensure patient was free from abuse.

Findings include:

1. On 7/12/2022 the Hospital's policy titled, "Processing Physical and/or Sexual Assault Complaints" (effective 4/2022) was reviewed and included, "... 1. All (Name of the Hospital) Employees... Allegation: An assertion, complaint, suspicion, or incident involving any of the following conduct by an employee... against an individual or individuals... physical abuse, sexual abuse... Procedure: This procedure applies to all (Name of the Hospital) employees who learn of any and all complaints of physical and/or sexual assault. Upon receipt of complaint, employee will notify their immediate supervisor..."

2. On 7/12/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 5/28/2022 with a diagnosis of bipolar depression (type of psychiatric illness).The clinical record included E #2's (Registered Nurse) progress notes on 5/31/2022 at 2:03 PM, "(Pt. #1's mother) called back to let us know her daughter (Pt. #1) was calling them this morning and making accusations. That she (Pt. #1) has been being beaten and has bruises. 'A black man comes in her room and rapes her' ..." There was no documentation that the immediate supervisor was notified by E #2.

3. On 7/12/2022 at approximately 3:00 PM, findings were discussed with E #5 (Assistant Vice President for Operations). E #5 stated that there was no documentation that the immediate supervisor was notified by E #2. E #5 said, "She (E #2) is new and I told her that it should be reported."

Based on document review and interview, it was determined that the Hospital failed to assess its discharge planning process on an ongoing basis by not including a periodic review of a representative sample of discharge plans, including patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the post-discharge needs.

Findings include:

1. The Hospital's policy titled, "Quality Assurance and Performance Improvement" (dated April 16, 2021), was reviewed on 7/13/2022, and required, "Purpose: To collect, measure, and analyze data using statistical tools and methods...To achieve, integrate and sustain reliable outcomes...The Director/Managers of each department is responsible for continuous quality assessment, patient safety and performance improvement for their services provided...The Director or designees of each department assures incorporation of quality indicators and performance improvement initiatives into daily departmental operations and management decisions and reports outcomes through the quality reporting structure."

2. On 7/12/2022, the Hospital's QAPI (Quality Assurance and Improvement) meeting minutes (dated 1/28/22, 2/28/22, 5/23/22, and 6/20/22), were reviewed. The meeting minutes did not include any evaluation of patient re-admissions within 30 days, or a review of discharge plans.

3. On 7/12/2022, the Hospital's Discharge Planning meeting minutes were requested. The Hospital was unable to provide the requested meeting minutes.

4. On 7/12/2022 at 11:10 AM, an interview was conducted with the Director of Quality Outcomes and Accreditation (E #9). E #9 stated that the Hospital does not have an accurate way of looking at or tracking re-admissions. E #9 acknowledged that there are no Discharge Planning meeting meetings.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #2) clinical records reviewed for discharge planning, the Hospital failed to conduct the initial assessment by the social worker/case manager, to ensure discharge planning was evaluated in a timely basis.

Findings include:

1. On 7/12/2022, the Hospital's policy titled, "Assessment and Reassessment for Discharge" (undated) was reviewed and included, "... 3. An initial assessment by (a social worker) will be performed and documented for each ... patient... within 24 hours of admission and will include but not limited to... b) Description of home environment... d) Mental status and history of emotional difficulties... f) Prior involvement with... community resources..."

2. On 7/12/2022, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted 3/20/2022 to the Hospital with a diagnosis of bipolar, manic (type of psychiatric disorder). The clinical record included E #10's (Social Worker's) initial assessment on 3/23/2022, "Spoke with ... (Pt. #1) diagnosed with the following ... medication list." The initial assessment included description of Pt. #2's home environment, mental status and history of emotional difficulties, prior involvement with community resources. The assessment was conducted 72 hours after admission.

3. On 7/12/2022 at approximately 1:48 PM, findings were discussed with E #10 (Social Worker/Discharge Planner). E #10 stated that her initial assessment was conducted 72 hours (not within 24 hours) after Pt. #2's admission.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #2) clinical records reviewed for discharge planning, the Hospital failed to ensure that the discharge planning evaluation was documented and discussed with the patient's representative.

Findings include:

1. On 7/12/2022, the Hospital's policy titled, "Assessment and Reassessment for Discharge" (undated) was reviewed and required, "... 5. Develop an individual plan... 7. CM/MSW/LSW (Case Manager/Master of Social Work/Licensed Social Worker) contact... family... to coordinate an effective, safe discharge plan. Documentation of the discharge plan will include... plan elements and interactions with family in EMR (electronic medical record).

2. On 7/12/2022, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 3/20/2022, to the Hospital with a diagnosis of bipolar, manic (type of psychiatric disorder). Pt. #2 was a DCFS (Department of Children's and Family Services) ward, unable to care for herself (developmentally disable), and was in need of hospitalization. The clinical record also included:

- E #10's (Social Worker/Discharge Planner) progress notes 3/25/2022, 3/30/2022, 4/1/2022, 4/27/2022, 5/2/2022, 5/3/2022, 5/6/2022, and 5/13/2022 indicated that the Hospital was in communication with DCFS (including guardian/Z #1) regarding potential discharge placement. There was no documentation regarding plan for Pt. #1 to be discharged to (Name of Community Integrated Living Arrangement/CILA/group home for adults 18 years old and older with developmental disabilities) and approval from Z #1.

- MD #1's (Medical Director of Psychiatry) order on 5/20/2022 for Pt. #2 to be discharged to home/Name of CILA
- A discharge instructions indicating Pt. #2 was discharged on 5/20/2022 to (Name of CILA)

3. On 7/12/2022, an email from Z1 dated 5/31/2022 was reviewed and included, "Hello (E #10 and E #11/Social Worker/Discharge Planner), I am contacting you to inquire about (Pt. #2's) discharge documentation... It is my understanding that (Pt. #2) was sent to the trial visit to (Name of CILA) without DCFS approval. (Pt. #2) was transported to (Name of CILA) on Friday 5/20/2022 where she spent the night and was informed next day 5/21/2022 that her trial visit was over. (Pt. #2) was transported from (Name of CILA) to (Name of Another Acute Care Hospital ED) ... where she was discharged ... (Pt. #2) was taken to DCFS office on 5/21/2022 ..."

4. On 7/13/2022 at approximately 1:48 PM, an interview was conducted with E #10. E #10 stated that she had discussion with Pt. #2's DCFS guardian/case manager (Z #1) regarding potential placement. However, there was no definite plan approved by DCFS/Z#1. E #10 stated that Pt. #2 was discharged to (Name of CILA). E #10 could not provide documentation that the discharge plan included (Name of CILA) and that Z #1 approved/discussed the discharge plan.

5. On 7/13/2022 at approximately 9:40 AM, an interview was conducted with MD #1 (Medical Director Psychiatry). MD #1 stated that if a patient is a ward of DCFS, it means that DCFS is making the decision for the patient. MD #1 agreed that there were no clear documentation regarding the discharge plan and discussion with Z #1.