HospitalInspections.org

Based on interview and record review, the facility failed to:

1. Reassess the pain level for two of 30 sampled patients (Patients 27 and 28) following the administration of pain medications (Ibuprofen [used to relieve pain and is administered by mouth] and Toradol [an anti-inflammatory drug used to manage moderate to severe pain]) in accordance with the facility's policy and procedure regarding assessment and reassessment.

This deficient practice had the potential to result in uncontrolled pain or ineffective management of pain for Patients 27 and 28, which can lead to psychological and physical suffering as a result of pain.

2. Initiate discharge screening (a screening to determine patient's risk for adverse health consequences post discharge) and refer to care coordination for further evaluation of discharge needs within 24 hours of admission for one of 30 sampled patients (Patient 1).

This deficient practice resulted in an unsafe discharge for Patient 1, who was combative upon arrival at the Post Acute Care facility, thus having to be administered a sedative (medication to help calm someone who is agitated) and eventually resulting to a re-admission back to the hospital and for arrangement of a post-acute care discharge to a different PAC.

3. Initiate inpatient admission process for one of 30 sampled patients (Patient 10) who had an order to admit to inpatient care but had to remain in the Emergency Department due to lack of available inpatient beds.

This deficient practice had the potential to delay meeting Patient 10's defined care needs and may negatively affect Patient 10's outcomes.

Findings:

1a. During a review of Patient 27's Emergency Department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) Physician Notes (documented medical history and assessment by a physician), dated 7/2/2023, at 6:23 p.m., the Emergency Department Physician Notes indicated Patient 27 had a chief complaint (a concise statement describing a patient's symptoms, problems, condition, and diagnosis) of right upper quadrant abdominal pain with nausea (uneasiness in the stomach), vomiting (a forceful discharge of stomach contents through the mouth) and diarrhea (passing loose stools) for one week.

During a review of Patient 27's Physician's Order, dated 7/2/2023, at 6:23 p.m., the physician's order indicated an order for Ketorolac (Toradol, an anti-inflammatory drug used to manage moderate to severe pain), 15 milligrams (mg, a unit of measurement), intravenous (IV, in the vein) push (medication given quickly in a vein within 30 seconds or less), once. The order further indicated a STAT (given immediately) order.

During a concurrent interview and record review on 1/24/2024 at 2:16 p.m. with Supervisor 1 (Sup 1), Sup 1 stated Patient 27 was admitted to the ED on 7/2/2023 at 6:18 p.m. with complaint of abdominal pain. Sup 1 confirmed that on 7/2/2023, at 6:22 p.m., Patient 27 had a pain assessment in the medical record of 9 out of 10 (indicative of severe pain) pain level.

Sup 1 confirmed that the patient (Patient 27) had an order for pain medication, Toradol, to be administered STAT (immediately), within 30 minutes. Sup 1 said that when there is a physician order for medications, this needs to be processed by the pharmacist before it can be administered by the Registered Nurse (RN). Sup 1 said Patient 27's Toradol was ordered by the physician on 7/2/2023, at 6:23 p.m., processed by the pharmacist on 7/2/2023, at 6:27 p.m., and given by the RN to patient 27 on 7/2/2023 at 9:51 p.m.

Sup 1 acknowledged that there was a delay by the RN administering Patient 27's pain medication. Sup 1 further stated that pain should be reassessed within 15 minutes of IV medication administration. Sup 1 verified that pain was not reassessed within 15 minutes after IV medication was given. Sup 1 said that patients need to be assessed to determine the patient's response to the pain medication. Sup 1 further stated that if pain is not assessed or reassessed, appropriate adjustment of pain medication dosage cannot be made, patient will not receive the right medication dosage to relieve pain, and the pain can get worse.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment, Reassessment and Management," revised 10/2022, the P&P indicated: "Purpose: To provide an organizational process for appropriate, effective, and safe pain management for all patients. Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness. To aid in the selection of medical and non-medical treatments for pain and to evaluate the efficacy of the selected treatment plans in clinical practice.

Responsibilities: ...Registered Nurse (RN)- the registered nurse maintains an acceptable comfort level for the patient through timely assessments and effective pain management ... A. Pain scales: ...9. NRS: Numeric Rating Scale- pain scale of 0 to 10 for patients who can self-report ... B. Pain will be assessed as the fifth vital sign. Patients will be screened for pain: 1. Upon admission (inpatient, outpatient, emergency department) and initial assessment. 2. After pain eliciting procedure 3. Routinely with each set of vital signs 4. At any time, patient complains of pain, or demonstrated evidence of pain ...

Procedure: Perform and conduct a pain assessment on inpatient admission ... 3. perform and document a comprehensive pain assessment if the pain history indicates acute or chronic pain. a. location b. pain level/intensity c. acceptable pain intensity (API) d. characteristics e. frequency (onset and duration) f. alleviating factors (pharmacological and non-pharmacological) g. aggravating factors h. effects of pain on activity and quality of life B. perform and document a pain assessment at any time a patient reports pain or there is a change in status. 1. for patients able to self-report a. location b. pain level/intensity c. acceptable pain intensity (API) d. characteristics e. frequency (onset and duration) f. alleviating factors (pharmacological and non-pharmacological) g. aggravating factors h. effects of pain on activity and quality of life ... D. Recommended reassessment intervals vary according to the route administered. 1. IV: 30 minutes 2. IM 30 minutes, subcutaneous: 30 minutes 4. PO/PR: 60 minutes ... Documentation: A. Patient's pain management will be documented in the EHR (Electronic Health Record) B. Document pain score in the EHR ..."

National Institutes of Health Warren Grant Magnuson Clinical Center: Pain intensity instruments... 0-10 numeric rating scale. Indications: Adults and Children (>9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain... it is sometimes helpful to further explain or conceptualize the numeric Rating Scale in the following manner: a. 0 = no pain b. 1-3 = mild pain (nagging, annoying, interfering with ADLs) c. 4-6 = Moderate Pain (interferes significantly with ADLs) d. 7-10 = Severe Pain (disabling, unable to perform ADLs). 3. The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to Numeric pain ratings ..."


1b. During a review of Patient 28's Emergency Department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) Physician Notes (documented medical history and assessment by a physician), dated 7/17/2023, the Emergency Department Physician Notes indicated, Patient 28 had a chief complaint (a concise statement describing the symptom, problem, condition, diagnosis) of neck pain.

During a review of Patient 28's Physician's Order, dated 7/17/2023 at 12:20 p.m., the Physician's Order indicated an order for Ibuprofen (used to relieve pain and is administered by mouth), 600 milligrams (mg, a unit of measurement), administered by mouth, once. The order further indicated a STAT (given immediately) order. The order was verified by the pharmacists on 7/17/2023 at 12:22 p.m. The order was reviewed by the RN on 7/17/2023 at 1:44 p.m.

During a concurrent interview and record review on 1/24/2024 at 2:55 p.m. with Supervisor 1 (Sup 1), Sup 1 confirmed Patient 28 was admitted to the ED on 7/17/2023 at 12:13 p.m. with a chief complaint of acute (severe and sudden in onset) neck pain. Sup 1 verified Patient 28 had a pain assessment of 6 (out of 10, indicative of moderate pain) pain. Sup 1 said that for Patient 28, pain assessment and reassessment were missed, when only one pain assessment was completed during Patient 28's ED admission. Sup 1 further stated that Patient 28 should have had a pain assessment every two hours with each vital signs check.

Sup 1 confirmed Ibuprofen was administered for pain on 7/17/2023 at 1:44 p.m. Sup 1 said Patient 28 should have been reassessed for pain 30 minutes after the administration of Ibuprofen. However, there was no pain reassessment documented. Sup 1 further stated that Patient 28's pain assessment documentation was also missing where the pain was located, and this should have been included in the assessment.

During a review of the facility's policy and procedure (P&P), titled "Pain Assessment, Reassessment and Management," revised 10/2022, the P&P indicated: "Purpose: To provide an organizational process for appropriate, effective, and safe pain management for all patients. Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness. To aid in the selection of medical and non-medical treatments for pain and to evaluate the efficacy of the selected treatment plans in clinical practice.

Responsibilities: ...Registered Nurse (RN)- the registered nurse maintains an acceptable comfort level for the patient through timely assessments and effective pain management ... A. Pain scales: ...9. NRS: Numeric Rating Scale- pain scale of 0 to 10 for patients who can self-report ... B. Pain will be assessed as the fifth vital sign. Patients will be screened for pain: 1. Upon admission (inpatient, outpatient, emergency department) and initial assessment. 2. After pain eliciting procedure 3. Routinely with each set of vital signs 4. At any time, patient complains of pain, or demonstrated evidence of pain ...

Procedure: Perform and conduct a pain assessment on inpatient admission ... 3. perform and document a comprehensive pain assessment if the pain history indicates acute or chronic pain. a. location b. pain level/intensity c. acceptable pain intensity (API) d. characteristics e. frequency (onset and duration) f. alleviating factors (pharmacological and non-pharmacological) g. aggravating factors h. effects of pain on activity and quality of life B. perform and document a pain assessment at any time a patient reports pain or there is a change in status. 1. for patients able to self-report a. location b. pain level/intensity c. acceptable pain intensity (API) d. characteristics e. frequency (onset and duration) f. alleviating factors (pharmacological and non-pharmacological) g. aggravating factors h. effects of pain on activity and quality of life ... D. Recommended reassessment intervals vary according to the route administered. 1. IV: 30 minutes 2. IM 30 minutes, subcutaneous: 30 minutes 4. PO/PR: 60 minutes... Documentation: A. Patient's pain management will be documented in the EHR (Electronic Health Record) B. Document pain score in the EHR ...

National Institutes of Health Warren Grant Magnuson Clinical Center: Pain intensity instruments... 0-10 numeric rating scale. Indications: Adults and Children (>9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain... it is sometimes helpful to further explain or conceptualize the numeric Rating Scale in the following manner: a. 0 = no pain b. 1-3 = mild pain (nagging, annoying, interfering with ADLs) c. 4-6 = Moderate Pain (interferes significantly with ADLs) d. 7-10 = Severe Pain (disabling, unable to perform ADLs). 3. The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to Numeric pain ratings ..."

2. During a review of Patient 1's medical record (MR) titled, "Emergency Department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) Physician's Note, "dated 9/15/2023, the Emergency Department Physician's Note indicated, Patient 1 was initially seen in the ED for agitation (a feeling of irritability or severe restlessness) and urinary tract infection (UTI, an infection of any part of the urinary system such as the bladder [an organ in the body that holds urine]). The Emergency Department Physician's Note further indicated, Patient 1's past medical history (PMH) included cerebral palsy (a condition marked by impaired muscle coordination typically caused by damage to the brain before or at birth), traumatic brain injury (results from a violent blow to the head), and developmental disorder (means a severe, chronic [a medical condition characterized by long duration] disability of an individual that: is attributable to a mental or physical impairment, or combination of mental and physical impairment).

During an interview on 1/23/2024 at 12:14 p.m. with the director of the ED (DED) and the ED manager (EDM), the DED stated, the facility's discharge process begins with a primary nurse and case manager (CM) who is responsible for arranging a patient's transfer to an accepting Post Acute Care (PAC, such as a Skilled Nursing Facility [SNF- a clinical facility where patients can receive medical care and rehabilitation services from trained professionals]) facility. The EDM further said, patients cannot be discharged to a PAC facility without prior arrangement, guaranteed acceptance, and patient's approval. However, in the case of Patient 1, there was no coordination for discharge evaluation prior to Patient 1's discharge to a PAC.

During a concurrent interview and record review on 1/23/2024 at 2:02 p.m. with the emergency department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) shift supervisor (Sup 1), Patient 1's medical record (MR) documentation titled, "Discharge Planning (the process of identifying and preparing for a patient's anticipated health care needs after they leave the hospital) Progress Note," dated 9/16/2023, was reviewed. Patient 1's Discharge Planning Progress Note indicated, on 9/16/2023, at 1:47 p.m., the case manager (CM) documented, "Patient 1 was sent back to the facility's ED because the PAC facility was unable to take Patient 1 back. Patient 1 will need placement." The Sup 1 stated, based on the Discharge Planning Progress Note documentation, there was no prior discharge arrangement coordinated by the facility to transfer Patient 1 back to the patient's (Patient 1) previous PAC facility.

During a review of Patient 1's medical record titled, "ED Physician Note," dated 9/16/2023, at 1:56 p.m., the ED Physician Note indicated, on 9/16/2023, Patient 1 was returned to the facility's ED due to being combative with paramedics and staff, and Patient 1 was brought in sedated (being in a calm, relaxed state resulting from or as if from the effect of a sedative medication). The ED Physician Note further indicated, Patient 1 had to be admitted to the facility and needed a different placement arrangement.

During a concurrent interview and record review on 1/23/2024 at 2:30 p.m., with the case manager (CM), Patient 1's medical record (MR), dated 9/15/2023-9/16/2023 was reviewed. The MR indicated no discharge planning documentation was done by CM on 9/16/2023 prior to Patient 1's transfer to the PAC facility. The MR further indicated, the primary nurse's documentation stated, the primary nurse was not able to call with report (updating the PAC facility on patient's health status and treatment prior to discharge) to the PAC facility before Patient 1's discharge on 9/16/2023. The MR also indicated, the facility's ED secretary arranged for the ambulance pick up to transfer Patient 1 to Patient 1's previous PAC, where he (Patient 1) was from, on 9/16/2023.

The CM stated, based on presented documentation in Patient 1's MR, discharge planning for Patient 1 was done improperly. The CM further clarified, per regulations and the facility's policy and procedures (P&P), discharge planning should involve coordinated care arrangements prior to discharging a patient to a PAC facility. The CM said, before discharging Patient 1 back to the PAC facility, transfer documents containing all pertinent patient information had to be faxed to the accepting facility; the PAC facility had to confirm the acceptance of the patient; the primary nurse had to call with report to the accepting PAC facility; Patient 1 had to agree with the discharge arrangement, and the entire process had to be documented in Patient 1's medical record.

During a review of the facility's policy and procedure (P&P) titled, "Care Coordination Discharge Planning," dated 11/2022, the P&P indicated, "Discharge planning, evaluation/assessment is completed by the care coordinator (designated registered nurse, Social Worker, or other appropriately qualified personnel) when discharge needs are identified during the admission process. Post discharge needs of patients identified in the first stage (screening) by the primary nurse, which identifies patients for whom lack of adequate discharge planning might result in an adverse impact on the patient's health."

During a review of the facility's policy and procedure (P&P) titled, "Care Coordination Discharge Planning," dated 11/2022, the P&P indicated, "Discharge planning will be initiated early in the patient's admission to facilitate safe and timely discharge. All activities related to discharge planning are documented in the medical record, including arrangements made for implementation of the discharge plan. A transfer summary shall accompany the patient upon transfer to a skilled nursing facility and this shall be documented in the patient's medical record."

3. During a review of Patient 10's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/22/2024, the H&P indicated, Patient 10 was seen in the Emergency Department (ED) for abdominal pain, elevated temperature, and tachycardia (increased heart rate above normal limits). The H&P further indicated Patient 10 was admitted to the facility with a diagnosis of sepsis (an infection you already have triggers a chain reaction throughout your body), pneumonia (PNA, Inflammation in the lungs), rhabdomyolysis (a rare muscle injury where your muscles break down, is a life-threatening condition), acute dehydration (occurs when you use or lose more fluid than you take in), and metabolic acidosis (The buildup of acid in the body due to kidney disease or kidney failure).

During a review of Patient 10's medical record (MR) titled, "physician's orders," dated 1/22/2024, the physician's orders indicated, Patient 10 had an order to be admitted on 1/22/2024 at 10:33 p.m. at the medical surgical floor. During further review of Patient 10's MR, the MR indicated, Patient 10 did not get an inpatient bed until 1/23/2024 at 9:07 p.m., and Patient 10 was held in the Emergency Department (ED) on 1/22/2024 until 1/23/2024.

During a review of Patient 10's medical record titled "Adult Admission History," dated 1/23/2024, the MR indicated, Patient 10's admission assessment was not documented until Patient 10 was physically transferred into an inpatient bed in a medical surgical floor on 1/23/2024 at 10:33 p.m.

During a concurrent interview and record review on 1/24/2024 at 10:09 a.m., with the ED nurse shift supervisor (Sup 1), Patient 10's medical record (MR), dated 1/22/2024-1/24/2024 was reviewed. The MR indicated, Patient 10's admission nursing assessment (Complete admission assessment on a patient upon admission to the hospital within 24 hours of admission to Medical Surgical/Telemetry units, based on an assessment of patient needs, requiring the primary nurse, at a minimum, to obtain admission line data specific to the review of all body systems and physiologic functioning, psychosocial status, physical support needs, self-care status, educational informational needs, and preliminary discharge plans) in accordance with the facility's Standards of Care for patients admitted to Medical Surgical/Telemetry floor, was not done by the ED nurses when Patient 10 was held in the emergency department from 1/22/2024-1/23/2024, after a decision was made to admit Patient 10 for further treatment.

The Sup 1 stated, ED nurses do not complete admission assessment in the emergency department. The Sup 1 said, ED nurses typically continue caring for admitted patients in the same manner they care for all patients in the Emergency Department and perform focused assessments (assessment of specific body system as indicated by patient's condition), carry out physician's orders, and continue monitoring patients until an inpatient bed becomes available. The Sup 1 stated, all admission assessments pertaining to Nursing Standards of Practice for inpatient Adult Nursing (Medical Surgical, Telemetry) are carried out by the inpatient admitting nurse.

During an interview on 1/25/2024 at 12:05 p.m., with the manager of the emergency department (EDM), the EDM stated, ED nurses do not have an established process to admit patients with pending inpatient admission when they stay in the Emergency Department because of unavailability of an inpatient bed. The EDM further stated, typically nurses in the emergency department do no initiate nursing care plans and do not complete the admitting profile as required to be performed by the inpatient registered nurse.

During an interview on 1/26/2024 at 9:49 a.m., with the Director of Emergency Department (DED), the DED stated, the facility does not have a distinguished process for the Emergency Department nurses to perform and complete an admission assessment on each patient who is admitted to inpatient care unit. The DED further said, the ED nurses typically carry out all physician's inpatient orders, such as give all due medications, follow up on consultations, but the ED nurses only perform focused assessment charting and do not complete all the assessments of patients' needs and don't develop nursing care plans that are expected to be completed by the admitting nurses on their specialty units.

During an interview on 1/26/2024, at 10:18 p.m., with emergency department nurse (RN 4), the RN 4 stated, there is no admission process for patients held in the ED while waiting for an available bed. The RN 4 further stated, the assessments typically done for admitted, but held in ED patients, included ED focused assessment, assessing fall risk, suicide risk, carry out physician's orders, daily medications, blood draws; admission assessment is done by the admitting nurse once patient goes to the floor.

During a review of the facility's policy and procedures (P&P), titled "Nursing Process: Implementation and Documentation," last revised 6/2023, the P&P indicated," The registered nurse (RN) initiates promptly and completes an admission assessment on each patient upon admission to the hospital within 24 hours of admission to Medical Surgical/Telemetry units. Nursing care is provided based on an assessment of patient needs, the formulation of nursing diagnoses, determination of nursing interventions and selection of nursing standards of patient care to meet defined care needs. Based on that plan, the RN evaluates the patient response or outcomes resulting from care team interventions and documents in the electronic health record of each patient. Data collected for the admission assessment include admission vital signs, weight, a review of allergies and dietary preferences, an inventory of personal belongings, identification of family who are important to the patient and the plan of care developed.

At a minimum, the RN shall obtain admission line data specific to the review of all body systems and physiologic functioning, psychosocial status, physical support needs, self-care status, educational informational needs, and preliminary discharge plans. The RN documents a nursing diagnosis/patient problem identification based on an evaluation of the assessment data and generates a nursing plan of care which is congruent with other disciplines involved in the patient's care."

During a review of the facility's policy and procedures (P&P) titled, "Core Nursing Standards of Practice for Adult Core Nursing (Medical Surgical, Telemetry, Orthopedic, Oncology, and Acute Rehab), dated 12/2021, the P&P indicated, "Admission history should be completed within 24 hours, focus assessment for chief complaint should be completed within 30 minutes of admission; physical assessment should be completed within 4 hours of admission; the RN should screen patients for falls, skin risk, sepsis, mobility and suicide within 4 hours of admission, and precautions should be implemented according to the results of the screening. The RN develops a nursing care plan based on nursing diagnosis after analyzing the assessment data, identifies actual and potential risks to the patient's health and safety."

During a review of the facility's policy and procedure (P&P) titled, "Plan for Provision of Care," last revised 4/2022, the P&P indicated, "Patient assessments are foundation for all disciplines to determine the need for acute intervention and hospitalization indication. The assessment includes physical, psychosocial, social, spiritual, educational, nursing care, functional, and pain needs. Interdisciplinary plan of care is developed based on the patient's primary reason for admission and the RN enters the care plan in the electronic health record (EHR) for the team and individual goals, interventions, and outcomes for each problem. Discharge planning for the continuum of care is reviewed daily with Care Coordinator and Social Worker and the assigned RN to identify barriers to discharge. The primary RN determines which patients require care coordinator involvement and refers them for discharge planning."

Based on interview and record review, the facility failed to evaluate the discharge needs and make appropriate arrangements for post-hospital care before discharging one of 30 sampled patients (Patient 1).

This deficient practice had the potential to result in unsafe discharge when the patient's post-discharge needs are not addressed, and appropriate arrangements are not made, which can result in adverse events (undesirable clinical outcome such as worsening of health condition) and unnecessary readmission for Patient 1.

Findings:

During a review of Patient 1's medical record (MR) titled, "Emergency Department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) Physician's Note, "dated 9/15/2023, the Emergency Department Physician's Note indicated, Patient 1 was initially seen in the ED for agitation (a feeling of irritability or severe restlessness) and urinary tract infection (UTI, an infection of any part of the urinary system such as the bladder [an organ in the body that holds urine]). The Emergency Department Physician's Note further indicated, Patient 1's past medical history (PMH) included cerebral palsy (a condition marked by impaired muscle coordination typically caused by damage to the brain before or at birth), traumatic brain injury (results from a violent blow to the head), and developmental disorder (means a severe, chronic [a medical condition characterized by long duration] disability of an individual that: is attributable to a mental or physical impairment, or combination of mental and physical impairment).

During an interview on 1/23/2024, at 12:14 p.m., with the director of the ED (DED) and the ED manager (EDM), the DED stated, the facility's discharge process begins with a primary nurse and case manager (CM) who is responsible for arranging a patient's transfer to an accepting Post Acute Care (PAC, such as a Skilled Nursing Facility [SNF- a clinical facility where patients can receive medical care and rehabilitation services from trained professionals]) facility. The EDM further said, patients cannot be discharged to a PAC facility without prior arrangement, guaranteed acceptance, and patient's approval.

During a concurrent interview and record review on 1/23/2024 at 2:02 p.m., with the emergency department (ED) shift supervisor (Sup 1), Patient 1's medical record (MR) documentation titled, "Discharge Planning (the process of identifying and preparing for a patient's anticipated health care needs after they leave the hospital) Progress Note," dated 9/16/2023, was reviewed. Patient 1's Discharge Planning Progress Note indicated, on 9/16/2023, at 1:47 p.m., the case manager (CM) documented, "Patient 1 was sent back to the facility's ED because the PAC facility was unable to take Patient 1 back. Patient 1 will need placement." The Sup 1 stated, based on the Discharge Planning Progress Note documentation, there was no prior discharge arrangement coordinated by the facility to transfer Patient 1 back to the patient's (Patient 1) previous PAC facility.

During a review of Patient 1's medical record titled, "ED Physician Note," dated 9/16/2023, at 1:56 p.m., the ED Physician Note indicated, on 9/16/2023, Patient 1 was returned to the facility's ED due to being combative with paramedics and staff, and Patient 1 was brought in sedated (being in a calm, relaxed state resulting from or as if from the effect of a sedative medication). The ED Physician Note further indicated, Patient 1 had to be admitted to the facility and needed a different placement arrangement.

During a concurrent interview and record review, on 1/23/2024 at 2:30 p.m., with the case manager (CM), Patient 1's medical record (MR), dated 9/15/2023-9/16/2023 was reviewed. The MR indicated no discharge planning documentation was done by CM on 9/16/2023 prior to Patient 1's transfer to the PAC facility.

The MR further indicated the primary nurse was not able to call with report (updating the facility on patient's health status and treatment prior to discharge) to the PAC facility before Patient 1's discharge on 9/16/2023. The MR also indicated, the facility's ED secretary arranged for the ambulance pick up to transfer Patient 1 to Patient 1's previous PAC, where he (Patient 1) was from, on 9/16/2023. The CM stated, based on presented documentation in Patient 1's MR, discharge planning for Patient 1 was done improperly.

The CM further clarified, per regulations and the facility's policy and procedures (P&P), discharge planning should involve coordinated care arrangements prior to discharging a patient to a PAC facility. The CM said, before discharging Patient 1 back to the PAC facility, transfer documents containing all pertinent patient information had to be faxed to the accepting facility; the PAC facility had to confirm the acceptance of the patient; the primary nurse had to call with report to the accepting PAC facility; Patient 1 had to agree with the discharge arrangement, and the entire process had to be documented in Patient 1's medical record.

During a review of the facility's policy and procedure (P&P) titled, "Care Coordination Discharge Planning," dated 11/2022, the P&P indicated, "Discharge planning will be initiated early in the patient's admission to facilitate safe and timely discharge. All activities related to discharge planning are documented in the medical record, including arrangements made for implementation of the discharge plan. A transfer summary shall accompany the patient upon transfer to a skilled nursing facility and this shall be documented in the patient's medical record."

During a review of the facility's policy and procedure (P&P) titled, "Care Coordination Discharge Planning," dated 11/2022, the P&P indicated, "Discharge planning, evaluation/assessment is completed by the care coordinator (designated registered nurse, Social Worker, or other appropriately qualified personnel) when discharge needs are identified during the admission process. The assessment includes the likelihood of the patient requiring post-hospital services, as well as the availability of services. The patient's living environment prior to entering hospital is also assessed and the patient's stated goals and treatment preferences are given priority whenever possible. All activities related to discharge planning, patient choice, and referrals are documented in the medical record, including screening, assessment, evaluations and arrangements made for implementation of the discharge plan."