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Based on hospital policy and procedure review, medical record review, and staff interviews, the hospital staff failed to ensure a complete History and Physical (H&P) was performed prior to a procedure requiring anesthesia for 3 of 3 patients (Patient #3, #11, and #12) per policy.

The findings include:

Review on 07/21/2016 of the hospital's policy titled "Interdisciplinary Admission Assessment and Reassessment, D-50-B22" revised 02/2013 revealed, "...PROCESS: I. When the patient enters the setting or service, information is gathered to identify the reason(s) that brings him or her to the hospital. II. Information gathered at the first person contact can indicate the need for more data regarding the patient's physical, psychological, and social status. ...IV. Areas of responsibility and timeliness for assessment and reassessment functions are defined as follows: A. Medical Staff ...4. The assessment of the patient by medical staff upon admission shall include: ...5. All histories and physicals will be completed within 24 hours of the patient's admission... If the history and physical examination has been performed within 7 days before admission, ...a durable copy of this report may be used...providing current documentation shows no changes have occurred or whatever changes have occurred are documented in the medical record at the time of admission.."

Review on 07/21/2016 of Hospital By-laws "Section 2 D. Conduct of Care: Medical Records B. History and Physical 1." revealed, "...This history and physical should include...pertinent past history to include medical-surgical conditions...5. A patient undergoing a procedure by a dentist, oral surgeon, or podiatrist will have a pertinent history documented by the provider prior to performing the procedure.

1. Medical record review on 07/20/2016 for Patient #3 revealed a 58 year old presented to the hospital's Outpatient Surgery Center on 06/09/2016 for a scheduled open reduction and internal fixation (ORIF: procedure performed to fix a fracture) on her left ankle. Review of the "Pre-Procedure/Surgery Physician Assessment" revealed it was performed by Physician Assistant (PA) #1 on 06/07/2016 at 1200. Review revealed "REASON FOR PROCEDURE (History of Current Illness)" was not documented. Review of the "HISTORY AND PHYSICAL UPDATE/ADDITION" revealed MD #1 reviewed the H&P and indicated "there were no changes to previous H&P exam or status." Medical record review revealed MD #1 did not update the H&P to include "History of Current Illness" per hospital by-laws and policy.

Interview on 07/20/2016 at 1500 with the CMO (Chief Medical Officer) revealed the expectation is that information addressing the patient's current illness is documented. Interview with the CMO indicated the current process "Can be improved. Physician's should be doing the assessment." Interview with the CMO revealed the expectation is that the physician should reassess the patient "on the day of surgery, reaffirming the patient's status." Continued interview with the CMO indicated, "The form is not efficient and does not include components of the by-laws." Interview confirmed the patient's H&P did not include all required components.

Interview on 07/21/2016 at 1030 with DPM #1 (Doctor of Podiatric Medicine) revealed he was the physician (podiatrist) who performed the procedure on 06/09/2016. Interview with DPM #1 revealed, "It's (PRE-PROCEDURE/SURGERY PHYSICIAN ASSESSMENT) missing the HPI (History of Present Illness)." Interview following review of H&P requirements in the hospital's by-laws revealed the H&P "Should include pertinent past history." Interview revealed DPM #1's current practice does not align with hospital by-laws.

2. Medical record review on 07/19/2016 for Patient #11 revealed a 56 year old presented to the hospital's Outpatient Surgery Center for a scheduled left foot partial excision talus (bone in ankle) and Flexor hallicus longus (FHL) tenosynovectomy (procedure to treat tendonitis in the ankle) on 07/07/2016. Review revealed the PRE-PROCEDURE SURGERY PHYSICIAN ASSESSMENT" revealed it was performed by PA #1 on 06/28/2016 at 0951. Medical record review indicated "Pain" documented in the section titled, "REASON FOR PROCEDURE (History of Current Illness)". Review of the "HISTORY AND PHYSICAL UPDATE/ADDITION" revealed DPM #1 (Doctor of Podiatric Medicine) reviewed the H&P and indicated "there were no changes to previous H&P exam or status" on 07/07/2016 at 0700. Medical record review revealed DPM #1 did not update the H&P to include "History of Current Illness" per hospital by-laws and policy.

Interview with the CMO indicated the current process "Can be improved. Physician's should be doing the assessment." Interview with the CMO revealed the expectation is that the physician should reassess the patient "on the day of surgery, reaffirming the patient's status." Continued interview with the CMO indicated, "The form is not efficient and does not include components of the by-laws." Interview confirmed the patient's H&P did not include all required components.

Interview on 07/21/2016 at 1030 with DPM #1 (Doctor of Podiatric Medicine) revealed he was the physician (podiatrist) who performed the procedure on 06/09/2016. Interview with DPM #1 revealed, "It's (PRE-PROCEDURE/SURGERY PHYSICIAN ASSESSMENT) missing the HPI (History of Present Illness)." Interview following review of H&P requirements in the hospital's by-laws revealed the H&P "Should include pertinent past history." Interview revealed DPM #1's current practice does not align with hospital by-laws.

3. Medical record review on 07/19/2016 for Patient #12 revealed a 39 year old presented to the hospital's Outpatient Medical Center for a scheduled "Right plantar fasciectomy" (removal of a tendon in the heel) on 07/07/2016. Review revealed the PRE-PROCEDURE SURGERY PHYSICIAN ASSESSMENT" was performed by PA #2 on 06/24/2016 at 1047. Review revealed "REASON FOR PROCEDURE (History of Current Illness)" was not documented. Review of the "HISTORY AND PHYSICAL UPDATE/ADDITION" revealed MD #1 reviewed the H&P and indicated "there were no changes to previous H&P exam or status" on 07/07/2016. Medical record review revealed DPM #1 (Doctor of Podiatric Medicine) did not update the H&P to include "History of Current Illness" per hospital by-laws and policy.

Interview with the CMO indicated the current process "Can be improved. Physician's should be doing the assessment." Interview with the CMO revealed the expectation is that the physician should reassess the patient "on the day of surgery, reaffirming the patient's status." Continued interview with the CMO indicated, "The form is not efficient and does not include components of the by-laws." Interview confirmed the patient's H&P did not include all required components.

Interview on 07/21/2016 at 1030 with DPM #1 (Doctor of Podiatric Medicine) revealed he was the physician (podiatrist) who performed the procedure on 06/09/2016. Interview with DPM #1 revealed, "It's (PRE-PROCEDURE/SURGERY PHYSICIAN ASSESSMENT) missing the HPI (History of Present Illness)." Interview following review of H&P requirements in the hospital's by-laws revealed the H&P "Should include pertinent past history." Interview revealed DPM #1's current practice does not align with hospital by-laws.

Based on policy and procedure review, medical record review, and staff interview, the hospital nursing staff failed to assess patient vital signs for 3 of 5 (Patient #4, #5, and #6) patients prior to discharge per policy.

The findings include:

Review on 07/22/2016 of the hospital's policy titled, "Discharge of Patients, D-50-ED-39" revised 07/2016 revealed, "POLICY: ...Prior to discharge, completed documentation to include vital signs within 60 minutes of discharge time, reassessment if change in condition, abnormal vitals [sic] signs are to be reported to the provider ..."

Review on 07/22/2016 of the hospital's policy titled, "Vital Signs, D-50-U-54" revised 02/2015 revealed, "SPECIAL NOTES/SUPPLEMENTAL DATA: PROCEDURE: ICU: 1. Temperature will be taken every four hours unless patient condition warrants a different practice."

1. Medical record review on 07/20/2016 for Patient #4 revealed a 59 year old was admitted on 06/21/2016 at 1805 via emergency medical services (EMS) with a diagnoses of Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Unintentional overdose. Medical record review indicated the patient was transferred to the Intensive Care Unit on 06/21/2016 at 2100 for continued treatment and stabilization. Medical record review the patient was discharged on 06/25/2016 at 1750. Continued review revealed at 1600, the patient's Blood Pressure (BP) was 129/73 and Pulse Rate (PR) 86 (1 hour, 50 minutes prior to discharge). Review revealed at 0931, the patient's Temp. was 98,0; Respirations (R) 20, and SPO2 92% (oxygenation) (8 hours, 19 minutes prior o discharge). Review failed to reveal the patient's vital signs were assessed within one (1) hour of discharge per policy.

Interview on 07/22/2016 at 1000 with the CNO (Chief Nursing Officer) revealed a complete set of VS should be obtained "within one (1) hour of discharge" on all patients. Interview revealed a complete set of vital signs include, BP; PR; R; Temp.; and SPO2. Interview confirmed nursing staff failed to assess vital signs within one (1) hour of discharge per policy.

2. Medical record review on 07/21/2016 for Patient #5 revealed a 72 year old presented to the hospital's emergency department (ED) on 07/13/2016 at 2149 with diagnoses of Sepsis (infection), Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), and Urinary Tract Infection (UTI). Medical record review indicated the patient was transferred from the ED and admitted to the Medical unit on 07/14/2016 at 0058. Medical record review revealed the patient stabilized and was discharged on 07/18/2016 at 1847 and VS were obtained on 07/18/2016 at 1416 were BP 145/77; PR 63; R 20; SPO2 91%; and Temperature 97.9 (4 hours, 31 minutes prior to discharge). Review failed to reveal the patient's vital signs were assessed within one (1) hour of discharge per policy.

Interview on 07/22/2016 at 1000 with the CNO (Chief Nursing Officer) revealed a complete set of VS should be obtained "within one (1) hour of discharge" on all patients. Interview revealed a completed set of vital signs include, BP; PR; R; Temp.; and SPO2. Interview confirmed nursing staff failed to assess vital signs within one (1) hour of discharge per policy.

3. Medical record review on 07/21/2016 for Patient #6 revealed a 59 year old presented to the hospital's emergency department (ED) on 07/13/2016 at 2313 with diagnoses of Chest Pain, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Acute Gastritis (irritation of the stomach lining) with alcohol intoxication, Hypertension, and Anxiety. Review revealed the patient stabilized and was discharged on 07/14/2016 at 1541. Further medical record review indicated the last set of VS were obtained on 07/14/2016 at 1200 (3 hours, 41 minutes prior to discharge) and were BP 137/83; PR 57; R 16; SPO2 97%; and Temperature 98.0. Review failed to reveal the patient's vital signs were assessed within one (1) hour of discharge per policy.

Interview on 07/22/2016 at 1000 with the CNO (Chief Nursing Officer) revealed a complete set of VS should be obtained "within one (1) hour of discharge" on all patients. Interview revealed a completed set of vital signs include, BP; PR; R; Temp.; and SPO2. Interview confirmed nursing staff failed to assess vital signs within one (1) hour of discharge per policy.

Based on hospital policy and procedure review, medical record review, and staff interviews, the hospital case management staff failed to promote a discharge process to ensure the needs of the patient were met for 1 of 5 discharged patients (Patient #3).

The findings include:

Review on 07/21/2016 of the hospital's policy titled, "Discharge Planning", revised 05/2015 revealed, PURPOSE: To provide an organized, coordinated hospital-wide process for the purpose of identifying at an early stage..., any patient likely to suffer adverse health consequences upon discharge if there is not discharge planning. ...Case Management Department 1. ...Case Management initial discharge planning evaluation will include high risk screening for: a. The pre-admission environment b. Activities of daily living (eating, toileting, dressing, etc.) ... f. The ability if any to return to the pre-admission environment ..."

Review on 07/21/2016 of the hospital's policy titled, "Continuing Care/Discharge Planning" revised 05/2015 revealed, "POLICY: ...PROCEDURE: ...I. Discharge to Home - If the patient is discharged home, the Case Manager will assess the: 1. Capability of the family to assume responsibility to understand and follow the treatment plan and to be available for support. 2. Availability of resources in the community, home health services and economic feasibility of staying at home. 2. Phyicial environment of the home in light of the physical capabilities of the patient. ...5. Desire of the patient to return home..."

Review on 07/21/2016 of the hospital's policy titled,"Patient Discharge Procedure" revised 03/2014 revealed, "PURPOSE" To ensure every patient discharged from the care of (Hospital name) is discharge/transferred [sic] safely to the community with appropriate arrangements made for their continuing care. POLICY: Discharge preparation is patient focused; patient/families/caregivers will be encouraged to be involved at all levels of the discharge process..."

Review on 07/21/2016 of the hospital's policy titled, "Discharge Assessment/Reassessment" revised 05/2015 revealed, "PURPOSE: To ensure the patient's discharge needs are assessed by Case Management, ...and reassessed throughout the duration of the hospital stay, up to the point of discharge. ...POLICY: ...The patient, family,. and discharge plan will be reassessed..., or more frequently if necessary, throughout the hospital stay, to determine if the plan needs revisions of additional assistance, Significant change in condition will constitute re-evaluation of patient needs."

Closed medical record review on 07/20/2016 for Patient #3 (visit #1) revealed a 58 year old presented to the hospital's Outpatient Surgery Center on 06/09/2016 for a scheduled open reduction and internal fixation (ORIF: procedure performed to fix a fracture) of the left ankle. Review of the "Patient Order Summary" revealed orders by Doctor of Podiatric Medicine (DPM) #1 to admit the patient to the Surgical Unit and place in Observation at 1400 "for pain management." Review of the nursing interventions and assessment on admission to the Surgical Unit by Registered Nurse (RN) #1 revealed, vital sign results were: Blood Pressure (BP) 154/85 (reference range: 120/80); Pulse Rate (PR) 67 (reference range: 60-100); Respirations (R) 20 (reference range: 15-20); SPO2 (oxygen level) 95% on 2 L/min (liters per minute) supplemental oxygen; 2+ (reference range: 0). Continued review of the nursing assessment revealed the patient presented with pitting edema (swelling) in the left foot with orders to elevate as needed. Review revealed a Fall Risk assessment indicating the patient was at risk due to an "Unsteady/Shuffling gait" as well as other contributing factors, with a score of 9 (score of greater than 8 MUST be placed on High Risk). Medical record review revealed a physician order by DPM #1 on 06/09/2016 at 1100 for Physical Therapy (PT) twice daily to "evaluate and treat in reference to post surgery rehab" (rehabilitation). Further review of physician orders by DPM #1 indicated a "Case Management Consult" for discharge planning was ordered on 06/09/29016 at 1049.

Review of the PT assessment by PT #1 on 06/10/2016 at 1327 included a history of "arthritis pain in shoulders, hip, and back. Pt. reports carpal tunnel syndrome (pain the wrist) in both wrists." Continued review indicated the patient lived with her elderly mother. Review revealed a Fall Risk score 13." Further review of the PT assessment indicated the patient was a fall risk, score increased from 9 to 13 (+4 points). Review of PT evaluation revealed the patient required moderate assistance with overall mobility and all transfers. Review revealed, "Pain, Obesity factor and arthritis make hard for her to get OOB (out of bed)....Plan - Skilled Interventions, Therapeutic Exercises, Balance Activities, Transfer Training...BID (twice daily). ...Suggest Inpt (in patient) rehab."

Review of the Case Management consultative findings on 06/10/2016 at 1525 revealed the patient told Case Manager (CM) #1 that, "She was unable to go home and requests Skilled rehab d/c (discharge)...explained D/C process (private insurance) and pre-cert (pre-certification) needs... she is caregiver for mom who is legally blind... since her injury (date of injury 06/06/2016) she has been in a recliner sleeping with difficulty getting to bathroom... referrals requested to (skilled facility #1) and (skilled facility #2).... Doctor of Podiatric Medicine (DPM #1) notified of pt request and no change in order status at this time. Lead Case Manager (LCM) made aware of pt request and in to see pt and Physical therapy assessed pt and Ins (insurance) Liaison (IL #1) made aware of pt request with d/c order. ...Swing bed (used when skilled and long term care is required) referral discussed with (LCM), spoke with (Hospital A) Swing Bed unit. Home Health offered for d/c...pt states they (HH) would only be there a short amount of time and she needs more care..." Record review revealed consultative findings on 06/10/2016 at 1537 by the LCM stating, " ...Worked with (CM #1) to assist with patient discharge today. Went in and assessed patient's needs .... Home health (HH) PT and bath aide (HHA) offered along with offer to call (Hospital A) to see if they might be interested....Spoke with Admissions Coordinator (Adm. Cord. #1) at (Hospital A), patient declined for service. (Home Health Care Agency) contacted by (IL #1) and they do work with (private insurance) and can provide care starting Monday (3 days post discharge)....Spoke with patient again and informed her of swing bed decline, (Hospital A), and that at this time we needed to move forward with discharge to home with HH PT and HHA to start on Monday (3 days post discharge). Patient is agreeable to plan. Mother will be present with her and ex-spouse will transport and assist to get into home. PT will be out on Monday (3 day post discharge) to eval (evaluate) and make any further recommendations...Informed primary RN (#1) that patient is now ready to be transported down for discharge to home. ...DPM (#1) aware of situation, Home health order obtained by (CM #1)." Review of the Discharge Summary on 06/10/2016 at 1530 indicated the patient was discharged home.

Closed medical record review on 07/20/2016 for Patient #3 (visit #2) revealed she presented to the emergency department (ED) on 06/13/2016 at 1244 via emergency medical services (EMS). Review of the H&P by MD #1 on 06/13/2016 at 1300 revealed Chief Complaint: "Requests Rehab Placement. Pt admitted here 5d (5 days) [actually 3 days prior] for LLE (left lower extremity) fx (fracture) and operative repair. D/C 4d [actually 2 days prior] ago w/o (without) Home Health or placement. Unsafe to accomplish ADL's (Activities of daily living). Requests admission for rehab (rehabilitation) placement."Continued review of the medical record revealed an order by Medical Doctor (MD) #1 for CM consultation on 06/13/2016 at 1403. Review of triage documentation by Registered Nurse (RN) #2 indicated, "Had surgery Thurs., sent home Friday, Pt wanting to be reevaluated for rehab." Review revealed vital sign results were listed as: BP 145/85; PR 71; R 18, Temp. 99.3; and SPO2 98%. Medical record review revealed RN #2 noted, "(CM #2) from Case Management into room to talk with patient, patient's son states he is staying home with mother tonight to help provide care for patient..."
Review of CM note on 06/13/2016 at 1316 by CM #2 revealed, "HHA contacted with (Dir. CM) present, spoke with (Adm. Cord. #3) at (HHA) who stated pt was not able to be admitted to their services due to it being an unsafe environment with Brother who is helping take care of her who was leaving to go back home, and she is taking care of her 80 yr. old blind mother."
Review of PT assessment by PT #1 on 06/13/2016 at 1714 revealed, "Pt received inpt (inpatient) PT evaluation on 06/10/2016 following ORIF of a bimalleolar ankle fx. Therapist suggested inpt rehab upon discharge. Pt was discharged from hospital to HHPT (Home Health Physical Therapy) 06/10/2016. Pt has a walker, crutches and w/c (wheelchair). Pt is not able to use knee walker/scooter because she could not flex her knee (secondary ) to to [sic] edema. Pt is NWB LLE (non-weight bearing, left lower extremity). ...Her mobility is limited mainly to w/c (secondary) to the fact that she can't hop on R (right) foot. Painful L (left) ankle. ...Suggest Inpt rehab."
Continued review of CM notes by CM #2 on 06/13/2016 at 1836 revealed, "(Assistant Director of Nursing: ADON) and (CM #2) in and explained to pt/brother we were d/c pt to home [sic]. stated (ADON) had spoken with ceo and Hospital would pay ambulance bill, and awaiting all 3 facilities to give approval for rehab. Brother stated he was staying tonight with pt and part of tomorrow and could arrange longer if needed, while awaiting for rehab to be approved, ..." Review revealed the patient was discharged home via EMS at 1946.
Interview on 07/20/2106 at 1050 with LCM revealed, the patient was an "observation, surgical patient with plans to go home and there was no awareness of other needs at that time, other than possibility of HH, until PT evaluated her and told her she needed skilled nursing. Interview with LCM revealed, "I visited with patient to feel out the situation to determine if there was a change in plan and her refusal to go home. She said she had an 80 year old mom who can't see. I observed mom ambulating, feeding patient at lunch, she pointed at her (patient) leg and said, 'If that's not a big ole surgery, then I don't know what is' when I was explaining the situation. She could see well enough to point that out....We were trying to work with her to make sure she was getting what she needed." Further interview with LCM indicated HH would be out to evaluate the patient, "the next day", and that she was not aware HH had not evaluated the patient until Monday, (3 days after discharge), when she presented to the ED. Interview revealed the LCM acknowledged documenting a HH assessment evaluation scheduled for the 13th but "thought they were coming out the next day."

Interview on 07/21/2016 at 1040 with PT #1 revealed, "She was not good with transfers and needed more assistance." Interview with PT indicated the patient was "Overweight and it was difficult for her to use one (1) leg and arms together. Her mom was going to have to be her primary care giver and the plan was acute or SNF setting. Continued interview revealed, "No, I do not feel she was discharged to a safe home environment. I did my evaluation and she wasn't there the next day. I was expecting to see her the next day." Interview revealed PT #1 discussed the findings of his evaluation with the CM, LCM, and DPM #1 and shared that according to his assessment, the patient needed further inpatient rehabilitation treatment.
Interview on 07/21/2016 at 1100 with CM #1 revealed, "Mom was support person and patient was her caregiver. There was a gentleman seated in the room during my initial contact with her. Interview with CM revealed, "She said she was going to need help at home and that it had been difficult for her after the injury. She said, 'Just to be honest, it embarrasses me to tell you, but I'm not always making it to the bathroom and have accidents on myself." Further interview with CM indicated, "I discussed the option of HH with her and explained (private insurance) re-cert. requirements." Interview revealed the patient was insistent she needed more than HH. "I discussed with (DPM #1), the PT notes were reviewed. I told him (DPM #1) if she went to a facility, it would take a couple of days and that she would be here over the weekend awaiting recert. He said if we decided she needed to stay to let him know and to keep him informed. We can recertify under observation status but since it was Friday, it would be Monday before we would hear anything. She had transport home, and I believed HH PT would assist at home. HH was asked to see her the next day." Interview with CM indicated she did not observe the patient's mother assist her to the bathroom to determine if she would able to manage her at home. "She (patient) was always in the chair when I was speaking with her." Interview revealed, "We discussed in the IDT (interdisciplinary team) meeting at 1330 that afternoon all agreed she needed additional help at home." Continued interview indicated, "I guess she finally just gave up when she saw we weren't going to be able to get her placed anywhere and agreed (to the discharge plan)."
Follow-up Interview on 07/21/2016 at 1145 with LCM revealed, "I guess what I had in my mind is that she had PT and an HH aide. The gentleman visiting was going to help get her in (the home). I just assumed he was staying with her. (PT) said she could pivot. She was fine with the discharge plans until (PT #1) went in and did his assessment. After that, her focus was on getting into a skilled nursing facility." Interview revealed LCM was not aware HH did not see the patient within 24 hours of discharge. Interview revealed, "I thought they were going to see her Saturday." I see that I put 'Monday' in my notes but I could've sworn they said they would be there Saturday, which is why I felt like it was safe to let her go." Interview revealed LCM was not aware of the patient's difficulties attending to ADL's prior to surgery.
Interview on 07/22/2016 at 0940 with the Director of Case Management (Dir. CM) revealed, "LCM called because of a difficult discharge. (PT) was initially OK with her (the patient) going home prior to his assessment, so they started their process after that." Interview indicated, "I'm not sure but I think the doctor's office told her that when she came in, she was going to stay. I asked about her insurance to make sure and to see if we could make it work, (private insurance) denied. They barely approved out patient stay." Interview revealed, "She couldn't meet and did not qualify for nursing home placement because she did not meet the three (3) midnight stay requirement. I told LCM to load her up with help at home, check with (HHA). There was a man here saying he was willing to help and mom was there feeding her."
Follow-up Interview on 07/22/106 at 1015 with the Dir. CM revealed, "Friday's are bad. The doctors discharge on Friday's but they discharge late and then if the patient or family change their minds, then all of a sudden we're faced with discharge challenges." Interview with Dir. CM indicated, "It is easier on Mondays to get folks referred because more facilities are fully staffed and we have a couple days to work with them and the patient. But, late on Fridays, we don't have that convenience." Interview with Dir. CM indicated it is "understood" that the HH agency will send a nurse to the home within 24 hours following a patient's discharge to ensure continuity of care. "That's why we don't like the weekend because of the communication gap. HH doesn't call us when or if they are not able to see the patient within 24 hours." Further interview revealed "We're not gonna send anyone home that's not gonna be able to go to the bathroom. It's just not the right thing to do." Interview with Dir. CM revealed she was not aware of the difficulties the patient had getting to the bathroom prior to surgery.
NC00119106, NC00118261, NC117809