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Based on the manner and degree of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM was out of compliance.

A-0286 -(a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities .....(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Based on interviews and document review, the facility failed to identify causative factors surrounding patient safety events and implement preventative actions. Specifically, the facility failed to analyze potential causes and implement preventative measures for three of three adverse patient events reviewed with the quality department.

Based on the manner and degree of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING was out of compliance.

§482.43(b) Standard: Discharge of the patient and the provision and transmission of the patient's necessary medical information. The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.

Based on record review and interviews, the facility's failed to identify the causative factors surrounding a patient safety event and implement actions to prevent reoccurrence. Specifically, the facility failed to analyze potential causes and implement preventive measures for one of one adverse patient discharge event which was not reviewed by the quality department. (Cross-reference A-0813)

Facility policy:

The policy Incident Reports read, an incident report will be completed for any incident deemed to be inconsistent with the normal or routine operation of the facility or the care of patients. Incident reports are prepared in anticipation of litigation, and for protection of the facility in the event of actual litigation, and therefore are considered confidential documents.

Additionally, any employee who witnesses or has knowledge of an incident shall, as soon as possible, complete the report in the incident reporting system. Reports must be completed prior to the end of the shift for the employee completing the report. An incident report must be completed when one of the following events has occurred, however the list is not considered to be all inclusive. These events include; any disturbance which does or may disrupt unit/hospital functions, a significant violation of established policy or procedure, or anytime a patient is transported to the hospital or emergency room. The rationale for submitting an occurrence report is for improving the facility's services.

Also, the Director of Quality Management will review each reported occurrence, and is the only one with authority to officially close an incident. Follow-up by the Director of Quality Management shall be completed as soon as practical after the occurrence has been entered into the incident reporting system. Prior to closing an incident, the Director of Quality Management shall conduct all appropriate follow-up, which may require interactions with one or more staff members before resolution can be obtained. Follow-up will be documented in the incident reporting system and filed as an attachment to the incident report.

1. The facility quality department failed to review, analyze potential causes and implement preventative measures following one of one adverse patient discharge event involving Patient #3. (Cross-reference A-0813)

A. Interviews

i. On 4/20/21 at 9:23 a.m., an interview was conducted with Chief Executive Officer (CEO) #1 regarding an adverse patient event. CEO #1 stated Patient #3 was transferred to a skilled nursing facility (SNF) that was not prepared or equipped to provide care for the patient who required a tracheostomy tube (a surgically created hole through the neck into the trachea (windpipe) to create an airway). The SNF would not accept the patient admission, and subsequently the patient was transferred to an emergency department.

The CEO said the process for a patient transfer to a SNF is the responsibility of and arranged by the case management department. This is the standard process for discharge planning of a patient to a SNF.

ii. On 4/21/21 at 2:14 p.m. another interview was conducted with CEO #1. CEO#1 said the discharge of Patient #3 was an unusual event but an incident report was not filed for Patient #3 because the event was an employee performance issue, not a reportable incident.

However, see above; the facility policy read an incident report will be filed when there is a significant violation of established policy or procedure, or anytime a patient is transported to the hospital or emergency room. Cross-reference A-0813; Patient #3's discharge and transfer to a SNF was not managed by the case management department in accordance to facility policy which led to the patient being transferred to a hospital emergency department. According to Incident Reporting policy, both of these events require the employee aware of the event to file an incident report.

iii. On 4/22/21 at 7:57 a.m., an interview was conducted with Licensed Practical Nurse (LPN) #6. LPN #6 stated she was the nurse caring for Patient #3 at the time of the patient's discharge and transfer. LPN #6 stated the process of patient discharge to a SNF is handled through the case management department. She said she did not know the receiving SNF could not care for the Patient #3 until after the patient had left the facility. She stated she was not timely updated by the facility's case management team of Patient #3's discharge and she was not prepared to transfer care of the patient to another nurse at the SNF. She said she was given the name of the SNF receiving Patient #3; however, she had to look up the phone number for the SNF and locate the correct nurse at the SNF to receive the report on the patient's care, treatment, services, current condition. LPN #6 stated when she told the receiving nurse the patient had a tracheostomy, the SNF nurse told her they could not care for a patient with tracheostomy.

LPN #6 stated she did not file an incident report for this event, as she did not know the process for filing an incident report. LPN #6 further stated administration did not review Patient #3's discharge and transfer incident with her to understand what caused the incident and to prevent reoccurrence and ensure safe and effective patient discharges in the future.

iv. On 4/22/21 at 9:28 a.m., an interview was conducted with Director of Quality Management (DQM) #5. DQM #5 stated she was unaware of the discharge event involving Patient #3 because an incident report was not filed with the Department of Quality. DQM # 5 stated if there had been an incident report filed she could have begun an investigation. However, contrary to facility policy, the incident was not entered into the incident reporting system, which prevented follow up and analysis of the incident.

Based on interview and record review, the facility failed to provide all necessary medical information pertaining to one of three patients' (#3) course of illness and treatment prior to a planned discharge and transfer to a skilled nursing facility (SNF). The failure led to an unplanned and unnecessary emergency department visit and the patient's discharge to an alternate SNF two days later.

Facility policies:

The facility policy Discharge Planning read, case managers and other members of the healthcare team will collaborate with patients, families, physicians, healthcare team members and community resources to ensure that all patients are provided discharge/transition planning. The facility provides a collaborative delivery or discharge/transition planning to each patient which includes analysis of initial assessment findings to determine discharge needs, the development and implementation of the discharge plan, evaluation of discharge plan, appropriateness with on-going monitoring and coordination of the final preparations for discharge and/or transitioning of care.

Additionally, nurses will communicate to the patient, family and designated caregiver of the date of discharge and confirm transportation arrangements. The nurses will provide the designated caregiver with discharge instructions and written information. The nurse will document the discharge activities in the medical record. The discharge activities include discharge instructions, outcome of the teach back of the instructions which include return demonstration, and clearly identify the disposition of the patient to a skilled nursing facility (SNF). The nurse will communicate and coordinate with healthcare providers at the SNF across the continuum pertaining to the patient as applicable.

Case managers will communicate and collaborate with patient, family or designated caregiver and members of the health care team to develop a safe and effective discharge or transition plan of care, avoiding duplication and fragmentation consistent with the patient's goal for care for his or her treatment preference. The case manager will confirm all necessary medical information is transferred and acceptance noted for post discharge needs for ordered service. The case manager will communicate and coordinate with the healthcare providers across the continuum which includes skilled nursing facilities.

The facility policy, Patient Safety Hand Off Communication, read a "hand off" of information between staff provides information about the patient's care and accurate information about the patient's care, treatment, services, current condition and any recent and anticipated changes. Hand off communication occurs during a shift change, physicians transferring responsibility for a patient, physicians transferring on-call responsibility, temporary responsibility for staff leaving the unit for a short time, reports from one unit to another, reports between hospitals, reports of critical values to physician's offices, reports to providers in the continuum of care including nursing homes and home health care.

1. The facility failed at the time of discharge to transmit to the receiving SNF, necessary information on Patient #3' medical needs, contrary to regulation and facility policy to ensure a safe and effective transition of care.

A. Interviews

i. Interviews conducted with Chief Executive Officer (CEO) #1 and Licensed Practical Nurse (LPN) #6 revealed the facility failed to confirm all Patient #3's necessary medical information was transferred and acceptance noted by the receiving SNF regarding the patient's post discharge needs.

a. On 4/20/21 at 9:23 a.m., an interview was conducted with CEO #1. CEO #1 stated she received a call on Friday 12/4/20 from the facility's nursing supervisor that Patient #3 was denied admission to the SNF she had been discharged to earlier that day. CEO #1 stated Patient #3 was in a transfer ambulance in route to the SNF when the SNF informed the facility discharging nurse (LPN #6) it would not accept the admission because Patient #3 required oxygenation through a tracheostomy tube (a surgically created hole through the neck into the trachea (windpipe)). CEO #1 stated the SNF reported it could not manage a patient with a tracheostomy tube.

CEO #1 stated when she learned the SNF could not manage Patient #3, the patient's bed had already been assigned to another patient; therefore, Patient #3 could not return to the facility. CEO #1 stated she called around, located a local hospital that would take the patient and worked with the case manager there, who arranged for Patient #3 to be transferred to the hospital's emergency department. CEO #1 stated she worked with the hospital's case manager Saturday (12/5/20) and Sunday (12/6/20) to locate an appropriate SNF placement for Patient #3.
CEO #1 stated she did not know if, on 12/5/20 and 12/6/20, Patient #3 had been admitted to a hospital bed or had stayed in the emergency department.

b. On 4/22/21 at 9:23 a.m., an interview was conducted with LPN #6. LPN #6 stated she cared for Patient #3 the day she was scheduled for discharge from the facility and transfer to the SNF. LPN #6 stated she was not told Patient #3 was being discharged and transferred to the SNF very far ahead of time. She stated she had less than an hour to prepare the patient for discharge. She. further stated the transfer ambulance arrived before she had given the hand off report on the patient's care, treatment, services, and current condition to the receiving nurse at the SNF.

LPN #6 stated that because she was not updated by the facility's case management team of Patient #3's discharge, and she was not prepared to transfer care of the patient to another nurse at the SNF. LPN #6 stated she was given the name of the SNF receiving Patient #3; however, she had to look up the phone number for the SNF and locate the correct nurse at the SNF to receive the hand off report. LPN #6 stated when she told the receiving nurse the patient had a tracheostomy, the SNF nurse told her they could not care for a patient with tracheostomy.

LPN #6 stated she then called the facility nursing supervisor to let her know the receiving SNF could not accept Patient #3. LPN #6 stated the transfer event occurred at the end of her shift, and she later found out the patient went to a hospital emergency department. LPN #6 stated a hand off report is important to ensure the patient is transferred to a safe place. She said hand off reports often occur after a patient has left the facility.

c. On 4/21/21 at 2:14 p.m., another interview was conducted with CEO #1. CEO #1 stated the discharge and transfer of Patient #3 to the SNF was assumed to be a safe transfer, but it was not. CEO #1 stated she could not see evidence in the medical record that the SNF had accepted the patient for transfer, contrary to facility policy.

2. Interview with the facility's Case Manager (CM) #4 confirmed facility failed to transmit necessary information on Patient #3' medical needs to the receiving SNF, contrary to regulation and facility policy to ensure a safe and effective transition of care.
On 4/21/21 at 7:58 a.m., an interview was conducted with Case Manager (CM) #4. CM #4 stated the role of the CM is to coordinate the discharge planning. She said the CM is responsible for communication between the facility, the family, the discharging nurse and the receiving SNF.

CM #4 explained, when a patient is prepared for discharge, the CM is responsible for providing the nurse in charge of the discharge with the contact information at the receiving facility. She confirmed the communication of contact information did not occur with Patient #3's discharge and transfer on 12/4/20.

She further stated there is a huge risk to the patient's care if they are not sent to the correct SNF, and if the receiving facility or SNF cannot not accept the patient, then the patient should come back to the facility. She said, however, that accepting the patient back was the decision of the CEO.

B. Medical Records

i. Review of Patient #3's medical record revealed the events above were not documented in the patient's record or reviewed by the facility's QAPI committee (Cross-reference to A-0286). Patient #3's record lacked documentation of any communication between the facility and the hospital where the patient was sent on 12/4/20. Further, the patient's record lacked documentation of communication between the facility and the receiving SNF. Specifically, the medical record lacked evidence of the patient's transferred medical information which would have included the patient had a tracheostomy tube for breathing. Further, the medical record lacked evidence of a hand off report to the receiving facility.

ii. An additional medical record review was completed for Patient #1 who was also transferred to a SNF. Patient #1's record, too, lacked documentation of communication between the facility and the receiving SNF. The medical record lacked evidence of a hands off report.

Based on record review and interviews, the facility failed to document in three of three patients' medical records (#1, #3 and #7) that a list of post discharge skilled nursing facilities (SNFs) had been presented to the patient or to the patient's representative as part of the discharge planning process. (Cross-reference A-0813)

Facility policy:

The facility policy Discharge Planning read, case managers and other members of the healthcare team will collaborate with patients, families, physicians, healthcare team members and community resources to ensure that all patients are provided discharge/transition planning. The facility provides a collaborative delivery or discharge/transition planning to each patient which includes analysis of initial assessment findings to determine discharge needs, the development and implementation of the discharge plan, evaluation of discharge plan, appropriateness with on-going monitoring and coordination of the final preparations for discharge and/or transitioning of care.

Case managers will communicate and collaborate with patient, family or designated caregiver and members of the health care team to develop a safe and effective discharge or transition plan of care, avoiding duplication and fragmentation consistent with the patient's goal for care for his or her treatment preference. The case manager will perform an initial discharge planning evaluation for early identification and thorough assessment of patient's likely post-hospitalization needs including determination of the availability of the appropriate post-hospitalization services as well the patient's access to these services. The case manager will communicate and coordinate with the healthcare providers across the continuum which includes skilled nursing facilities.

1. The facility failed to provide documentation in Patient #3's medical record, as well as Patients #1 and #7's medical records, that a list of SNFs was presented to the patient or to the patient's representative as part of the discharge planning process.

A. Interviews

i. On 4/21/21 at 12:13 p.m., an interview was conducted with Case Manager (CM) #7. CM #7 stated a list of SNFs is provided to a patient and patient's representative at the initial assessment; however, CM #7 stated if the patient has a preference of SNF, the patient and/or patient's representative is not given a list of names of SNFs. (See below; Patient #3 chart did not document a preference or a list of SNFs.)

ii. On 4/20/21 at 2:14 p.m., an interview was conducted with Chief Executive Officer (CEO) #1. CEO #1 confirmed patients are not given a list of SNFs if the patient or patient's representative has already selected a SNF. However, there is a risk to the patient if the patient or patient representation does not have a preference and are not provided a list of options.

iii. On 4/21/21 at 2:57 p.m., an interview was conducted with the Director of Case Management (DCM) #4. DCM #4 stated family involvement is important and the case managers needs to be the primary advocate for the chronically ill.

B. Medical Records

i. Three of three medical records lacked evidence a list of SNFs was provided to the patient or patient's representative as part of the discharge planning process.

a. The medical record for Patient #3 lacked evidence a list of SNFs was provided to the patient's spouse or documentation the patient had a preferred SNF and therefore, did not require a list of options. Lack of evidence of documentation was confirmed by CNO # 2 and Director of Quality Management (DQM) #5.

b. The medical record for Patient #1 lacked evidence a list of SNFs was provided to the patient's proxy decision-maker. Lack of evidence of documentation was confirmed by Chief Nursing Officer (CNO) # 2 and DQM #5.

c. The medical record for Patient #7 lacked evidence a list of SNFs was provided to the patient's spouse. Lack of evidence of documentation was confirmed by CNO # 2 and DQM #5