HospitalInspections.org

Based on interviews and record review (RR), the Hospital (H)1 did not ensure an effective transition at the time of discharge for one patient (P)1 of a sample size of three. P1 was not competent to provide self-care for his diabetes management, which included checking blood sugars and administering insulin injections. H1 failed to ensure the designated care giver (CG) had the supplies and training required to immediately meet P1's care needs upon discharge. Specifically, there was no order for the needles that attach to the insulin pen, so the medication could be administered, and P1 did not have a working glucometer. In addition, the CG did not receive sufficient inhospital training prior to discharge. As a result of this deficiency, P1 did not receive the insulin as ordered and went to the Emergency Department on 02/15/2024 for hyperglycemia (high blood sugar level). Due to the nature of the deficiencies, this resulted in a Condition Level deficiency in Discharge Planning.

Findings include:

1) The Office of Healthcare Assurance (OHCA) received a report from an external agency on 02/21/2024, regarding allegations of self neglect by P1. The report included: "1. A vulnerable adult's (P1) inability or failure, due to physical or mental impairment, to perform tasks essential to caring for oneself. ... "AV (alleged victim) was hospitalized at H1 from approximately from 12/30/2024 - 02/12/2024 after police did a wellness check and found AV naked/confused on the floor; H1 stated AV needed 24 hour care and would be waitlisted for ... but it is unknown why AV was discharged home instead without any plan for AV's care. -Per H1, AV is suppose to take insulin and is unable to administer his own insulin or check his own blood sugars; ... 2. The vulnerable adult appears to lack sufficient understanding or capacity to make or communicate responsible decisions and appears to be exposed to a situation or condition that poses an immediate risk or death or serious physical harm. ...A. AV's capacity to make decisions appears questionable because AV is not oriented to time or place and sometimes not oriented to person. B. AV may be at immediate risk for serious physical harm or death if his blood sugars are out of control. ...-Shortly before AV was hospitalized, he attempted to drive and backed into his neighbors parked car. ..."

2) P1 was a 75 year old male admitted to H1 on 12/30/2024. The Emergency Department Provider note revealed he had been found on the floor of his house after neighbors called for a welfare check. He lived alone and had not been taking his insulin for an unknown period of time. P1 was admitted to Intensive Care for diagnosis that included dehydration, hyperglycemia (high blood sugar), DKA (Diabetes ketoacidosis-a serious complication due to lack of insulin), and dementia. A family member (FM)1, was designated his Durable Power of Attorney (POA) for Healthcare decisions. P1's medical condition improved, and his level of care (LOC) was changed to SNF/ICF (Skilled Nursing Facility/Intermediate Care Facility) level on 01/04.2023. He was discharged home with FM1 on 02/05/2024. On 02/15/2024, P1 returned to the Emergency Department for hyperglycemia.

2) Reviewed P1's PT note dated 01/23/2024. The note included:
"Interval History: Per discussion with case management and per chart review, current plan is to continue to work on LTC (Long term care) insurance for placement. Case management aware of discharge from PT today and transition to restorative aide program. ...Assessment: Pt reached a plateau with physical therapy, being limited mostly due to cognition. When pt given education or a task at hand, pt not able to remember the sequence, or is not sure of what to do next and needs spv/SBA (supervision/Stand By Assistance) with mobility to due this. ..."

Reviewed P1's Occupational Therapy Treatment note dated 01/23.2024. The note included: "...Assessment: Pt continues to require 1 P SBA (one person stand by assist) at times CGA (Care giver assist) for mobility and transfers related to ADL's (Activities of Daily living, i.e. Ambulating, dressing, bathing). Due to memory challenges pt needs step by step cuing to initiate and complete ADL's ... For safety reason, it is recommended that patient does not live by himself and engage in tasks such as cooking and driving. Pt needs assist to maintain his safety in mobility and ADL's together with assist with DM (Diabetes Management) and medication management. ...Plan: ...the plan is to transition to restorative. Discharge Disposition Recommendations: 24/7 assist for needs in health management and safety during mobility and ADL's and IADL's (instrumental activities of daily living, i.e. cooking). ..."

When P1 was discharged from PT/OT service, the plan was P1 would be going to another facility rather than home.

3) Reviewed the Case Management (CM) and Social Worker (SW) progress notes which included, but not limited to the following:
01/02/2024 CM note: "Discussed patient (P1) after IDT (interdisciplinary) meeting. Plan for SNF rehab (rehabilitation). ..."
01/03/2024 CM note: PT (physical therapy) recommending SNF. ...Pt Denies having wife or children. No family on island and lives alone. Monitor d/c (discharge) needs."
01/05/2024 CM note: "...DC plan is for SNF. Referrals made to facilities. Awaiting accepting facility. ... "
01/06/2024 SW note: "FM1 confirmed that there is limited support as FM1 is in Arizona and they have a cousin in Waimea. There is no one available to check on patient daily. ...FM1 hopes to fly out in a few days. ..."
01/11/2024 CM note: "...Patient is SNF LOC (level of care) and there is a problem with disposition. Patient aware that FM1 is coming to the island this weekend but unsure if FM1 will be able to stay with him after discharge. Patient is alert and aware that he needs to be independent with care before going home. ..."
01/15/2024 CM note: "...CM spoke with patient's FM1. FM1 is concerned about patient inability to care for himself. FM verbalizes patient's home is a "mess". FM1 knows patient denies needing help but would like patient to be in a "care home" and to start process for LTC (long term care). ..."
01/15/2024 SW note: "... Plan is to sell patient's home and get him into a care home in Hawaii. ..."
01/16/2024 CM note: "...Patient verbalized and agreed that he needs "long term care." Patient aware that FM1 will assist to get him a proper place. .."
01/17/2024 CM note: "... DC plan: SNF. Barriers: 1. Lives alone 2. No LTC insurance 3. Over Asset d/t home owner. ..Chart Review: ...3. CM re-sent SNF referrals 1/16/24..."
01/18/2024 CM note: "Patient participating in PT/OT and recommends SNF. No accepting facility at this time. ...Patient to continue with PT/OT in acute setting unless there is accepting facility and safe discharge is determined. ..."
01/19/2024 CM note: "...Patient lives alone and unsafe. Patient needs assistance but no family or friend available to assist. Patient's FM1 will be assisting with LTC process. ..."
01/22/2024 CM note: "...Discharge still mainly with LTC due to safety issue being home alone. ...Patient with Restorative aide with activities. ..."
01/23/2024 CM note: "...Possible downgrade to ICF (intermediate care facility/LOC) this week. CM/SW to continue working on LTC insurance for placement with patient's FM1."
01/26/2024 CM note: "...Pt will need LTC or Care Home Placement. ..."
01/31/2024 CM note: "...LOC ICF. Patient discussed in HIGH Risk meeting today. ...Per NP (Nurse Practitioner): a. Pt is forgetful ..."
02/01/2024 SW note: "...FM1 back on island. Would like to discuss a home plan. ..."
02/02/2024 at 10:04 AM, CM note: 1. ...Family meeting scheduled... 2. FM1 expressed wanting to take pt home to his house, ...b. FM1 will continue working on LTC after H1 discharge. ... 5. CM called & spoke with NP re:dc plan,=Monday 2/5/2024. 6. CM requested NP to include the following: 7. DC orders/summary to go home 8. DME (durable medical equipment) order re: FWW (front wheel walker)... 8. Home Health orders re: Med (medication) management and PT."
02/02/2024 at 11:00 AM, SW note: "...FM1 would like to take patient home. SW and CM discussed the necessary steps to DC patient and take him home safely. ...-Patient and family teaching re: insulin/diabetes management - Referral to HH (home health) for medication management. FM1 will continue to work on selling patient's home and then using funds to pay for a private care home. SW and CM explained that once Dc'd, a external SW will be assigned and will help patient and FM1 for LTC insurance once he qualifies. SW and CM will no longer be able to assist w/application and placement ..."
02/05/2024 CM note: "...DC home today with FM1. ...Update:
"1. ...Outpatient SW: referral sent."
"2. Home Health PT & RN for education/meds: referral placed."
"4c. Possible admission with ....(HH) RN (Registered Nurse) on Wednesday 2/7/2024."
"5. CM spoke with RN: a. Requested pt teaching/education re: DM (glucometer/insulin dose & administration).
"6. CM spoke with Restorative Therapy...confirmed SBA (stand by assist) re (regarding): ambulation. "9. FM1 planning to p/u (pick up) Rx (prescriptions) before picking pt up at H1 ...today. ..." "14. At 3:46pm -...FM1 re: arrived at pts beside with glucometer. a. RN called CM to re: family at bedside. b. CM/SW met FM1 with pt in hallway. c. RN asked pt to return to bed for privacy re:teaching/dc instructions d. Pt chose to stay in hallway. e. Pt explained and demonstrated proper technique to check blood glucose. f. CM instructed FM1 -best/safe practice to dispose used lancet into disposable plastic bottle and cap, prior to discarding in trash."
"15. CM/SW witnessed RN completing all DC instructions and DM teaching. ..."

5) RR of P1's acute care admission revealed the following:
02/05/2024 at 10:55 AM, Registered Nurse (RN)1 progress note: "patient (P)1 is A&O x2-3, oriented but forgetful. ...Patient is to be discharged today to go to FM's home (P1 actually went to his home with FM1) per CM (Case Manager).

02/05/2024 at 04:45 PM, RN1 progress note: "...Patient discharged from unit via wheelchair accompanied by Social Worker ...All DC (discharge) instructions/handouts given to patient. Patient and FM1 verbalized understanding of discharge education." Review of P1's "After Visit Summary (discharge instructions)," revealed instructions included "...Pick up your medications at ...Pharmacy... : "Atorvastatin (for cholesterol), Blood-Glucose Meter (to test blood sugar), insulin glargine-yfgn (long acting injectable insulin pen to control blood sugar), magnesium oxide (treat or prevent low magnesium), Metformin (oral diabetes medicine) and OneTouch Verio test strips (use with meter).

RR revealed there was no documented discussion regarding P1's dementia and cognitive status or education of how to manage behaviors when caring of him. In addition, there were no instructions provided that P1 should not be driving or cooking for safety reasons.

6) RR revealed documentation of follow up after discharge phone call made on 02/08/2024 at 11:57 by Quality Staff (1). The Note read "Contacted and spoke to Family Member (FM1) of patient (P)1, who is here from Arizona trying to assist patient, who notes that he is doing ok, seems a lot better (walking using his cane), but that he is NOT monitoring his blood sugars as instructed nor taking his insulin. She states both he and their brother manage their diabetes in their own way and FM1 feels like its not FM1's place to tell him what to do, as they are adults. FM1 confirms that she did pick up the Rx at discharge and can confirm that she reminds him to take his pills and he has been compliant with them. HH (Home Health) did contact her and will be coming tomorrow to do evaluation. ... Discussed importance of regular MD follow up, medication compliance and plan of care. ..."

7) On 05/30/2024 at 09:30 AM, during an interview with the Nursing Director (ND), she said it would be the expectation diabetic management education would include "print out teaching materials," as well staff demonstration and return demonstration of hands on by the patient and family of the tasks required, such as checking blood sugars using the glucometer and administering insulin injections. The ND reviewed the nursing progress notes and medical records and confirmed she did not see any documentation that FM1 demonstrated ability to use the glucometer, and there was no notation that FM1 or P1 received education or demonstrated ability to administer the insulin. The ND agreed it would be the standard of care if there was a designated caregiver that they would also be trained to assist with ADL/IADL needs and how to safely provide "Stand by assist/SBA" and review what P1's functional ability was and the type of care FM1 needed to assist with. ND said the education should be documented, and if they have a hard time with the task or procedure, it should be repeated. ND said PT/OT would be the ones that do the caregiver training for ADL assistance.

On 05/30/2024, at 11:00 AM, during an interview with the Case Manager (CM)1, she said they often will have a psychiatrist evaluation to determine competency, but did not see any documentation regarding his competency. Inquired if CG, FM1 had any training, and she said on the day of discharge, she observed P1 doing the glucose test. CM1 said she thought it was a brand new glucometer that FM1 brought in at the time of dicharge. She said she sent a referral to the HH agencym, who said they could possible do the admission at the home on 02/07/2024. CM1 said she had asked RN1 to do the teaching.

On 05/30/24 at 12:00 PM, during an interview with the Social Worker (SW), when asked about the decision to discharge home rather than LTC, she said she thought the family decided they wanted to take him home and continue to pursue placement from the outside after selling the house. She said she thought P1 had a problem with remembering to take his insulin. SW said she recalled being the hallway and P1 was doing "the teach back" with the glucometer and FM1 was trying to help, but he wasn't going to let her be any part of it. When inquired about his competency, she said "I assume he is not competent, as we were going through the POA."

On 05/31/2024 at 09:15 AM, interviewed the Registered Nurse (RN)1, who confirmed she discharged P1 on 02/05/2024. When asked about his cognitive status, she said "he would say things that would make me think he didn't know exactly what was going on. He was hard to direct sometimes." RN1 said she recalled saying hello to FM1. She said Case Management was present and talking to FM1, and "we were all in the hall." RN1 said FM1 brought in a glucometer, but that "there was a problem with it." She did not remember the exact specifics, but that she thought FM1 did not have the strips for that glucometer and the ones we had didn't work in that meter, so they had to use the hospitals glucometer. "Something wasn't working with the glucometer. I did show her how to do a blood sugar check in the hallway and we were able to get a BS (blood sugar) before he left." RN1 said they usually provide education on how to do the insulin injection the same time they teach the glucometer, but had not done it that day. She said she thought maybe she had been thinking P1 was still going to a long-term care facility.

8) On 05/30/2024 at 11:15 AM, during an interview with Home Health staff (HH)1, HH1 said the initial admission visit to P1's home was on 02/09/2024 (tentative date documented by CM was 02/07/2024). At that time, HH1 found out P1 had not been monitoring his blood sugar and had not been taking the insulin as prescribed. An inventory of supplies was done, and HH1 said there was no functioning Glucometer at the home to check blood sugar and no insulin pen needles to attach to the insulin pen, so it could be administered. HH1 went on to say FM1 said H1 did not teach her how to give the insulin. HH1 said she contacted the pharmacy and confirmed they had an order for the glucometer, but had not been picked up, but they did not have an order for the needles. HH1 facilitated the order. On 02/15/2024, HH1 made the second home visit and said P1's "glucose was in the 400's, and it was clear taking the insulin was still not a priority, so recommended P1 go to the ER (Emergency Room) immediately for treatment."

9) On 05/31/2024, confirmed with the outside Pharmacy the following:
On 02/05/2024 (day of discharge), the following six items were picked up:
-Atorvastatin
-insulin pens
-magnesium oxide
-Metformin
-lancet supplies
-test strips supplies
There was no order for the needles that are needed to use with the insulin pens.

On 02/09/2024, the following two items were picked up:
- needles for the insulin pens
- glucometer

10) Reviewed P1's medical record of Emergency Department visit on 02/15/2024. Records included"
02/15/2023 at 02:14 PM: RN Triage Note: "Sent by ...home health agency for evaluation of elevated blood glucose, reading >600 mg/dl @ home."
02/15/2024 at 02:35 PM: lab resulted Glucose 721(target 80-150 older adults with type 2 diabetes)
02/15/2024 at 04:51 PM, Provider notes: "... Patient recently discharged with new insulin schedule, he has not been taking his insulin as scheduled. ...Patient given fluids, IV (intravenous) insulin, education was performed on checking his blood sugar and administering his insulin both with the patient and the patients wife (P1 was not married, FM1 accompanied)." The clinical impression included "Hyperglycemia," and Medication noncompliance due to cognitive impairment."
02/15/2024 at 05:00 PM RN note: "Extensive education given to family and patient, demonstration of blood glucose with patient able to repeat multiple times on own in demonstration of glucometer and insulin administration."
02/15/20224 at 05:06 PM, lab resulted Glucose of 366.
P1 was discharged back home.