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Based on interview, observation and record review (RR), the facility's discharge planning process failed to reduce the factors leading to a preventable hospital readmission or negative outcome in two of five patients sampled that were discharged home. P1 was discharged after a two day length of stay for diabetic ketoacidosis and expired five days post discharge. In addition, P2 required 24/7 supervision, but the facility failed to establish a safe discharge plan with her family member (FM), who requested she be sent home, which did not meet P2's needs. As a result of this deficiency, P2 fell again, and was readmitted. Due to the serious nature of these events, it was determined to be a Condition level deficiency in discharge planning.

Findings include:

1) P2 is a 96 year old female with history of chronic back pain, diabetes type 2, gastric and liver mass, chronic anemia and dementia. She had cognitive impairment and was alert and oriented x 2 (aware of their identity and place, but does not know time or situation). P2 lives alone and has a family member (FM) that is actively involved in her care. Her primary language is Japanese, but she can make needs known. P2 had multiple falls, three of which resulted in hospitalizations, 05/12/2024-06/04/2024, 01/20/2025-01/23/2025, and 02/20/2025-current.

RR of P2's 05/12/2024 admission revealed the following entries: Physician Discharge Summary dated 06/04/2024: "She presented after being found in the bathtub. She did not know how long she was in the bathtub or how she got in." P2 had a subdural hematoma (bleeding near the brain after head injury) and a fracture of lumbar vertebrae (L1). Discharge disposition indicated P2 was to be discharged to a skilled nursing facility.
Clinical progress notes by Physical Therapy dated 06/03/2024 at 10:25 AM: "Current recommendations: Discharge Disposition: STR (short term rehabilitation) to LTC (long term care) or setting with 24/7 supervision. Caregiver support at current level of function: Continuous supervision for bed mobility, transfers, and ambulation due to cognition, memory, judgement, insight, impulsivity, fall risk, and safety awareness. Barriers to discharge requires significant assist for ADL's (activities of daily living), insufficient activity tolerance, cognitive status, and impaired safety awareness with risk of falls. ..."

Review of P2's medical records during hospital admission date 01/20/2025 revealed the following entries:
Physical Therapy Evaluation/Discharge dated 01/21/2025 included: "...Pt (P2) is near her functional mobility, however it is unsafe for pt to return to prior living situation as she lives alone with very limited assistance and remains a high fall risk. Recommending home with HHPT (home health physical therapy) and with 24/7 supervision. ...Caregiver support at current level of function: Continuous supervision for bed mobility, transfers, and ambulation due to cognition, memory, judgement, insight, impulsivity, fall risk, and safety awareness. ..."
01/22/2025 at 04:58 PM, Care Coordinator notes: "Chart reviewed and FM/POA (power of attorney) called on 1/21 and 1/22 to discuss discharge planning. FM aware of recommendation for 24/7 assistance/supervision as it was also recommended prior to last discharge. FM reports that she has 2 surveillance cameras in place in patient's home that she checks regularly and will alert her if there is no movement in a specific amount of time. Aware of the risk of not having someone present 24/7. Patient has declined placement to care home/foster family, assistive living per FM. Patient with private duty caregiver along with caregiver through Office of Aging and home delivered meals. FM regularly sees patient daily in the evening. FM scheduled to return from Las Vegas on 01/26/25. During her absence, she schedule [sic] a private pay caregiver to assist with care. Friend lives on same property. Anticipating DC (discharge) tomorrow 1/23 (Thursday). FM set up for patients friend ...to pick patient up at 2 PM. Private duty caregiver will meet patient and friend at patients home to provide care on arrival. Called Office of Aging to confirm discharge for tomorrow. Home delivered meals to resume on Saturday or Monday. FM aware and states she had prepared meals in patients home for patient that caregiver is able to assist with."
01/23/2025 at 06:42 AM, Physician (MD)1 Discharge Summary:
- "...Pt's neighbor checked on the patient and found her sitting on the floor. When Pt was asked what happened, she says she simply tripped over. Somewhat unreliable history because she is only A&Ox2 (alert and oriented to) (self, location)). She answers questions better in Japanese. She answers less reliably in English. ...XR (xray) shows no fracture. ...Pt requested to be discharged home but the FM ...requested to get the patient admitted for observation. ...FM is currently on the flight to Las Vegas.
- "pt has a caretaker that visits her twice a day, and FM takes care of the mom daily."
- "discussed with pt's FM, and informed her about the recommendations from therapy which was 24/7 care. FM informed me this was the same recommendation from her mom's prior hospitalization. FM understands, but wants to respect her mom's decision of remaining at Hale Mahoulu (living community). Pt has informed FM, that she would rather die and fall at home. If the pt was moved to another facility, the pt will kill her self as per FM. ...The patient was found to have a UTI (urinary tract infection)."

RR of 02/20/2025 to current admission revealed the following entries: Medical history and physical dated 02/20/2025: "96 yr old woman ...who presented after an unwitnessed fall with complaint of right hip pain. ...She has had multiple falls over the last year. One occurred while her Family Member (FM) was traveling. While FM enroute to her destination, she was not reachable. This resulted in APS (Adult Protective Services). Today, the patient's FM was at a meeting with APS when FM's mother fell again. ...Spoke to APS Case Worker, ...and informed patient needs placement for 24/7 care. ...confirmed that FM is working with ...for LTC Medicaid and plans to apply on March 1st ..."

On 02/28/2025 at 10:00 AM, met with P2 at bedside. She was lying in bed, pleasantly confused with calm demeanor. P2 smiled and was able to answer simple yes and no questions, but not interviewable due to her level of cognition.

Reviewed the facility policy titled "Discharge Planning" with revised date of 05/2024. The policy included: - Discharge Planning: "A process that is consistent with the patient's goals for care and treatment preferences, ensures an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable readmission." - "The process includes the following components: ...4.1.8 Implementation of a safe discharge plan that reduces the likelihood of a hospital readmission."
- "5.2.7 When the patient's or patient representative's goals and preferences are unavailable or do not support the care needs, the care management team will work with the patient or patient's representative to develop a discharge plan that can be implemented."

On 02/27/2025 at 11:00 AM, interviewed Case Manager (CM) in the conference room. She was familiar with P2 and currently working on the discharge plan with FM. She said she knew the FM had put cameras in P2's home and that she had met with APS. CM agreed that cameras were not an appropriate substitute for 24/7 supervision. CM said they now have a physician statement that P2 was incapacitated and unable to make her own decisions, which may have been seen as a barrier by FM as she wanted to honor P2's wishes to stay home. The CM agreed that although they did not have a physician statement of competency on the earlier admissions, P2's cognitive impairment was the same. CM went on to say if FM truly didn't want to place P2, other options could have been explored to find a safe compromise, such as day care seven days a week with paid caregivers at her home the rest of the time. The CM said P2 is currently waiting to be placed.

2) Cross Reference A802 Discharge Planning Re-Evaluation
P1's condition was not reassessed to ensure his nutritional needs would be met post discharge. It was a priority to ensure P1's blood pressure was controlled and the nausea/vomiting, so he had adequate nutrition. P1 was treated with intravenous medication for high blood pressure approximately two hours prior to leaving the hospital, but the BP was not rechecked. In addition, he had a critical alert level platelet count that needed timely follow up post discharge and his PCP did not get copies of the medical records. P1's discharge instructions included "Diabetes and Alcohol: Care Instructions," but did not include instructions for hypertension, Diabetic Ketoacidosis or thombocytosis. P1 expired four days post discharge.

Based on interviews, record and document review, the facility failed to reevaluate one patient's (P)1 condition of a sample size of five to ensure he was stable for discharge. P1's status at discharge was 1) he had not been adequately monitored to ensure he would have adequate intake to meet his nutritional needs after a change of medication, 2) he was given intravenous medication for high blood pressure (BP), without a recheck approximately two hours before discharge and 3) he had an alert platelet value related to thrombocytosis that was not addressed in his discharge instructions or with a timely referral for follow up. This deficient practice put P1 at high risk of complications, readmission or death.

Findings include:

A review was conducted of P1's medical records, which revealed the following:
P1 was a 35-year-old male with a history of Diabetes Type 1 (DM1), gastroparesis (condition where stomach empties contents more slowly), alcohol use disorder, essential thrombocytosis (abnormally high platelets, not lifethreatening, but the complications of blood clots or severe bleeding, can be), and hypertension. He had a history of being noncompliant with his medical treatment and was seen in the ED three times in the previous six months. P1 presented to the Emergency Department on 10/09/2024 with nausea/vomiting and high blood sugar. He was admitted with diagnosis of ketoacidosis (life-threatening complication of diabetes) and transferred to the intensive care (ICU) at approximately 07:00 AM on an insulin drip and could have nothing by mouth (NPO). R1 transitioned to subcutaneous (under the skin injection) insulin and transferred out of ICU on 10/10/2024. A new order for cardiac, diabetic consistent carbohydrate diet was entered at 09:29 AM. R1 was discharged home 10/11/2024 and expired four days later.

On 10/09/2024 at 06:40 AM, a Clinical Dietician (RD)1 documented: "Current Intake: Inadequate but appropriate: NPO Status." The goal was to resume oral diet when medically appropriate.

On 10/10/2024 at 12:33 PM, Physician (MD)1, documented a discharge summary after examining him in the ICU. The discharge summary included: "Date of Discharge: 10/10/2024. ...Reason for Admission: DM1 DKA (Diabetes Mellitus Type 1, Diabetic ketoacidosis), intractable nausea and vomiting, moderate cannabis use, severe alcohol use, htn (hypertension) essential thrombocytosis. LOS (length of stay) 1 day ...He (P1) was treated in ICU standard protocol. He admits to noncompliance with insulin. No other factor were [sic] identified for trigger of DKA. He improved with hospitalization, was transitioned to subcutaneous insulin. He is being discharged with continued outpatient follow-up." MD1 wrote a discharge order at 12:25 PM that was later discontinued at 02:56 PM. An order to transfer out of ICU was entered 10/10/2024 at 02:56 PM.

On 10/10/2024 at 05:15 PM, Nursing note: "MD1 informed that pt BP 203/166 HR (heart rate/pulse) 105, not yet due for IV prn (intravenous as needed) hydralazine (for high blood pressure) or IV prn labetalol (for high blood pressure). Pt also nauseated and vomiting with no relief from odt Zofran and not due for IV prn Phenergan. MD, okay for RN to place order for 12.5 mg IV x1 and to increase prn IV Phenergan from 12.5 mg to 25 mg; regarding BP he will review pt's chart and no additional orders at this time."

On 10/11/2024 at 04:59 AM, Nursing note: "..Multiple episodes of vomiting/retching. Minimal relief with Zofran. Felt no relief from Phenergan. Valium given for feelings of agitation due to constant nausea/vomiting. Tolerates only small sips of water. ... cl (clear) liquid as tol (tolerated). ...BS (blood sugar 227, 208. No coverage (insulin) given due to unable to keep food/fluids down. ..."

Review of Intake and Output (I&O) documented after transfer to telemetry included: Emesis: 10/10/2024 at 10:00 AM: 60 ml. (milliliters (2 ounces))
10/10/2024 at 01:00 PM: 1 unmeasured 10/10/2024 at 02:00 PM: 2 unmeasured 10/10/2024 at 03:00 PM: 3 unmeasured 10/10/1014 at 04:00 PM: 3 unmeasured 10/10/2024 at 05:00 PM: 400 ml. (13.6 ounces) 10/10/2024 at 08:05 PM: 200 ml. (6.8 ounces) 10/10/2024 at 09:53 PM: 240 ml. (8 ounces)

Stool output: 10/10/2024 at 08:00 AM: "loose liquid." 10/10/2024 at 02:00 PM: "loose stool small liquid" 10/10/2024 at 09:53 PM: "loose"

Urine output and color (urine color changes from clear to orange with hydration level) 10/10/2024 at 05:24 AM: unmeasured 10/10/2024 at 08:00 AM: unmeasured 10/10/2025 at 02:00 PM: 475, yellow 10/10/2024 at 05:00 PM: 175, yellow amber 10/10/2024 at 08:10 PM: unmeasured, yellow amber 10/10/2024 at 10:20 PM: unmeasured, yellow amber 10/11/2024 at 01:00 PM: yellow amber

Total Fluid Intake (excluding IV fluids) 10/10/2024: PO fluids, 540 ml
10/11/2024: PO fluids, 480 ml

Food intake: 10/10/2024 at 02:00 PM: 25% (first meal since NPO) 10/11/2025 at 08:32 AM: Breakfast refused, 10/11/2024 at 11:15 AM: 50%

Weights: 10/09/2024 210 lb. (documented as stated weight) 10/11/2024 191 lb. 9.3 oz

On 10/11/2024 at 07:41 AM, MD1 put in a new order for Metoclopramide (Reglan) 10 mg by mouth for nausea and vomiting, three times a day before meals. The first dose was administered on 10/11/2024 at 08:27 AM. R1 refused breakfast, after that dose. The second dose of Reglan was administered at 11:49 AM. R1 ate 50% of lunch prior to being discharged shortly after lunch.

On 10/11/2024 at 09:34 AM, MD1 wrote the order to discharge P1.
On 10/11/2024 at 09:35 AM, MD1 documented an addendum to the discharge summary written 10/10/2024. The discharge date was changed to 10/11/2024. The addendum added: "Patient stayed overnight for intractable nausea and vomiting and uncontrolled hypertension. This had improved with the resumption of Reglan and low-dose benzodiazepines for anxiety. Prescriptions were given and he is being discharged home today. Patient does have chronic known thrombocytosis. There is no history of thrombotic complications. This needs to be followed as an outpatient. At the time of discharge: Patient's condition is stable for discharge." The addendum documented the last BP of 146/106, which was taken before he wrote the discharge order, It also included the last diet intake over the past 24 hrs to be 25% of breakfast (first meal after NPO) on 10/10/24. There was no documentation regarding P1's nutritional intake after that or the IV hydrolazine at 11:48 AM on 10/11/205 for high blood pressure.

On 10/11/2025 at 09:56 AM, nursing note: "...Critical platelets=1042 (high platelet count can cause blood clots/reference range 150-450 10 (9)L). MD (1) notified. 1143 (11:43 AM)-hydralazine IV given; BP 182/107. ..." There was no repeat BP after the IV medication was given or prior to P1's leaving the hospital at 01:00 PM. It is the standard of nursing practice to monitor response of medication.

On 10/11/2024 at 09:56 AM, dietitian note: "Follow up re: nutrition therapy education. N/V noted overnight, Pt sound asleep during time of visit. Healthy Hawaii Daily Food Guide for Diabetes Meal Planning handout left at bedside. RD to follow up with education as able/appropriate."

Reviewed the" After Visit Summary," discharge instructions, which were documented to be given to P1 at 11:10 AM. The discharge instructions included "Diabetes and Alcohol: Care Instructions," but did not include any instructions/education related to diabetic ketoacidosis, thrombocytosis or hypertension. In addition, P1's primary care physician was not notified of the hospitalization as his name had been somehow "unlinked" to P1's account. The instructions said to "F/u (follow up) PCP (primary care physician) 1-2 weeks."

On 02/27/2025 at 10:13 AM, interviewed RD2. She confirmed there was a consult order for dietician for P1 written on 10/09/2025. She said in general; they need to wait until someone is out of ICU and off the insulin drip. RD2 said many times a DKA patient just needs diet education, but if having cyclic vomiting and not tolerating food, despite noncompliance, would do education, but the priority is to ensure his nutritional needs are met. She went on to say, in this case, he had nausea and vomiting and need to make sure we are "getting enough into him." RD2 said P1 was sleeping when she went to see him 10/11/2025 and wasn't going to wake him because he had been throwing up all night. At that time, she was not aware he was being discharged that day.

On 02/28/2025 at 09:30 AM, interviewed RD1 in the conference room. She said the consult for P1 was acknowledged and he was NPO and going through insulin therapy. RD1 said with intractable nausea and vomiting, it would be important to make sure he is eating well and gets good nutrition. "At least 50 % of meals on an average, anything less than 50% would be inadequate." P1 had one meal 10/11/2025 documented at 50% and he went home shortly after.

On 2/27/25 at 01:00 PM, interviewed RN1 in the conference room. She confirmed she discharged P1 on 10/11/2024 and said she was only assigned to him one day. RN1 said she recalled he had nausea and got Reglan that morning. She said she reviewed the discharge instructions and medications with him and told him to make an appointment with his PCP. RN1 said P1 had lunch before he left. She confirmed after the discharge order was written, she notified MD1 of the platelet critical value and high blood pressure and received an order to give P1 IV medication for the blood pressure. She acknowledged she should have, but did not check a repeat blood pressure after the administration of the IV medication and prior to his discharge.

On 02/28/2025 at 10:30 AM, interviewed MD1 in the conference room. He said from his recall, P1 had recurrent DKA, came into the ER dehydrated and went to ICU on insulin drip. MD1 said "he improved overnight and did well on the floor. He tolerated diet and discharged the following day." MD1 confirmed his documentation of dates and content of the discharge summary and addendum. He said, "it seemed to be a pretty straight forward case," as there did not seem to be anything else except the noncompliance with medication that triggered the DKA. When asked MD1 if he had access to view I&O documentation, he responded yes.

On 02/27/2025 at 09:10 AM, interviewed the Registration Supervisor (RS) in the conference room. She said she had been made aware there was an issue with P1's PCP not showing on this admission, and explained someone had "unlinked" the name to the account. She said the PCP was present on the last admission, and looked like someone at the clinic rather than the hospital unlinked it, but was unable to determine specifics. She went on to explain it was importanct so the PCP is notified when a patient is admitted, and has access to the medical records. RS said the PCP can be added to the account at any time when an error is identified.

Reviewed the facility policy titled "Discharge Planning" with revised date of 05/2024. The policy included: - Discharge Planning: "A process that is consistent with the patient's goals for care and treatment preferences, ensures an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable readmission." - "Reassessment of the patient's condition to identify changes that require modification of the discharge plan. ..."
-"Implementation of a safe discharge plan that reduces the likelihood of a hospital readmission." - "5.3.3 Hospital records, including but not limited to medical information pertaining to the patient's current course of illness and treatment, post discharge goals of care and treatment, are transmitted to the PCP upon discharge."