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Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure safe discharge for a patient suspected to be a victim of abuse/neglect (0145). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient.

The IJ was identified on 5/22/24 at 1:45 PM. The IJ template was provided to the facility on 5/22/24 at 2:30 PM and an acceptable IJ removal plan was received at 4:44 PM on 5/23/24. On 5/23/24, verification of the IJ removal plan was conducted and included the following: review of staff re-education sign in-sheets and staff interviews regarding the facility's process for suspected patient abuse/neglect. The IJ was lifted on 5/23/24 at 4:50 PM.

Cross Reference:
482.13(c)(3) Patient Rights: The Right To Be Free From All Forms Of Abuse Or Harassment

Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure a safe discharge for a patient suspected to be a victim of abuse/neglect.

Findings include:

On 5/21/2024 at 11:03 AM, during a review of the medical record (MR) for Patient (P)1, in the presence of Staff (S)1 (Regulatory Coordinator), S3 (Quality Coordinator) and S4 (Nurse Manager), the following was revealed:

On 5/1/2024, P1 arrived at the facility's Emergency Department (ED) with complaints of right arm pain.

A Case Management Progress Note, dated 5/2/2024 at 10:26 AM, stated the following: " ... PT [patient] was recently at [name of facility] Acute Rehab [Rehabilitation]. SW [social worker] advised [P1's son/daughter] that we anticipate a discharge to rehab. SW explained SAR [Subacute Rehab] level of care. Per [son/daughter], he/she will have to discuss further with [his/her] [brother/sister] as PT will not be agreeable. Of note, due to the frequency of this pt's falls, rehab is encouraged. SW to follow accordingly ... ."

Physical Therapy (PT) Evaluation note dated 5/3/2024 at 3:55 PM, stated, " ... [he/she] will benefit from rehab to address noted impairments and optimize pt's functional status for safe return home with family. ... ."

On 5/5/2024 at 2:40 PM, an addendum written by S9, a physician, stated, " ... [Son/daughter] at bedside who does not know the patient's history well and appeared to be making up information. ... Plan: ... - I am highly concerned about this patient being a victim of elder abuse/neglect given multiple falls and extensive fractures apparent on imaging. Home is not a safe environment. Will refer to SW for safety assessment. Patient needs to find a new living situation under monitored conditions. ..."

On 5/6/2024 at 8:27 AM, a progress note documented by S8, a Licensed Social Worker, stated, " ...SW received chat yesterday from internal medicine, suspecting abuse of neglect due to multiple falls and extensive fractures. SW added CM [case management] leadership to the chat to best know how to proceed and help DC [discharge] plan safe. ..."

On 5/6/2024 at 3:29 PM, a progress note documented in P1's medical record by S33 Resident of Internal Medicine, stated, "... - Low suspicion for elder abuse given multiple family members very concerned about his/her status, possible neglect given he/she is stubborn and forces family to let [him/her] ambulate alone and falls. ... -Concern for neglect/ insufficient supervision at home. - Spoke with [grandchild] who reports patient has many many[sic] family members at home and [he/she] is never alone but is independent and often walks alone and falls despite family being present. Given culture preferences, would not like to send patient to LTAC [Long Term Acute Care] as this will be seen as a breach of filial duties. Given concern about poor supervision, will recommend family to come in for education regarding steps to prevent further falls. - Will have SW set up APS [Adult Protective Services] investigation on DC. ..."

On 5/6/2024 at 4:16 PM, a progress note was entered into P1's medical record by S34, a physician in the Geriatric Medicine department. The progress note stated, "Given wavering concerns of elder abuse/neglect by primary team, would recommend referral to APS for thorough investigations. ..."

On 5/10/2024 at 1:41 PM, a progress note documented by S8, a Social Worker, stated "SW reviewed the referral portal this AM. There are no acceptances for this patient, but at 8:30 am their 1st choice [rehab facility name] denied patients referral due to no beds available. ... for this reason they want to refuse rehab and do a home with assist plan. ... SW still aware of the instructions given to me previously, that I must call APS upon DC."

A discharge order was placed in the medical record on 5/11/2024 at 1:49 PM by S35, a Resident of Internal Medicine. The discharge summary stated, " ... Patient worked with PT and was recommended rehab, however patient and family prefer for [him/her] to be discharged home with PT. Given [his/her] frequent and extensive fractures, an APS evaluation is also planned- SW reminded of this need on the day of discharge, and they will be reaching out. ...Pertinent Physical Exam at Time of Discharge...Neurological: Mental Status: [he/she] is alert. Mental Status is at baseline. Comments: AO [alert oriented] to person, able to say in hospital but not which one, unable to say month, year or season, but answering questions appropriately, seems to be baseline per family..."

On 5/11/2024 at 3:30 PM a progress note was documented in P1's medical record by S32, a Social Worker, which stated, "SW contacted [name of county] APS to advise of DC home despite safety concerns being addressed with family. APS office closed today as their business hours are M[Monday]- F [Friday], SW left voicemail and advised they contact CM [Case Management] department with any additional questions at [CM phone number]."

On 5/14/2024 at 10:53 AM, a progress note was documented by S8, a Social Worker, stating "SW called APS as instructed today at 10:40 AM. [APS county and phone number]. Representative did question why we D/C'd [him/her] home if we thought there was abuse/neglect. SW gave the story and background from beginning to end."

On 5/21/2024 at 11:26 AM, S8, a Social Worker, stated that he/she was involved with the discharge of P1. S8 stated that he/she did not feel comfortable with P1 being discharged into the community with family, because there was suspected abuse and/or neglect. The family of P1 declined having P1 discharged to a skilled nursing facility due to cultural beliefs and values. S8 stated that he/she made referrals for community resources and services. S8 stated that he/she last spoke with P1's family on 5/10/24 to discuss a discharge plan, and then P1 was discharged on 5/11/24, without his/her knowledge. S8 stated that P1 should have never been discharged from the facility on a weekend without speaking to someone from Adult Protective Services (APS) due to the suspicion of abuse and/or neglect in the home of P1.

On 5/21/2024 at 1:28 PM, an interview was conducted with S9, a Physician, S9 explained that he/she learned of P1's history and saw images of multiple fractures. S9 stated that he/she only cared for the patient for one day and then his/her rotation ended. He/she stated "I had multiple red flags. The first red flag was because [he/she] has so many injuries that could have been prevented. The second red flag was when I spoke with the [son/daughter] it seemed like [he/she] was so disconnected and almost laughing at the fact of trauma presented." S9 explained that he/she advised the oncoming medical team and social work of concerns for abuse. He/she also stated, "If I thought a patient was being abused, I would keep the patient in the hospital until the patient is safe."

On 5/21/24 at 1:45 PM, during an interview was conducted with S8, a Social Worker, he/she stated "APS asked why the patient went home. I said, 'I knew this conversation would happen and that APS would be disappointed that [he/she] was discharged. I didn't think [he/she] was going to be discharged over the weekend."

On 5/21/24 at 2:11 PM, S21, a Case Manager, stated that he/she was involved and aware of the case of P1. S21 stated that P1 should not have been discharged on 5/11/24 because of possible abuse and/or neglect in the home, due to P1's history of multiples falls in less than six months, resulting in multiple fractures.

On 5/22/24 at 10:02 AM, an interview was conducted with S6, a Director of Case Management and Social work. S6 stated that if he/she felt that a patient who was being discharged home to his/her family where abuse and/or neglect was suspected, then he/she would apply for guardianship of the patient. S6 stated that he/she didn't feel that P1 was discharged in a safe manner. S6 also stated that "someone" should have interviewed P1 by themselves to get the exact feelings of P1 being discharged home with family.

On 5/22/24 at 11:11 AM, S22, a Case Manager, confirmed that he/she did not document the discharge of P1 in medical record. S22 stated that in hindsight P1 should not have been discharged on 5/11 due to suspected abuse and/or neglect.

Facility policy titled, "Elder Abuse RWJUH New Brunswick," dated 7/14/2022, stated, " ... 2. If there is substantial evidence or reason to suspect that the patient is being abused and/or neglected, the social worker will refer the patient to Adult Protective Services Unit within the county of the patient's residence. ... 3. The social worker will collaborate with the Adult Protective Services Unit and will refer to the other community agencies/resources, as appropriate, to establish ongoing support, care and follow-up. ..."