HospitalInspections.org

Based on clinical record review, staff interview and review of facility documents and complaint information, the facility staff failed to ensure the grievance policy was followed when a concern was identified and communicated to the facility staff regarding Patient #12.

The findings included:

Patient #12 was admitted to observation status on 11/16/17 with the diagnoses that included, but not limited to: chest pain. Patient #12 was discharged on 11/18/17. After the patient had been discharged, a concern was communicated to the facility regarding the patient's discharge. Review of the facility "Grievance Log" did not reveal any evidence of this concern. In an interview with Staff Member # 20 (System Lead Case Management), on 1/18/18 at 11:18 a.m., the surveyors discussed whether or not the facility had addressed the concerns that had been communicated to them regarding the discharge for Patient #12. Staff Member #20 stated, "We were notified by Home Health liaison (Staff Member #24) and he/she indicated the patient was readmitted to (another hospital) and what had happened...I can't speak to the complaint not being in the grievance log...What I will do is follow-up that a complaint came through them...I did not log this as a grievance when it came to me...I will evaluate if when this came in at the point of entry it was escalated as a grievance through the liaison; whether or not (he/she) reported it as a complaint or not... I did not escalate it through the grievance process...."

Review of the facility policy and procedure "Patient Complaint/Grievance Process in the Hospital" was reviewed and evidenced, in part: "...Definition of Terms: Patient Grievance: 1. A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient's representative, regarding the patient's care..VI. Procedure...3. Hospital employees are expected to respond to complaints expressed by a patient or their representative. If the employee is unable to resolve the patient complaint, he/she should take initiative to escalate the issue to the appropriate manager and/or the Patient Relations Department..."

On 1/18/18 at approximately 4:15 p.m., the surveyor discussed the findings with the facility Administrative Leadership.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure one (1) of eight (8) Patient's whose records were reviewed for discharge planning needs, contained the designation or the refusal of designation of a person to be involved in their care plan and discharge planning needs, Patient #12.

The findings included:

Patient #12 was admitted to observation status on 11/16/17 with the diagnoses that included, but were not limited to: chest pain. Patient #12 was discharged on 11/18/17. Review of the clinical record for Patient #12 on 1/18/18 revealed documentation in the EMR (electronic medical record) under "Care Act designee: Unable to obtain information" dated 11/16/17. There was no further documentation that any other attempt to obtain this information was done during the patient's stay. This was evidenced during review of the clinical record on 1/18/18 at 11:06 a.m., with Staff Member # 5 (Registered Nurse/Navigator) who confirmed the designation was not present in the clinical record

The facility policy and procedure "Patient rights and Responsibilities" was reviewed and evidenced, in part: "...A. Patient Rights The Patient has the right to: ...12. Designate a caregiver/Care Act Designee, as an inpatient, who will be an integral part of the discharge planning, educated on tasks associated with home based care and support the patient once he/she leaves the hospital for home..."

On 1/18/18 at approximately 4:15 p.m., the surveyor discussed the findings with the facility Administrative Leadership.

Based on staff interview, clinical record review, and review of facility policy and procedure, the facility staff failed to ensure the patient plan of care was updated to include the use of restraints/seclusion for three (3) of eight (8) patient records reviewed for restraint usage. This included Patient # 4, #5, and #6.

The findings included:

Patient #4 was admitted on 1/10/18 with diagnoses that included, but were not limited to: Acute respiratory failure with hypoxia (lack of oxygen to the organs and tissues of the body) and severe sepsis (a life threatening complication of an infection). Review of the clinical record revealed orders for the use of "non-violent" restraints (left and right soft wrist restraints) to prevent the patient from pulling out "lines and tubes" and interfering with medical care. According to the clinical record, the patient had to be intubated (tube placed in the patient's throat in order for the patient to be able to breathe) as the patient was not able to tolerate less invasive treatment. The patient was ordered the restraints initially on 1/16/18 and 1/17/18 (in use at the time of the survey). Review of the clinical record with the assistance of Staff Member #5 (Registered Nurse/Navigator) on 1/17/18 at 11:00 a.m. did not reveal a modification to the patient's "care plan" to include the use of the restraints. At 11:10 a.m., Staff Member #5 stated, "I don't see it...let me see if they addressed it somewhere else...No, it's not there. They should have put it in when the restraints were first started..."

Patient #5 was admitted on 1/16/18 with diagnoses that included, but were not limited to: sepsis and respiratory failure. The clinical record was reviewed on 1/17/18 at 11:40 a.m., and revealed an order written initially on 1/16/18 for the use of "soft wrist restraints" (non-violent). Further review of the clinical record did not reveal a "care plan" that included the use of the restraints. Staff Member #5 assisted the surveyor to navigate the record. At 11:45 a.m., Staff Member #5 stated, "The restraints were discontinued today, but there was nothing added to the care plan."

Patient #6 was admitted to the facility on 1/7/17 with diagnoses that included, but was not limited to: Guillain-Barre Syndrome. Review of the clinical record with Staff Member #5 revealed an order for "soft wrist restraints" (non-violent) which was written on 1/16/18. Further review of the clinical record revealed no "care plan" for the use of the restraints. Staff Member #5 stated, on 1/17/18 at 11:55 a.m., "There is no care plan for the restraints."

Review of the facility policy and procedure "Restraints and Restraint Alternatives" revealed the following: VII. Medical Restraint: Non-Violent and/or Non-Self Destructive Behavior and Behavioral Restraint: Violent and/or Self-Destructive Behavior...B. Documentation 1. The following must be documented in the EHR (electronic health record)... g. Plan of Care and any modifications...2. Documentation on a daily basis must include the following components: ...g. Modifications to the plan of care as applicable...

On 1/18/18 at approximately 4:15 p.m., the surveyor discussed the findings with the facility Administrative Leadership.

Based on interview, record review, and review of the facility's policies and procedures, the facility staff failed to ensure that one (1) of six (6) records reviewed for discharge planning, included a discharge planning evaluation, Patient #12.

Findings include:

A MSW (Masters of Social Work) Intern from a college with which the facility has an agreement, wrote the following note dated 11/17/17 at 11:34 a.m. under Social Worker #15's log in : "MSW intern spoke to patient and caregiver at bedside. Patient initially was cooperative, but when the writer attempted assessment [patient] became quickly agitated. The writer deferred to gather assessment information from the caregiver, but the caregiver reported that [he/she] is unable to release any information due to the patient's request. SW will attempt d/c (discharge) planning at a later time". The note did not identify who the caregiver was, and was not co-signed by Social Worker #15 who was supervising the intern. A discharge assessment was not available for review in the record.

An interview was conducted with Staff Member (SM) #20, the Case Management System Leader, on 1/18/18 at approximately 11:30 a.m. SM #20 stated, " a discharge assessment wasn't done that we can see in the chart. If it had been opened/filed, it would be in here".

At 3:15 p.m. on 1/18/18 the Case Management Manager #9 presented the surveyor with a blank copy of the document "Initial Discharge Planning Assessment" and stated " [Patient #12] did not have an initial discharge planning assessment on that admission".

The facility's policy and procedure entitled, "Discharge Planning, Multidisciplinary Team" was reviewed. The following was noted: "I. Policy 1. The case managers and social workers, working in conjunction with the multidisciplinary team of physicians, clinical nurses, pharmacists, specialists, and ancillary services, will devise a patient-centered treatment plan leading to restoration of health and continued care in the outpatient setting...3. The personalized treatment plan should begin at the time of admission, resulting in a patient-centered discharge plan that includes continued follow-up care to the next appropriate level of care...

Procedure A. Discharge Planning Process 1. The discharge planning process begins at the point of admission. Medicare participating hospitals must identify patients who need or have requested a discharge plan at an early stage of their hospitalization. 2. All patients placed in a bed (inpatient or observation) in the acute hospital will be screened for discharge needs. 3. Using an interdisciplinary approach to patient care, a proper and patient-centered treatment plan should be initiated, education surrounding the disease process begun, a discharge date established, and discharge planning initiated. B. Screening and Assessment Case Management will: 1. Establish the goals of treatment upon admission. 2. Establish a discharge date. 3. Verify support system, both internal and external, e.g. housing, primary care physician, care givers if noted, family support or other support systems...9. Assess prior level of function and patient's ability to return to the pre-hospital environment...".

C. Planning Discharge planning includes: 1. Coordination with the plan of care to establish a discharge plan. 2. Seeking the assessment of the multidisciplinary team; enhancing the screening and assessment process. E. Documentation of the Discharge Plan Documentation of the discharge plans include: a. Understanding of the discharge plan by the patient, family and/or care giver. b. Patient choice has been given and documentation of the provider chosen as indicated. c. Indication patient understands medications, has a follow up appointment and understands the treatment plan as established by the the attending physician during hospitalization...e. Handoff of information to the home health agency, skilled nursing facility, or acute inpatient rehabilitation facility assuring a safe transition of care and a verified treatment plan...g. Indication the discharge plan was discussed upon discharge from the acute level of care to the next appropriate level of care".

Concerns were discussed with Staff Member #20, the Case Management System Leader on 1/18/18 at approximately 11:20 a.m. The findings were also discussed with members of the administrative team, for a final time, on the afternoon of 1/18/18.

Based on interview, record review, and review of the facility's policies and procedures, the facility staff failed to ensure that one (1) of six (6) records reviewed for discharge planning included a discharge assessment which was developed by or supervised by a registered nurse, social worker, or other appropriately qualified personnel, Patient #12.

Findings include:

A MSW (masters of Social Work) Intern from a college with which the facility has an agreement, wrote the following note dated 11/17/17 at 11:34 a.m. under Social Worker #15's log in : "MSW intern spoke to patient and caregiver at bedside. Patient initially was cooperative, but when the writer attempted assessment [patient] became quickly agitated. The writer deferred to gather assessment information from the caregiver, but the caregiver reported that [he/she] is unable to release any information due to the patient's request. SW will attempt d/c (discharge) planning at a later time". The note did not identify who the caregiver was, and was not co-signed by Social Worker #15 who was supervising the intern. A discharge assessment was not available for review in the record.

An interview was conducted with Staff Member (SM) #20, the Case Management System Leader, on 1/18/18 at approximately 11:30 a.m. SM #20 stated, "I do not believe we have a policy and procedure (P&P) in place defining roles and responsibilities for supervising students. There are a number of opportunities we will be addressing. The intern documented under Social Worker #15's sign in. It is the process for social worker interns to write under supervising staffs sign in, then that staff goes into the note and says they agree with observations and documentation by the student. That isn't the case here. Social worker #15 did not sign the note". SM #20 added " a discharge assessment wasn't done that we can see in the chart. If it had been opened/filed, it would be in here".

At 3:15 p.m. on 1/18/18 the Case Management Manager #9 presented the surveyor with a blank copy of the document "Initial Discharge Planning Assessment" and stated " [Patient #12] did not have an initial discharge planning assessment on that admission".

The facility's P&P entitled "Discharge Planning, Multidisciplinary Team" was reviewed and stated in part the following information: "I. Policy 1. The case managers and social workers, working in conjunction with the multidisciplinary team of physicians, clinical nurses, pharmacists, specialists, and ancillary services, will devise a patient-centered treatment plan leading to restoration of health and continued care in the outpatient setting...3. The personalized treatment plan should begin at the time of admission, resulting in a patient-centered discharge plan that includes continued follow-up care to the next appropriate level of care...V. Procedure A. Discharge Planning Process 1. The discharge planning process begins at the point of admission.

Concerns were discussed with Staff Member #20, the Case Management System Leader on 1/18/18 at approximately 11:20 a.m. The findings were also discussed with members of the administrative team, for a final time, during the afternoon of 1/18/18.