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Based on staff interviews and record review staff failed to ensure the physical and emotional comfort and safety of 1 of 13 applicable patients who was discharged home, alone, following a traumatic MVC (motor vehicle collision). (Patient #1). Findings include:
Per record review Patient #1 was evaluated and treated, in the ED (Emergency Department) for injuries sustained following a motor vehicle collision on 1/26/15. The patient arrived in the ED via ambulance with complaints of left wrist and left hip pain. X-rays of the left wrist identified fractures of both the radius and ulnar bones. A pain assessment completed by RN (Registered Nurse) #1, during triage upon arrival in the ED at 4:57 PM, revealed that the patient identified the wrist pain as 10/10 (on a scale of 1-10 with 10 being the worst pain). Although the patient had also complained of pain in the left hip there was no evidence of any assessment of the hip to clearly identify the intensity of pain or aggravating or alleviating factors associated with the pain. The patient received pain medication at 7:39 PM and again at 10:04 PM during two separate procedures to realign the fractured wrist bone/s. Although pain assessments were conducted during recovery from the sedative used during the second procedure, between 10:14 PM and 11:00 PM, and the patient identified wrist pain as 8/10 each time, there was no evidence that interventions to reduce pain, including pain medication, were offered, and no further pain assessments were conducted prior to the patient's discharge almost 2.5 hours later at 1:22 AM. In addition, and although there had been no assessment of the left hip pain Patient #1 had identified on arrival in the ED, a nurse's note, at 12:45 AM on 1/27/15, stated; "Pt was having some difficulty ambulating from stretcher to wheelchair....." A note by Physician #1 stated; 'patient was hesitant to go home at the end of visit. [S/he] reported [s/he] could not walk, and [his/her] complaint was hip pain, but was able to bear weight and was able to be transitioned into a wheelchair. X-rays show no fracture, dislocation, and there was no pain to palpation on exam and no pain to ROM on PE....' There was no further indication of what was causing the hip pain, and there was no evidence that a trial of ambulation had occurred, prior to discharge, to determine if walking would aggravate the hip pain, potentially prohibiting ambulation and increasing the risk to patient safety. The patient, who lived alone, was discharged home in the company of a family member, at 1:22 AM on 1/27/15, and was given 2 Percocet (narcotic pain reliever) tablets at that time, to be used at home. The Discharge Instructions provided to the patient were specific to the wrist injury and use of splint and sling that had been applied, and did not address hip pain.

During interview, at 7:15 AM on 2/25/17, RN #2, who was responsible for providing direct care to Patient #1, acknowledged the lack of evidence of pain assessments and stated that, the patient had complained, at the time of discharge, of spasms in his/her left hip causing pain, and had expressed concerns about going home as s/he was concerned about not being able to ambulate. S/he stated that s/he had reported this to Physician #1 who had evaluated the patient and determined the patient was ready for discharge. RN #2 stated that s/he had observed Patient #1 take a step or two to transfer from the wheel chair to the car, at discharge, but had not observed the patient ambulate any further. RN #3, who had also interacted with Patient #1 around the time of his/her discharge, confirmed, during interview on 2/25/15 at 7:40 AM, that the patient had been quite hesitant to go home. RN #3 also stated that s/he had not observed Patient #1 ambulate. S/he stated that the family member who escorted the patient had returned to the ED, after leaving with the patient, and verbalized that s/he did not know what to do about getting Patient #1 from the car into his/her home. RN #3 stated that s/he provided a wheel chair to the family member for use in transferring Patient #1 from the car into his/her home.

Physician #1 confirmed, during interview at noon on 2/26/15, that Patient #1 had expressed hesitancy, at discharge, at going home related to pain in his/her hip. The physician stated that a physical assessment of the hip did not produce pain or identify limitations, the x-ray had not shown any fracture or dislocation and the patient had been able to bear weight. S/he further stated that s/he had assumed, that the home in which the patient resided, included the presence of other people. Physician #1 stated that, although s/he had not documented it, s/he had given the patient the option of remaining in the hospital. However, because inpatient beds were full at the time, the patient was informed that s/he would have to remain on an ED stretcher, and therefore the patient reportedly made the decision to go home. Physician #1 further stated that, in terms of adequate pain management, it is his/her general practice to address pain with patients each time s/he sees them throughout their ED visit and therefore s/he would have done the same for Patient #1. S/he stated the patient was given pain medication for home use after discharge.

Per record review Patient #1 returned to the ED, via ambulance, at 1:20 PM on 1/27/15, approximately 12 hours after his/her discharge from the ED. ED physician documentation included: '....presents by ambulance with increased pain in the left hip and inability to ambulate at home......Family has concerns of patient ambulating at home and being able to take care of [him/herself]..--will obtain a CT to look for any signs of occult fracture or other traumatic injury explaining [his/her] pain.' Diagnostic testing revealed a 2 vertebral fractures in the patient's back. The patient was admitted to the hospital for pain control and conservative treatment of the spinal vertebral fractures, to include Physical Therapy (PT) and Occupational Therapy (OT). An OT evaluation note, dated 1/28/15, stated that the patient had commented: "I couldn't walk into my bathroom or anything when I went home [after ED]." The patient was discharged on 1/30/15 to a SAR (Subacute Rehabilitation) facility.

Per interview, at 1:02 PM on 2/25/15, the Medical Director of the ED stated s/he had reviewed Patient #1's record, after concerns had been raised by surveyors. S/he acknowledged the lack of pain assessment and lack of evidence that the patient had showed ample evidence of ability to ambulate prior to discharge and stated; " it's evident the ambulatory challenge was not aggressive enough for this patient."

Based on the information obtained there is a lack of ongoing assessment, and pain relieving interventions, of Patient #1's wrist injury. In, addition, although a physical assessment had been conducted of the patient's left hip, there is no evidence of assessment of the intensity of the hip pain, no evidence of the possible source of hip pain and no assessment of an adequate trial of ambulation to determine if it would aggravate the hip pain. And, despite the fact that the patient had reportedly refused the offer, by Physician #1, to remain in the ED, there was no evidence that pain management, adequate to promote physical comfort and safety, had been addressed with the patient prior to discharge.

Based on information obtained through staff interview and record review it has been determined the Condition of Participation: Discharge Planning was not met as evidenced by the hospitals failure to ensure, that prior to the discharge of a hospitalized patient, identified as a vulnerable adult with significant injury of unknown origin, received an appropriate screening and discharge planning evaluation.

Refer to Tags: A - 800 & A - 806

Based on staff interview and record review, the hospital failed to ensure that prior to the discharge of a hospitalized patient, identified as a vulnerable adult with significant injury of unknown origin, received an appropriate screening and discharge planning evaluation for 1 of 13 patients. (Patient #2) Findings include:

On 1/16/15 at approximately 2:00 PM, Patient #2, age 83 with a history of dementia, arrived via ambulance from home to the Emergency Department (ED). The ED physician note states: "Patient presents here with significant abdominal ecchymosis of unknown cause. X-ray revealed significant pelvic fractures. Pan scan CT done to evaluate for other injuries given limited history, reveal bleeding in abdomen from pelvic fractures with patient who is significantly anemic. will need blood transfusions.....Adult protective services (APS) contacted as this is generally a high mechanism injury...". Per Consultation Notes dated 1/16/15, Hospitalist #1 (requested by the admitting Orthopedic Specialist for medical management) states: "...the patient was found to have multiple pelvic fractures and a large amount of hemorrhage....."and noting "Three days ago, the patient was noted to be pale with brusing over her/his lower abdomen and also in her/his groin....the patient is unable to give any history or answer direct questions". Per Consultation Notes dated 1/17/15, the Orthopedic Specialist states: "...based on this injury pattern that it would be very likely that the patient was dropped.....it would be my impression that the energy required to sustain this fracture would be a significant fall or being dropped getting into a bathtub or similar". Family reported paid staff provide 24 hour care to Patient #2, yet neither the staff or family were able to provide an explanation for the injury and denied awareness of possible "drop" or "fall", although the patient is non-ambulatory and dependent on staff for total care.

Patient #2 was admitted on 1/16/15 to the hospital for treatment for closed fractures of the sacrum and coccyx, acute posthemorrhagic anemia, hip contusion and a urinary tract infection. Hospitalist #1 ordered a Social Work consultation on 1/16/15 at 20:00 with "Reason for Consult: Abuse/Neglect" and a consult for Palliative Care to assist with the management of medical decisions. On 1/17/15 at 05:29 the Orthopedic Specialist ordered a wound assessment and management for a pressure ulcer to Patient #2's left heel.

The hospital policy Patient Discharge Preparation last reviewed on 03/2011 states "Effective patient discharge preparation assures that the patient is properly placed at the appropriate level of care for his/her continuing needs. Patient Discharge preparation is the joint responsibility of and results from, the collaborative efforts of physicians, nurses, case manager, social workers and members of the Patient Care Team." Per interview on 2/23/15 at 2:30 PM the Director of Case Management/ Utilization Review/Social Services confirmed 5 days per week there is a daily process for evaluating patients for discharge planning, noting Case Managers play an important role in developing individual discharge plans. Also noting the hospital is in the development of a unit based model, Case Managers partake in daily rounds at which time each patient is discussed, evaluating their discharge status and preparing a discharge plan in collaboration with social workers, physicians, nursing and patient and/or family. It was also confirmed by the Director that weekend coverage is limited to 1 Case Manager for the entire hospital limiting the availability to evaluate all patients who may be considered for discharge. However, upon request by Nursing or a Physician the Case Manager can provide an assessment of potential discharge plans and assist both nursing and patient and/or family to assure a discharge plan is safe and appropriate.

On 1/17/15, family requested Patient #2 be discharged. Per interview on 2/24/15 at 10:50 AM Nurse #1, assigned to Patient #2 on 1/17/15, stated the Orthopedic Specialist had provided a verbal order for Patient #2 to be discharged. Nurse #2 confirmed that although information was available regarding the APS referral, made as a result of the significant injuries Patient #2 sustained, the consults for both Social Services and Wound Care Specialist, s/he failed to consider contacting the Case Manager regarding these significant factors prior to discharging Patient #2. In addition, a referral to the Home Health Agency was not made by Nurse #2 nor was there any assurance the necessary equipment was in place at home prior to discharge and whether private home care staff were proficient and/or appropriate to continue to provide care to this vulnerable individual. Per interview on 2/24/15 at 3:10 PM, the Clinical Manager for Utilization Review and also a Case Manager stated "...typically I don't see the physician as qualified for forming a discharge plan, I see them as part of the discharge plan". The Clinical Manager further stated given the injuries sustained at home, a pending referral to APS for possible abuse and/or neglect, it would have been beneficial for nursing to have consulted with the available Case Manager on 1/17/15 prior to arranging for discharge. Per interview on the afternoon of 2/25/15, the Manager of Social Services confirmed if Patient #2 had not been discharged they would have played a role in evaluating the potential for a safe discharge and also following-up with APS regarding the implications of returning Patient #2 to the same environment where an injury resulted. As evidenced by the hospital's policy Mandatory Reporting of Abuse, Neglect and Exploitation last approved 1/2012, which states the Department/Unit Leader is "...responsible for notifying the Social Work Department whenever a report is made and consulting with the Social Work Department whenever there is a question as to whether an act or omission is reportable". Although ED staff made the referral to APS, a consult was made to Social Services as per policy but because of the lack of Social Service staff on the weekend the consult was never obtained and other interdisciplinary processes were not provided or utilized to assure Patient #2's circumstances and complexities within the home environment were effectively considered and evaluated prior to discharge.

Based on interview and record review, the discharge planning evaluation for 1 of 13 applicable patients failed to ensure the patient was evaluated for needing appropriate post-hospital services and the continuance of receiving care in the environment from where the patient had sustained an injury of unknown origin prior to being admitted to the hospital. (Patient #2) Findings include:

Although the hospital has policies and procedures for assuring each patient receives an effective and timely multi-disciplinary discharge plan which evaluates level of continuing care needs for each inpatient, the hospital failed to provide an effective discharge evaluation for an elderly vulnerable patient. On 1/16/15 at approximately 2:00 PM, Patient #2, age 83 with a history of dementia, arrived via ambulance to the Emergency Department (ED). The ED physician note states: " Patient presents here with significant abdominal ecchymosis of unknown cause. X-ray revealed significant pelvic fractures. Pan scan CT done to evaluate for other injuries given limited history, reveal bleeding in abdomen from pelvic fractures with patient who is significantly anemic. will need blood transfusions.....Adult protective services (APS) contacted as this is generally a high mechanism injury...". Per Consultation Notes dated 1/16/15, Hospitalist #1 (requested by the admitting Orthopedic Specialist for medical management) states: "...the patient was found to have multiple pelvic fractures and a large amount of hemorrhage....." and noting "Three days ago, the patient was noted to be pale with brusing over her/his lower abdomen and also in her/his groin....the patient is unable to give any history or answer direct questions". Per Consultation Notes dated 1/17/15, the Orthopedic Specialist states: "...based on this injury pattern that it would be very likely that the patient was dropped.....it would be my impression that the energy required to sustain this fracture would be a significant fall or being dropped getting into a bathtub or similar". Family reported paid staff provide 24 hour care to Patient #2, yet neither the staff or family were able to provide an explanation for the injury and denied awareness of possible "drop" or "fall", although the patient is dependent on staff for total care.

Patient #2 was admitted on 1/16/15 to the hospital for treatment for closed fractures of the sacrum and coccyx, acute posthemorrhagic anemia, hip contusion and a urinary tract infection. Hospitalist #1 ordered a Social Work consultation on 1/16/15 at 20:00 with "Reason for Consult: Abuse/Neglect" and a consult for Palliative Care to assist with the management of medical decisions. On 1/17/15 at 05:29 the Orthopedic Specialist ordered a wound assessment and management for a pressure ulcer to Patient #2's left heel.

The hospital policy Patient Discharge Preparation last reviewed on 03/2011 states "Effective patient discharge preparation assures that the patient is properly placed at the appropriate level of care for his/her continuing needs. Patient Discharge preparation is the joint responsibility of and results from, the collaborative efforts of physicians, nurses, case manager, social workers and members of the Patient Care Team." Per interview on 2/23/15 at 2:30 PM the Director of Case Management/ Utilization Review/Social Services confirmed 5 days per week there is a daily process for evaluating patients for discharge planning, noting Case Managers play an important role in developing individual discharge plans. Also noting the hospital is in the development of a unit based model, Case Managers partake in daily rounds at which time each patient is discussed, evaluating their discharge status and preparing a discharge plan in collaboration with social workers, physicians, nursing and patient and/or family. It was also confirmed by the Director weekend coverage is limited to 1 Case Manager for the entire hospital limiting the availability to evaluate all patients who maybe considered for discharge. However, upon request by Nursing or a Physician the Case Manager can provide an assessment of potential discharge plans and assist both nursing and patient and/or family to assure a discharge plan is safe and appropriate.

On 1/17/15, family requested Patient #2 be discharged. Per interview on 2/24/15 at 10:50 AM Nurse #1, assigned to Patient #2 on 1/17/15, stated the Orthopedic Specialist had provided a verbal order for Patient #2 to be discharged. Nurse #2 confirmed although information was available regarding the APS referral, the significant injuries Patient #2 sustained, the consults for both Social Services and Wound Care Specialist, s/he failed to consider contacting the Case Manager regarding these significant factors prior to discharging Patient #2. In addition, a referral to the Home Health Agency was not made by Nurse #1 nor was there any assurance the necessary equipment was in place at home prior to discharge and whether staff were proficient and/or appropriate to continue to provide care to this vulnerable individual. Per interview on 2/24/15 at 3:10 PM, the Clinical Manager for Utilization Review and also a Case Manager stated "...typically I don't see the physician as qualified for forming a discharge plan, I see them as part of the discharge plan". The Clinical Manager further stated given the injuries sustained at home, a pending referral to APS for possible abuse and/or neglect, it would have been beneficial for nursing to have consulted with the available Case Manager on 1/17/15 prior to arranging for discharge. Per interview on the afternoon of 2/25/15, the Manager of Social Services confirmed if Patient #2 was not discharged they would have played a role in evaluating the potential for a safe discharge and also following-up with APS regarding the implications of returning Patient #2 to the same environment where an injury resulted.