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Based on record review, policy review and staff interview, it was determined that the facility failed to ensure that a safe, effective, and appropriate discharge plan was implemented for a medically complex child, under the age of one year, in order to ensure a smooth and safe transition from the hospital to the child's discharge destination of home.

Findings included:

1. A medically complex pediatric patient (#1) was discharged home on 11/28/2016 with discharge orders for private duty nursing, 8-12 hours at night, 5-7 days/week. On 12/18/2016, twenty days post discharge, the child arrived to the ER (Emergency Room), via EMS (Emergency Medical Services), in cardiac/respiratory arrest. The ER physician noted the child arrived apenic, no heart rate and cold to touch. Despite resusitative attempts the child expired.

Documentation revealed the child was brought back to the facility's ER (Emergency Room) on 11/29/2016, less than 24 hours post-discharge, for vomiting. Physician documentation revealed the child's g-tube was not being vented.Review of the Case Management (CM), the same CM that followed the child as an inpatient, note dated 11/29/16 at 8:54 a.m., after the infant had been discharged, revealed the information was obtained from the Medical Record and the healthcare team. The CM note indicated the representative from the payor source was called to follow up and update on the infant's status. The Case Manager documented "The urgent need to staff the home with home nursing to assist this family in the transition was discussed". There was no evidence of coordination with the healthcare team to assess and intervene as needed to ensure the safety of the infant in the home environment. (Refer to A820)

Case Manager documentation, dated 12/14/2016, sixteen days post-discharge, stated the PDN (Private Duty Nursing) company contacted the Case Manager to inform her the private duty nursing had not been implemented due to lack of authorization from the insurance company. The facility failed to ensure physician ordered services for patient #1, for PDN 5-7 days/week for 8-12 hours at night, was in place or comparable substitution was in place at the time of discharge on 11/28/2016. The facility failed to ensure coordination with insurers for the prescribed service was approved and available prior to the child's discharge home. (Refer to A806)

2. The facility failed to ensure the child's primary caregivers were educated and competent in the child's required needs prior to discharge. Documentation in the medical record revealed during the admission of 11/3 - 11/28/2016 the child required a procedure to remove the existing g-tube and replace it with a gj (gastro-jejunal) tube due to the child vomiting and not tolerating feedings with the g-tube. Review of the education record revealed on several occasions from 11/15 - 11/24 there were no caregivers available for teaching. Documentation on 11/25/2016 revealed the RN attempted to educate and the parents stated they were unable to stay. On 11/26/2016 nursing documented education was provided to the mother and father regarding admininstration of medications and venting the g-tube. The RN documented the parents required additional interventions with these tasks. The child was discharged home in the care of the mother and father on 11/28/2016 and returned to the ER on 11/29/2016 with complaints of vomiting. It was determined the g-tube was not being vented therefore causing the child to vomit. (Refer to A820)

3. The facility failed to ensure appropriate preparation for discharge for one (#1) of ten patients. Review of the record revealed on 11/28/16 at 3:10 pm an order for discharge home was given. The order stated to ensure the mother called her insurance company to switch the child's primary care physician and to attend the follow-up appointment scheduled for 11/29/2016 at 2:00 pm. Review of the record revealed no evidence the mother was assisted in completing this task. Review of the discharge summary provided at discharge revealed no evidence of the scheduled appointment date, time, physician or address. (Refer to A837).

Due to the cumulative effect of these systemic problems, it was determined that the Condition of Participation for Discharge Planning was out of compliance.

Based on medical record reviews, staff interviews and review of policy and procedures it was determined the facility failed to ensure the availability of post-hospital ordered services and the care-giver's capacity to provide the care for one (#1) of ten patients sampled.

Findings included:

1. Review of the facility policy, "Discharge Planning", effective 4/7/2015, states the designated discharge planner will develop a coordinated discharge plan using evaluations and assessments of the multidisciplinary team along with the goals of the caregiver. The policy states the facility will arrange referrals to home health and medical equipment suppliers.

2. Review of the medical record for patient #1 revealed a medically complex child, under the age of 1 year, was admitted to the facility on 11/3/2016 for vomiting. Review of the child's history revealed the child tested positive for meth and opiates at birth, was born with birth defects that included agenesis of the corpus callosum, vertebral abnormalities, microcephaly, and PFO (Patent Foramen Ovale). Medical record review revealed a previous admission from 10/8 - 10/20/2016 for dehydration and hypovolemic shock. Documentation revealed during that admission a G-tube (gastrostomy tube) was placed to supplement the child's nutritional needs. On 10/20/2016 the child was discharged home in the care of the mother.

Review of the H&P (History & Physical), dated 11/3/2016, revealed the child had been seen in the ER (Emergency Room) three times in the past four days for vomiting. The child was now noted to be hypovolemic and the parents were unable to keep her hydrated via her G-tube due to vomiting after all G-tube feeds. The child was admitted for further evaluation and stabilization.

Review of the medical record revealed Case Management and Social Worker documentation with concerns of possible child neglect. The concerns were the result of an interview with the child's PPEC (Prescribed Pediatric Extended Care) facility nurse. Review of Case Management notes from the previous admission from 10/8 - 10/20/2016 revealed the child attended PPEC 5 days per week/ from 8:00 am - 5:00 pm. On 11/8/2016 Social Worker noted the PPEC nurse reported the child's mother missed several appointments with the child's neurologist and gastroenterologist as well as concerns the child was not receiving G-tube feedings at home during the night as ordered. Social Worker documentation revealed the mother had a learning disability and often times required further assistance and reminders to comprehend information and education provided. The mother was noted to be the primary caregiver at home, she had two other children and lived with her grandmother. The father was noted to be involved in the care of the child but did not live in the home. The Case Manager noted the child attended PPEC during the day, no documentation of how many days per week or amount of hours per day.

On 11/15/2016 the Social Worker documented the medical team raised concerns regarding the mother's ability to care for the medically complex child and the child's required 24 hour care. Documentation revealed the mother had been into the hospital the last three days under the influence of a substance, slurring her speech and unsteady on her feet. The Social Worker met with the mother at the child's bedside on 11/15/2016 and documented the mother was intoxicated and stayed to visit the child for approximately 10 minutes. The Social Worker documented the abuse hotline was called, a report was made and accepted.

On 11/16/2016 Child Protection Investigator (CPI) presented to the facility to conduct an investigation into the allegations. On 11/17/2016 the Social Worker documented CPI informed the Social Worker that following the investigation the mother was cleared to take the child home upon discharge.

On 11/28/2016 an order to discharge the patient was given by the physician. An order for Private Duty Nursing, 8-12 hr nights, 5-7 days/week was written on 11/28/2016. Review of the Case Management documentation, dated 11/28/2016 at 12:13 pm, stated private duty nursing shifts were ordered. There was no evidence of coordination with the child's insurers, as necessary, to ensure services prescribed were approved and available prior to discharge. Review of the documentation revealed no evidence the DME (Durable Medical Equipment) company, previously in place, was contacted to inform them of the child's discharge. Case Management noted on 11/28/2016 there was concern about the parent's ability to care for the child at home with all of her needs. Review of the discharge instructions revealed no evidence of private duty nursing in place or DME for supplies/equipment.

Interview and review of the medical record for patient #1 with the Manager Clinical Policies and Regulatory Readiness on 2/23/2017 at approximately 2:00 pm confirmed the above findings.

3. The facility failed to ensure the child's primary caregivers were educated and competent in the child's required needs prior to discharge. Documentation in the medical record revealed during the admission of 11/3 - 11/28/2016 the child required a procedure to remove the existing G-tube and replace it with a gj (gastro-jejunal) tube due to the child vomiting and not tolerating feedings with the G-tube.

Review of the education record revealed on several occasions from 11/15 - 11/24 there were no caregivers available for teaching. Documentation on 11/25/2016 revealed the RN attempted to educate the parents on administration of Lovenox by subcutaneous injection but the parents stated they were unable to stay. On 11/26/2016 nursing documented education was provided to the mother and father regarding administration of medications and venting the G-tube. The RN documented the parents required additional interventions with these tasks.

The child was discharged home on 11/28/2016 with no additional education/teaching provided. Review of the discharge instructions, dated 11/28/2016, revealed the child was discharged with continuous j-tube feedings at 35 ml (milliliters)/hour and education handout provided for sleeping safety, G-tube infection and gj-tube dislodgement. There was no evidence information was provided for care and use of the gj-tube to include medication administration, venting the G-tube or information for Lovenox medication.

Interview and review of the medical record for patient #1 with the Manager Clinical Policies and Regulatory Readiness on 2/23/2017 at approximately 2:00 pm confirmed the above findings.

Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure staff arranged for initial implementation of the patient's discharge plan and caregivers were educated and competent in the care of the child for a safe discharge home for three (#1, #9, #10) of ten patients sampled.

Findings included:

1. Review of the facility policy, "Discharge Planning", effective 4/7/2015, states the facility will provide education/training to the family, arrange referrals and provide medical information for patients discharged home. The medical information will include a brief description of care instructions and list of follow-up appointments.

2. Review of the medical record for patient #1 revealed a medically complex child, under the age of 1 year, was admitted to the facility on 11/3/2016 for vomiting. Review of the child's history revealed the child tested positive for meth and opiates at birth, was born with birth defects that included agenesis of the corpus callosum, vertebral abnormalities, microcephaly, and PFO (Patent Foramen Ovale). Medical record review revealed a previous admission from 10/8 - 10/20/2016 for dehydration and hypovolemic shock. Documentation revealed during that admission a G-tube (gastrostomy tube) was placed to supplement the child's nutritional needs. On 10/20/2016 the child was discharged home in the care of the mother.

Review of the H&P (History & Physical), dated 11/3/2016, revealed the child had been seen in the ER (Emergency Room) three times in the past four days for vomiting. The child was now noted to be hypovolemic and the parents were unable to keep her hydrated via her G-tube due to vomiting after all G-tube feeds. The child was admitted for further evaluation and stabilization.

Review of the medical record revealed Case Management and Social Worker documentation with concerns of possible child neglect. The concerns were the result of an interview with the child's PPEC (Prescribed Pediatric Extended Care) facility nurse. The PPEC nurse reported that the child's mother missed several appointments with the child's neurologist and gastroenterologist as well as concerns the child was not receiving G-tube feedings at home during the night as ordered. Social Worker documentation revealed the mother had a learning disability and often times required further assistance and reminders to comprehend information and education provided. The mother was noted to be the primary caregiver at home, she had two other children and lived with her grandmother. The father was noted to be involved in the care of the child but did not live in the home.

On 11/15/2016 the Social Worker documented the medical team raised concerns regarding the mother's ability to care for the medically complex child and the child's required 24 hour care. Documentation revealed the mother had been into the hospital the last three days under the influence of a substance, slurring her speech and unsteady on her feet. The Social Worker met with the mother at the child's bedside on 11/15/2016 and documented the mother was intoxicated and stayed to visit the child for approximately 10 minutes. The Social Worker documented the abuse hotline was called, a report was made and accepted.

On 11/16/2016 Child Protection Investigator (CPI) presented to the facility to conduct an investigation into the allegations. Documentation revealed the CPI was introduced to the child's medical team and updated on the child's medical needs and the interactions with the child's mother. On 11/17/2016 the Social Worker documented CPI informed the Social Worker the mother was cleared to take the child home upon discharge.

The facility failed to ensure the child's primary caregivers were educated and competent in the child's required needs prior to discharge. Documentation in the medical record revealed during the admission of 11/3 - 11/28/2016 the child required a procedure to remove the existing G-tube and replace it with a gj (gastro-jejunal) tube due to the child vomiting and not tolerating feedings with the G-tube.

Review of the education record revealed on several occasions from 11/15 - 11/24 there were no caregivers available for teaching. Documentation on 11/25/2016 revealed the RN attempted to educate the parents but the parents stated they were unable to stay. On 11/26/2016 nursing documented education was provided to the mother and father regarding administration of medications and venting the G-tube. The RN documented the parents required additional interventions with these tasks. The child was discharged home on 11/28/2016 with no additional education/teaching provided. Review of the discharge instructions, dated 11/28/2016, revealed the child was discharged with continuous j-tube feedings at 35 ml (milliliters)/hour and education for sleeping safety, G-tube infection and gj-tube dislodgement.

3. On 11/29/16 at 5:41 a.m. patient #1 presented to the facility's EC (Emergency Care) accompanied by the father with a chief complaint of vomiting twice that morning. The documentation noted the child had been discharged from inpatient care on 11/28/16 with a gatrojujenostomy (feeding) tube, the day prior.

Review of the EC physician notes, dated 11/29/16, noted the child had vomited a small amount twice that morning. The physician documented the family was instructed on how to vent the feeding tube prior to feeding before inpatient discharge. The family had not been venting the tube. The medical decision was possible vomiting due to failure to vent the feeding tube. Physician documentation noted the infant tolerated one tube feeding per instructions given to the family. The infant was discharged home at 8:26 a.m.

Review of discharge instruction, dated 11/29/16, and signed by father, revealed instructions for "Sick Infant". There was no documentation of instruction for the venting of the feeding tube. There was no evidence of instructions for how, the frequency, the duration for the venting or if the feeding were bolus or continuous. There was no evidence of communication with case management prior to discharge of an infant returning to the EC less than twenty four hours post discharge related to the family not following the instruction for venting the feeding tube. The child was to follow up at the health department clinic.

Review of the Case Management (CM), the same CM that followed the infant as an inpatient, note dated 11/29/16 at 8:54 a.m., after the infant had been discharged, revealed the information was obtained from the Medical Record and the healthcare team. The note indicated the Projected Discharge Planning Needs were home nursing shifts 12 hour per night and the orders had been faxed to the home health agency. The documentation indicated the child returned to EC shortly after discharge with vomiting. The parents had not been venting the feeding tube. The CM note indicated the representative from the payor source was called to follow up and update on the infant's status. The Case Manager documented "The urgent need to staff the home with home nursing to assist this family in the transition was discussed". There was no evidence of coordination with the healthcare team to assess and intervene as needed to ensure the safety of the infant in the home environment.

Interview on 2/22/17 at 12:08 p.m. with the Manager Clinical Policies and Regulatory Readiness and on 2/23/17 revealed and confirmed she was unable to find further documentation related the teaching for the 11/29/16 EC visit or follow up by the case manager following the 11/29/16 return visit to the EC for the "urgent need" for the home nursing. She confirmed the home nursing was not implemented prior to the infant's cardiac/respiratory arrest at home and subsequent expiration on 12/18/16 approximately three weeks later.

4. Review of the medical record for Patient #9 noted an admission date of 11/8/16 with a discharge date of 11/14/16. Review of the admission documentation revealed the child was tracheotomy dependent, had microcephaly with a seizure disorder, dystonia and had a feeding tube.

Review of the Initial Discharge Plan on the Admission Record by a Registered Nurse (RN) on 11/8/16 and 11/9/16 indicated a plan to discharge with the family and no needs identified at the time.

Case Management (CM) note dated 11/9/16 at 11:08 a.m. revealed the primary caregiver was the mother with 24/7 home nursing care provide by a home health agency (HHA). The CM verified the care with the HHA. The CM noted dated 11/9/16 indicated the Pharmacy may need authorization for the Clonidine patch.

On 11/11/16 another CM documented the mother was not present and anticipated discharge on 11/12/16. The CM spoke with the HHA about the discharge date being 11/12/16. The documentation noted the mother was to call the HHA. Physician notes dated 11/12/16 to 11/13/16 revealed the discharge was delayed until 11/14/16 due to the medical condition.

Review of Depart Summary/Orders by the physician dated 11/14/16 instructed to discharge home with the parents. The orders included an order for Clonidine patch 0.2 mg/24 hours and to change every Thursday. There was no order for the resumption of home care. Review of the Medication Administration Record revealed the patch was applied on 11/10/16. Physician note dated 11/13/17 at 3:27 p.m. indicated the mother was to call the HHA for discharge the next day.

Review of the record with the Advanced Nursing Education Specialist and the Case Manager on 2/23/17 at approximately 1:00 p.m. revealed there was no further documentation of follow up with the possible need for authorization for the Clonidine patch, notification of the HHA of the discharge by the facility or if the mother had contacted the HHA to ensure a safe effective coordinated discharge.

5. Review of the medical record for Patient #10 noted an admission date of 12/16/16 with a discharge date of 12/20/16. Review of the admission documentation revealed a history that included chromosomal anomaly, a cardiac condition, kidney stones. visual and hearing impairments and feeding tube dependent.

Review of the Initial Discharge Plan on the Admission Record by a Registered Nurse (RN) on 12/16/16 indicated a plan to discharge with the family and the infant received home care. The name of the HHA and type of home were not noted. Social Worker documentation dated 12/19/16 at 11:35 a.m. indicated there were no needs identified and the infant may be discharged tomorrow per rounds.

Case Management note, dated 12/19/16, revealed the child received home care from a HHA. There was no documentation of the services or hours provided.

Physician order dated 12/20/16 at 1:39 p.m. stated to discharge home. Physician note, dated 12/20/16, revealed no documentation of the need for home care.

Review of the Departure Summary, dated 12/20/16, indicated to resume home nursing. There was no mention of the HHA name, services/hours of care or if the HHA had been notified of the discharge.

Review of the record with the Advanced Nursing Education Specialist and the Case Manager on 2/23/17 at approximately 2:30 p.m. revealed there was no further documentation of the home health care or if the HHA had been notified of the discharge to ensure a safe effective coordinated discharge.

Based on medical record review, review of facility policy and procedures and staff interview it was determined the facility failed to ensure staff provided necessary information for follow-up for three (#1, #9, #10) of ten patients sampled.

Findings included:

1. Review of the facility policy, "Discharge Planning", effective 4/7/2015, states the designated discharge planner will develop a coordinated discharge plan using evaluations and assessments of the multidisciplinary team along with the goals of the caregiver. The policy states the implementation of the discharge plan will include medical information provided for patients discharged to home including a list of follow-up appointments and arranging referrals to home health, medical equipment suppliers, etc.

2. Review of the medical record for patient #1 revealed a medically complex child, under the age of 1 year, was admitted to the facility on 11/3/2016 for vomiting. Review of the child's history revealed the child tested positive for meth and opiates at birth, was born with birth defects that included agenesis of the corpus callosum, vertebral abnormalities, microcephaly, and PFO (Patent Foramen Ovale).

Medical record review revealed a previous admission from 10/8 - 10/20/2016 for dehydration and hypovolemic shock. Documentation revealed during that admission a G-tube (gastrostomy tube) was placed to supplement the child's nutritional needs. On 10/20/2016 the child was discharged home in the care of the mother.

Review of the H&P (History & Physical) for the most recent admission, dated 11/3/2016, revealed the child had been seen in the ER (Emergency Room) three times in the past four days for vomiting. The child was now noted to be hypovolemic and the parents were unable to keep her hydrated via her G-tube due to vomiting after all G-tube feeds. The child was admitted for further evaluation and stabilization.

Review of the medical record revealed Case Management and Social Worker documentation with concerns of possible child neglect. Social Worker documentation revealed the mother had a learning disability and often times required further assistance and reminders to comprehend information and education provided. The mother was noted to be the primary caregiver at home, she had two other children and lived with her grandmother. The father was noted to be involved in the care of the child but did not live in the home.

On 11/15/2016 the Social Worker documented the medical team raised concerns regarding the mother's ability to care for the medically complex child and the child's required 24 hour care. Documentation revealed the mother had been into the hospital the last three days under the influence of a substance, slurring her speech and unsteady on her feet.

On 11/28/2016 an order to discharge the patient was given by the physician. An order for Private Duty Nursing, 8-12 hr nights, 5-7 days/week was written on 11/28/2016. Review of the Case Management documentation, dated 11/28/2016 at 12:13 pm, stated private duty nursing shifts were ordered. There was no evidence of coordination with the child's insurers, as necessary, to ensure services prescribed were approved and available prior to discharge.

Review of the documentation revealed no evidence the DME (Durable Medical Equipment) company, previously in place, was contacted to inform them of the child's discharge. Case Management noted on 11/28/2016 there was concern about the parent's ability to care for the child at home with all of her needs. Review of the discharge instructions revealed no evidence of private duty nursing in place or DME for supplies/equipment.

Review of the physician's orders revealed on 11/28/2016 an order to assist the mother to call the insurance company to switch Primary Care Physicians and to bring confirmation to the child's clinic appointment scheduled for 11/29/2016 at 2:00 pm in the outpatient care clinic of the facility on the 5th floor. Review of the record revealed no evidence the mother was assisted with the call to the insurance company. Review of the Discharge Summary provided to the caretaker of the child revealed a list of follow-up appointments. Review of the appointments listed revealed no evidence of the appointment with the discharging physician as set up prior to discharge.

Interview and review of the medical record for patient #1 with the Manager Clinical Policies and Regulatory Readiness on 2/23/2017 at approximately 2:00 pm confirmed the above findings.

3. Review of the medical record for Patient #9 noted an admission date of 11/8/16 with a discharge date of 11/14/16. Case Management (CM) note dated 11/9/16 at 11:08 a.m. revealed the primary caregiver was the mother with 24/7 home nursing care provide by a home health agency (HHA). The CM verified the care with the HHA. The CM noted dated 11/9/16 indicated the Pharmacy may need authorization for the Clonidine patch.

On 11/11/16 another CM documented the mother was not present and anticipated discharge on 11/12/16. The CM spoke with the HHA about the discharge date being 11/12/16. The documentation noted the mother was to call the HHA. Physician notes dated 11/12/16 to 11/13/16 revealed the discharge was delayed until 11/14/16 due to the medical condition.

Review of Depart Summary/Orders by the physician dated 11/14/16 instructed to discharge home with the parents. The orders included an order for Clonidine patch 0.2 mg/24 hours and to change every Thursday. There was no order for the resumption of home care. Review of the Medication Administration Record revealed the patch was applied on 11/10/16. Physician note dated 11/13/17 at 3:27 p.m. indicated the mother was to call the HHA for discharge the next day.

Review of the record with the Advanced Nursing Education Specialist and the Case Manager on 2/23/17 at approximately 1:00 p.m. revealed there was no further documentation of follow up with the possible need for authorization for the Clonidine patch, notification of the HHA of the discharge by the facility or if the mother had contacted the HHA to ensure a safe effective coordinated discharge.

4. Review of the medical record for Patient #10 noted an admission date of 12/16/16 with a discharge date of 12/20/16. Review of the Initial Discharge Plan on the Admission Record by a Registered Nurse (RN) on 12/16/16 indicated a plan to discharge with the family and the infant received home care. The name of the HHA and type of home were not noted. Social Worker documentation dated 12/19/16 at 11:35 a.m. indicated there were no needs identified and the infant may be discharged tomorrow per rounds.

Case Management note, dated 12/19/16, revealed the child received home care from a HHA. There was no documentation of the services or hours provided.

Physician order dated 12/20/16 at 1:39 p.m. stated to discharge home. Physician note, dated 12/20/16, revealed no documentation of the need for home care.

Review of the Departure Summary, dated 12/20/16, indicated to resume home nursing. There was no mention of the HHA name, services/hours of care or if the HHA had been notified of the discharge.

Review of the record with the Advanced Nursing Education Specialist and the Case Manager on 2/23/17 at approximately 2:30 p.m. revealed there was no further documentation of the home health care or if the HHA had been notified of the discharge to ensure a safe effective coordinated discharge.