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Based on interview and document review the facility failed to ensure the Pharmacy and Therapeutics Committee (P&T) and Quality Committee (QC) analyzed medication errors and approved corrective action to reduce or eliminate them from re-occurring. This failure may allow the same or similar medication errors to continue, which creates an unsafe patient care environment.

Findings:

P&T minutes (a medical staff committee) from July 2012 to July 2013 were reviewed on September 12, 2013, at 8:45 a.m. There was no evidence in the minutes that medication errors were analyzed and corrective action approved to reduce or eliminate reoccurrence.

The July 26, 2013 minutes under, "Medication Errors-2013" read: "...statistics regard medication error rates April thru July of 2013; all are level 1 errors." Under "Action/Follow Up," the minutes read: "After review and discussion a motion is made and seconded to approve the Medication Error rates report."

There was no evidence of:
a. A description of level 1 errors.
b. What caused the errors.
c. The identification of any re-occurring errors.
d. A discussion of corrective action(s) to reduce or eliminate errors from re-occurring.

During a meeting with MD 1 at 9 a.m., on September 12, 2013, he said the medication error analysis was contained in the QC minutes (a medical staff committee).

A review of the QC minutes from December 2012 to May 2013, revealed there was no evidence of any discussion of medication errors.

During a meeting with the Director of Pharmacy (DOP), on September 12, 2013, at 11:15 a.m., he acknowledged the P&T and QC minutes did not contain any analysis of medication errors.

Based on observation interview and record review, the facility failed to ensure:

1. There was documented evidence nursing personnel were competent to perform their assigned duties for one of five employee files reviewed (Staff 31). This resulted in the facility not knowing if the staff assigned to care for patients was clinically competent.

2. The performance of an employee was evaluated annually per facility policy and procedure for four of five employee files reviewed (Staff 31, 32, 39, and 40).

3. Three of three sampled nurses (Staff 31, 32 and 33) assigned to the emergency department (ED) were capable of calculating and preparing pediatric emergency medications. This placed children patients at risk for experiencing an adverse event.

4. Two of two sampled nurses (Staff 34 and 35) in the medical-surgical unit (MS) were capable of calculating and preparing pediatric emergency medications. This placed children patients at risk for experiencing an adverse event.

Findings:

1. On September 11, 2013, the employee file for Staff 31 was reviewed. Staff 31 was hired on May 28, 2012, and was a registered nurse (RN) assigned to the emergency department (ED).

There were no current clinical skill competencies in Staff 31's employee file.

On September 11, 2013, at 3:30 p.m., the Human Resources Manager (HRM) was interviewed. The HRM was unable to find documentation of Staff 31's current competencies. She stated it was the responsibility of the department manager to ensure all competencies were completed timely.

On September 11, 2013, at 4:05 p.m., the department manager for the ED (Staff 1) was interviewed. Staff 1 stated she was not aware that Staff 31 was past due for his annual competencies.

The policy and procedure titled, "Performance Evaluations - Competency," was reviewed, The policy indicated, "The Department Director/Supervisor will review competency placement on an annual basis to determine consistency in placement among departments. Annual age specific skills competencies are to be completed on each clinical employee... The Department Director/Supervisor assures all required competencies have been satisfactorily completed within the allowed time frame."

2a. On September 11, 2013, the employee file for Staff 31 was reviewed. Staff 31 was hired on May 28, 2012, and was a RN assigned to the emergency department (ED).

There was no performance review for Staff 31 in the employee file (Greater than 15 months after Staff 31's date of hire).

b. On September 11, 2013, the employee file for Staff 32 was reviewed. Staff 32 was hired on August 1, 2011, and was a RN assigned to the ED.

The most recent performance review for Staff 32 was conducted on June 18, 2012 (Greater than 14 months ago)

c. On September 11, 2013, the employee file for Staff 39 was reviewed. Staff 39 was hired on September 14, 2009, and was a registered nurse (RN) assigned to the Obstetric Department.

The most recent performance review for Staff 39 was conducted on June 21, 2012 (Greater than 14 months ago).

d. On September 11, 2013, the employee file for Staff 40 was reviewed. Staff 40 was hired on December 5, 2001, and was a registered nurse (RN) assigned to the Medical/Surgical/Telemetry Unit.

The most recent performance review for Staff 40 was conducted on August 28, 2012. (Greater than 12 months ago).

On September 11, 2013, at 3:30 p.m., the Human Resources Manager (HRM) was interviewed. The HRM was unable to find documentation of Staff 31, 32, 39, and 40's current performance reviews. She stated it was the responsibility of the department manager to ensure all performance reviews were completed timely. The HRM stated the performance reviews were done electronically, and collected by an outside subscription program. She stated the subscription was up in May of 2013. She stated the facility was currently working on a new program, and hoped to have it up and running by October or November. The HRM stated any performance evaluations or reviews that were due after May 2013 have not been done because there was no way for the managers to complete them.

The policy and procedure titled, "Performance Evaluations - Competency," was reviewed, The policy indicated, "All components of the competency assessment program require an annual evaluation... Formal annual performance reviews will be conducted on all employees. Immediate supervisors shall conduct regular one on one performance appraisals reviewing expectations and setting goals and job objectives to help govern the employee's work."



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3. During an observation of the emergency department (ED) on September 10, 2013, at 2:30 p.m., a pediatric emergency cart was observed. The cart contained the emergency medications and supplies necessary to treat a child in the event of an emergency. The cart also contained a Broselow Tape (a measuring tape which is used to measure the length (height) of the child. The tape is used when the weight of the child has not, or cannot, be determined quickly. When used properly, the tape translates the length of the child to the child's approximate weight and identifies a dose of the needed emergency medication.

In concurrent interviews, Staff 31, Staff 32 and Staff 33 stated they were all assigned to the ED and each stated he/she provided care for pediatric patients. Staff 31, Staff 32 and Staff 33 were each asked independently to prepare an IV dose of epinephrine for a pediatric patient in a practice emergency.

According to Lexicomp, a nationally recognized drug information source, epinephrine IV (intravenous) is used to treat: "bronchial asthma [a chronic lung disorder which makes it difficult to breathe], anaphylactic reactions [potentially fatal allergic responses], and cardiac arrest [stopping of the heart]"

Staff 31, Staff 32 and Staff 33 were each given the height of the practice pediatric patient and asked, separately, to prepare the epinephrine dose for a child of that height. Staff 31, Staff 32 and Staff 33 were unable to calculate and prepare the IV epinephrine dose.

4. On September 11, 2013, at 3:25 p.m., a tour of the medical surgical (MS) unit was conducted. A pediatric emergency cart was observed on the unit. The cart contained the emergency medications and supplies necessary to treat a child in the event of an emergency.

Staff 34 and Staff 35 each stated they were assigned to the MS unit and provided care for pediatric patients.

Staff 34 and Staff 35 were each given the height of a practice pediatric patient and asked, separately, to prepare a dose of IV epinephrine for a child of that height. Staffs 34 and Staff 35 were unable to calculate and prepare the IV epinephrine dose.





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Based on observation, interview, record and document review, the facility failed to:

1. Ensure the Pharmacy & Therapeutics Committee (P&T) and Quality Committee (QC) analyzed medication errors and approved corrective action to reduce or eliminate them from re-occurring. (Refer to A309);

2. Ensure five of five sampled nurses (RNs) responsible for pediatric patient care were competent to calculate and prepare an emergency pediatric (child's) intravenous (IV) dose. (Refer to A397);

3. Ensure medications labeled for four patients who had been discharged and four medications with no patient label were removed from an automated dispensing cabinet and returned to the pharmacy. (Refer to A500);

4. Ensure medications contained in three anesthesia trays were verified for use and properly replenished. (Refer to A500);

5. Ensure medications removed from ADC's as overrides complied with facility policy and professional standards of practice. (Refer to A500);

6. Ensure that 35 of 42 facility policies were updated according to facility policy. (Refer to A500);

7. Ensure that physician orders for one of three sampled patients were complete. (Refer to A500); and

8. Ensure that an insulin order for one of three patients was followed. (Refer to A500).

The cumulative effect of these systemic failures resulted in the facility's inability to ensure pharmaceutical services met the needs of the patients.

Based on observation, interview, document and record review, the facility:

1. Failed to ensure medications labeled for four patients who had been discharged and four medications with no patient label were removed from the Pyxis (an automated dispensing cabinet-ADC) and returned to the pharmacy. Ready access to these medications can result in potentially improper use and lead to a medication error.

2. Failed to ensure medications contained in three anesthesia trays were verified for use and properly replenished resulting in non-compliance with facility policy and professional standards of practice. This failure may lead to the improper use of these medications.

3. Failed to ensure medications removed from ADC's as overrides complied with facility policy and professional standards of practice. This failure may lead to a medication error.

4. Failed to follow its policy of review/revise for 35 of 42 provided policies causing them to be outdated. Outdated policies may not reflect current or up-to-date practices and lead to systemic failures and adverse events for patients.

5. Failed to ensure physician (MD) orders for Levophed and dopamine for one of three sampled patients (Patient 6) were complete. An incomplete order for Levophed or dopamine may cause an error in their administration and lead to patient harm.

6. Failed to ensure an insulin order for one of three patients (Patient 5) was followed. Not following a MD order for insulin may result in patient harm.

These failures have the potential to result in an unsafe patient care environment.


Findings:

An Automated Dispensing Cabinet (ADC) permits quick access to medications by authorized staff. The ADC is filled by pharmacy with medications approved by the Pharmacy & Therapeutics Committee. The ADC electronically permits authorized staff to remove a medication only after a pharmacist has reviewed and entered the new physician's order into the correct patient profile in the pharmacy computer. (The review confirms the appropriateness of the drug and accuracy of the dose to ensure patient safety.) The pharmacist's entry allows authorized staff to remove the dose from the ADC. This removal is permitted because the computer located in the pharmacy is electronically connected to the ADC.

1. The medical surgical nursing unit (MS) was visited on September 9, 2013 at 2 p.m. with Pharm1 and Staff 21. Medications in plastic bins were observed in the MS ADC behind a glass door.

All but one bin (the unlabeled bin) behind the glass door were labeled with room numbers.

In a concurrent interview, Pharm1 stated, medications in the unlabeled bin were either placed there in error or were discontinued.

When a medication is needed for a current patient from one of the room numbered bins, authorized staff enter the patient's name and drug into the ADC. The glass door then opens. Staff can then select a medication from any of the bins including the unlabeled bin. Access to the unlabeled bin is therefore not controlled since the glass door was opened for a specified patient in a room numbered bin. Uncontrolled access to the unlabeled bin permits staff to remove, without any pharmacist review, medications in the unlabeled bin.

Medications in the unlabeled bin were examined and included:

a. Two L-thyroxine (for low thyroid), two Klor-Con 10 (for low potassium) and a half-full pint bottle of kayexalate (for high potassium), all labeled for Patient 1. Staff 21 stated: "[Patient 1] was discharged on September 6, 2013(three days ago) at 4 p.m."

b. Two fenofibrate (for high cholesterol), two tramadol (for pain) and a used vial of Lantus insulin (for diabetes), all labeled for Patient 2. Staff 21 stated: "Patient 2 was discharged on September 7, 2013 (two days ago) at 4:55 p.m."

c. Advair (for inhalation therapy), labeled for Patient 3. Staff 21 stated: "Patient 3 was discharged on September 5, 2013 (four days ago) at 1:40 p.m.

d. Spiriva (for inhalation therapy), QVar (for inhalation therapy) and Ventolin (for inhalation therapy), all labeled for Patient 4. Staff 21 stated: "Patient 4 was discharged on September 6, 2013 (three days ago) at 7:05 p.m."

e. Lactulose (to treat encephalopathy - a disease of the brain), enoxaparin (to thin the blood), docusate (a stool softener), and a vial of injectable Protonix (for inflammation of the esophagus - which passes food to the stomach) each with no patient label. Staff 1 indicated medications without a patient label may have been discontinued or was for a patient or patients who have been discharged.

Page 3 of the Pharmacy Manual entitled "Dispensing" under "Return of Drugs from Patient Care Areas to the Pharmacy" reads: "Discontinued drugs, drugs remaining after a patient is discharged, excessive drugs, and unusable drugs shall be returned to the pharmacy."

The American Society of Health-System Pharmacists (ASHP) is recognized as the organization that provides standards of professional practice for pharmacists practicing in hospitals. Page 131 of the section "ASHP Guidelines on Preventing Medication Errors in Hospitals" reads: "14. All discontinued or unused drugs should be returned to the department of pharmacy immediately on discontinuation or at patient discharge."

Pharm1 acknowledged the medications in the unlabeled bin should have been returned to the pharmacy.

Staff have unrestricted access to the unlabeled bin in the ADC where discharged and unlabeled medication may be removed without documentation. Pharmacists, therefore, are unable to verify whether or not medication in the unlabeled bin are used properly for a patient or taken by staff for personal or other use.

2. The post anesthesia care unit (PACU) was visited on September 9, 2013 at 2:40 p.m., with Pharm1 and staff 36. Three anesthesia trays were reviewed.

Staff 36 stated these trays were identical, contained medications used by the certified registered nurse anesthetist (CRNA) during surgical procedures and were removed and restocked daily by the pharmacy.

The first tray had a cracked and unlocked cover with a list attached. Staff 36 indicated the list identified 22 medications and their approved inventory levels (par levels) contained in the tray. The 2nd and 3rd trays had no cover and no list of medications attached. Sample medication quantities were examined in each tray and compared with the par level.

a. For the first tray there were: 21 terbutaline (used to prevent bronchospasm); 19 naloxone (to treat narcotic overdose); 14 metoclopramide (to treat reflux); and 11 epinephrine (emergency treatment for allergic reaction) found. The par level for each of the drugs was five.

b. For the second tray there were: 10 furosemide (Treatment of edema); 17 ondansetron (for nausea and vomiting); and 14 propofol (a sedative) found. The par levels for furosemide and ondansetron were five. For propofol, the par level was four.

c. For the third tray there were: 10 propofol and 1 Anectine (a muscle relaxation used during general anesthesia to assist in intubation) found. The par level for Anectine was two.

In a concurrent interview, Pharm1 was asked if the pharmacy verified the doses used with the doses remaining in the tray to determine if the remaining inventory level is correct. Pharm1 said: "We are supposed to."

Page 1 of the Pharmacy Manual titled "Floor Stock", dated March 2010, under "Par Levels" read: "The pharmacy shall maintain floor stock at predetermined or reasonable levels."

Page 3 of the Pharmacy Manual titled "Dispensing" under "Return of Drugs from Patient Care Areas to the Pharmacy" read: "... excessive drugs ... shall be returned to the pharmacy."

Having two to four times the par levels (or less than the par level for Anectine) of medication in the anesthesia trays does not comply with facility policy which read to "maintain floor stock at predetermined or reasonable levels" and "excessive drugs ... shall be returned to the pharmacy". The removal and use of these medications occur without a pharmacist's verification. Thus pharmacists are unaware of whether or not drugs in the anesthesia trays are used for patients or simply taken by staff for personal or other use.

3. A list of overrides (O/R) generated between August 12, 2013 and September 10, 2013, provided by the Director of Pharmacy (DOP), was reviewed on September 10, 2013 at 12:30 p.m. O/R's are used by staff to remove a medication from an ADC without a pharmacist's review.

A total of 709 O/Rs were on the list as follows:

a. All 709 O/Rs had no reason the medication was removed.

b. 284 O/Rs from the ADC plastic bins did not have the name of the medication removed.

Page 2 of the Pharmacy Manual titled "Dispensing", dated January 2013, under "Reviews of Original or Direct Copy of Order by a Pharmacist" read: "A pharmacist shall review the prescriber's original order, or a direct copy thereof, before the initial dose is dispensed (with the exception of emergency orders when time does not permit)."

Page 439 of the "ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals" under "Standard III: Optimizing Medication Therapy" read: "Medication-Therapy monitoring shall be conducted for appropriate patients and medication use. Medication-therapy monitoring includes an assessment of: Therapeutic appropriateness; therapeutic duplication and the appropriateness of the route..."

Review of the O/Rs revealed a pharmacist:

a. Did not know what medication was removed from the ADC plastic bins. Once the ADC glass door was open, all bins were accessible. Thus a pharmacist does not know if the medication removed was for the right patient or appropriate.

b. Did not know why a medication was removed as an O/R and could not determine if the dose was needed in an emergency.

Current policy read: "A pharmacist shall review the prescriber's original order, or a direct copy thereof, before the initial dose is dispensed (with the exception of emergency orders ...)." Current ASHP standards for practice indicate a pharmacist shall assess: "Therapeutic appropriateness ..." of the medication order.

Current facility policy does not identify an O/R is to be used only in an emergency. Current policy also does not require a reason to be documented for use of an O/R. Thus, contrary to facility policy, O/R's may be used at any time without a reason for their use and the medications taken without any pharmacist's review. Without a review of the medication order before an O/R is used, contrary to ASHP standards for professional practice, a pharmacist cannot monitor the therapeutic appropriateness of the order.

4. Patient care policies provided by the facility were reviewed. For 35 of 42 patient care policies reviewed, the last date of review occurred in March 2010 (more than 3 years ago).

Page 2 of the facility's policy titled "Policy Management System SOP", dated December 5, 2012, under "Periodic Review and Responsibilities" read: "Patient care related documents should be reviewed annually... Non-patient care related documents review process should not exceed 3 years..."

5. Patient 6's record was reviewed with Staff 37 on September 11, 2013 starting at 8:20 a.m. The record revealed a physician's (MD 6's) order for dopamine (for heart failure) written on August 15, 2013, at 8 a.m. as follows: "Titrate (adjust) dopamine and attempt to wean off (eventually stop)." The order did not identify how a registered nurse (RN) should adjust the dose to eventually stop dopamine. Staff 37 stated the order was incomplete.

Patient 6's record revealed another order by MD 6 written on August 16, 2013 at 6:30 p.m. as follows: Stat Levophed (for acute low blood pressure) - titrate to MAP (mean arterial pressure) equal to or greater than 60." The order also did not identify how a RN should adjust the Levophed dose to achieve a MAP of equal to or greater than 60. The order also did not identify what the RN should do when the MAP reached 60. Staff 37 acknowledged this order was also incomplete.

Page 1 of the Pharmacy Manual titled, "Verification/Clarification of Orders," under "Section III: Policy" read: "Orders that are incomplete, illegible, or otherwise unclear shall not be filled and shall be verified or clarified prior to dispensing."

Page 1 of the Pharmacy Manual entitled "Drug Therapy Monitoring, Monitoring the Effects of Drugs on Patients," reviewed March 2010, read: "Section III: Policy. Drug therapy monitoring shall be an ongoing, prospective or concurrent process to assure effective, appropriate, and safe drug therapy."

Staff 37 was unable to find documentation an RN or pharmacist called MD 6 to clarify the orders for dopamine and Levophed.

6. Patient 5's record was reviewed with Staff 2 and Staff 3 on September 11, 2013 starting at 9:15 a.m. The record revealed a telephone order by MD 5 transcribed by Staff 38 on August 29, 2013 at 11:55 p.m. on the "Regular Insulin Subcutaneous Dosing Protocol (RISD)." (MD 5 signed the protocol but did not identify a date or time.)

The protocol identified the target blood glucose (BG) range as 80-120mg (milligrams) per dl (deciliter) or (80-120). The order directed BG checks to occur "before meals and at bedtime" and to use the "Mild (Low) Insulin Scale."

A second telephone order by MD 5 on August 30, 2013 at 5:30 p.m. read: "Stat Glucose per Protocol for sugar greater than 500."

A third order by MD 5 on August 30, 2013 at 6:25 p.m. read: "Stat Insulin drip at 5 units per hour." There was no documented evidence of an order that discontinued the original subcutaneous order.

Patient 5's record revealed that an insulin drip was started on August 30, 2013 at 7:55 p.m. when Patient 5's BG was 570. Five units per hour was continued until the drip was discontinued and subcutaneous (under the skin) insulin via a sliding scale with a BG check every 4 hours was ordered by MD 5 on August 31, 2013, at 2:30 a.m.

Staff 2 and Staff 3 indicated the sliding scale order referred to using the RISD mild insulin scale. MD 5's order did not specify to use the mild scale. The protocol identified the target BG range as 80-120.

Continued review of Patient 5's medical record revealed the following:
a. At noon on August 31, 2013 Patient 5's BG was 496. Staffs 2 and Staff 3 indicated there was no insulin dose charted as given. The RISD indicated Patient 5 should have received 12 units of insulin subcutaneous.

b. At 2:42 p.m. on August 31, 2013 Patient 5's BG was 399. The RISD indicated Patient 5 should have received 10 units. Staff 2 and 3 indicated there was no dose charted at that time.

Page 1 of the Pharmacy Manual titled, "Administration of Drugs, Medication Administration Record (MAR)" dated March 2010, under "Section III: Policy", read: "Persons who administer drugs shall record the administration in a medication administration record (MAR)."

c. At 1:50 a.m. on September 1, 2013, Patient 5's BG was 292 and should have received 4 units of insulin subcutaneous. Patient 5's record showed he received 3 units.

d. At 4:30 a.m., on September 1, 2013 with a BG of 357, Patient 5 should have received 10 units of insulin. His record indicated he received 4 units.

Subcutaneous insulin for Patient 5 was eventually discontinued on September 7, 2013 at 12:16 a.m. There were a total of 26 incorrect doses of subcutaneous insulin administered to Patient 5 between noon on August 31, 2013 and 12:16 a.m. on September 7, 2013. There were four occasions where Patient 5 became hypoglycemic (low BG). On one occasion the BG was so low (20, at 7:30 p.m. on August 31, 2013) Patient 5 required an intravenous dose of dextrose.

Lexi-Comp, a nationally recognized drug information source, indicates: "The most common adverse effect of insulin is hypoglycemia. Profound and prolonged episodes of hypoglycemia may result in convulsions, unconsciousness, temporary or permanent brain damage, or even death."

Page 1 of the Pharmacy Manual titled, "Drug Therapy Monitoring, Monitoring the effects of Drugs on Patients" requires a pharmacist to "assure effective, appropriate, and safe drug therapy. There was no evidence in Patient 5's record a pharmacist:
a. Verified the sliding scale insulin ordered on August 29, 2013 at 11:55 p.m. was discontinued.
b. Verified the intensity level of the sliding scale insulin order written at 2:30 a.m. on August 31, 2013.
c. Identified the insulin dosing errors which started on August 31, 2013 at noon and took corrective action to prevent them from continuing through September 7, 2013.

Staff 2 and 3 acknowledged insulin was not administered correctly to Patient 5 as identified above, and confirmed there was no evidence of a pharmacist's intervention.

Based on interview and record review, the facility failed to ensure a patient (Patient 12) was provided an effective and safe discharge plan including an evaluation of the patient's capacity for self-care, and the likelihood of the patient's need for post-hospital services. This had the potential to result in the patient's needs not being met.

Findings:

The medical record for Patient 12 was reviewed. Patient 12 was admitted to the facility on May 23, 2013, with diagnoses that included urosepsis and cellulitis (an infection of the skin and deep underlying tissues).

The nurse documentation, dated May 23, 2013, at 3:57 a.m., "Arrives with malodorous (foul smelling) purulent drainage from the right calf wound."

Physician orders dated, May 23, 2013, indicated to keep right leg elevated, place a Kerlix 4 X 4 (a gauze bandage) on right leg and ace wrap it from foot up. Clinical documentation indicated wound care was done twice a day. The last assessment prior to discharge on May 26, 2013, at 9 a.m., indicated dressing applied or changed, "Red granulation noted on wound bed, with small amount of bleeding. Removed old dressing. Applied 44 gauze with Kerlix and ace wrap."

A case management note, dated May 24, 2013, at 2:03 p.m., indicated, "Discharge Plan... I anticipated this patient needed dressing changes at discharge, pt (patient) unable to come in for out pt wound care due to no car. Possible home health might be able to see pt..." An additional note by the case manager (CM) on May 24, 2013, at 3:09 p.m., indicated, "I spoke with [Staff 41] RN regarding this pt and her dressing of her wound. Nurse [Staff 41] does not think the pt is capable of doing her own dressing changes. I spoke to her about talking to MD regarding home health to see this pt."

On September 12, 2013, at 8:05 a.m., Staff 41 was interviewed. Staff 41 stated she did not remember Patient 12. Staff 41 stated it was case management's responsibility to notify the physician about the need for home health. However, she stated, if the CM told her to notify the physician then she probably did. Staff 41 was unable to find documentation to indicate if the physician was notified of the need for a home health referral. Staff 41 stated, the physician did not order a home health referral, so she does not know if he knew about the recommendation by the CM.

On September 12, 2013, at 8:15 a.m., the CM staff was interviewed. The CM stated her usual process was to notify the physician herself if a patient was evaluated as needing a home health referral. She stated she can not remember if she ever personally talked with the physician regarding this patient. The CM stated, according to her notes, she saw Patient 12 on May 24, 2013, which was a Friday, and the patient was discharged on May 26, 2013, which was her day off. The CM stated, again according to her notes, she spoke with Staff 41 on the 24th, and maybe Staff 41 notified the physician. The CM was unable to find any documentation that the physician was notified, either by her or Staff 41, regarding Patient 12's need for home health. The CM stated this patient, "Fell through the cracks."

The policy and procedure titled, "Discharge Planning," dated April 16, 2013, was reviewed. The policy indicated, "The RN in conjunction with the case manager will continuously evaluate the patient for post-hospital needs... Clinical Case Managers are responsible for assisting patients and families with coordination of all home care services... Case manager or Nursing staff should document any referrals that have been made... "