HospitalInspections.org

Based on interview and review of medical record, the facility failed to provide 2 (Patient #s 6 and 8) of 10 sampled patients, the Patient's Rights, in advance of discontinuing patient care in the form of "An important Message from Medicare About Your Rights."


The findings include:


A review of the medical record for Patient #6 revealed that he was a Medicare recipient and that "An Important Message From Medicare About Your Rights" was provided to the patient upon admission 4/10/2018 at 9:17 AM; however, this form was not again presented as required by the documented form - at his discharge on 5/02/2018. [Copies obtained].


A review of the medical record for Patient #8 revealed that he was a Medicare recipient and that the CMS - R - 193 "An Important Message From Medicare About Your Rights" was not provided to him upon discharge, dated 4/17/2018.


An interview with the Risk Manager on 5/17/2018 at 3:09 PM confirmed that Nursing was supposed to provide the form CMS - R -193 at admission and discharge by detaching the appropriate carbon copy from the Master (pink) at admission and yellow at discharge, following the patient's signature. If the patient was a Medicare recipient and did not sign the discharge information and received the yellow discharge copy of this form, this would not be the appropriate procedure. The patient must sign and be provided the correct form. She confirmed that the form was not signed, nor provided to Patient #6, who was discharged to an Adult Crisis Center on 5/02/2018.


An interview was conducted with the Director of Clinical Services on 5/17/2018 at 11:08 AM about the CMS -R - 193 and she confirmed that the form was clearly marked "white form is for the chart; yellow form is for the patient at discharge and the pink form is provided to the patient at admission". She also confirmed that the form was not provided to Patient #6 and Patient #8 for signature, nor were they provided their copy, as the form was observed intact in the medical record.

Based on interview and record review, the facility failed to ensure Physician's orders were followed to monitor behavioral health patients every 5 minutes; sampled Patient #1 in 1 of 10 sampled patients, and to monitor behavioral health patients every 15 minutes for 1 of 10 sampled patients (Patient #1).



The findings include:



Sampled Patient #1's medical record review revealed he was 76-years-old, admitted to the facility on 3/3/18 with bizarre behavior. He had a diagnosis of Major Neuro Cognitive Disorder/Alzheimer's.


According to Patient #1's 3008 Form, used for discharge instructions, it revealed the facility identified Patient #1 as an Elopement Patient Risk Alert (Section G). He ambulated independently (Section S) and needed Q5 minute observations.


A review of the Physician's discharge note dated 5/2/18 revealed the document indicated Patient #1's admitting diagnosis was Major Cognitive Disorder Alzheimer's Type 4/5 dementia type. Patient had poor social support. The patient was very convivial. He had an MSE of 13/30, which speaks high of a high intensity dementia. Very poor speech and aphasia were present. The patient was not able to repeat or to write or read any words, and he performed very poorly. Zilch judgement and zilch insight.


According to the Behavioral Health 24-hour Special Observation Monitoring Log sheet, Patient #1 was on Q (every) 5 minute observation roundings, as ordered by the Physician, since 3/30/18 to 4/5/18. The facility failed to follow MD orders for Q5min checks on 3/19/18, as evidenced by review of the Observation Flow Sheet/Q15 minute check sheet dated 3/19/18, which revealed Patient #1 was monitored Q15 minutes instead of Q5 minutes from 7:15 AM to 7:00 PM, a period of 11 hours and 45 minutes.


The Special Observation Flow Sheet Q5 minute check sheet dated 4/5/18 revealed Patient #1 was visualized in patient's room at 7:00 a.m. on 4/5/18 and not again until 11:30 a.m. On 4/5/18, there was no documentation to show that Patient #1 was observed for a period of 4 hours and 30 minutes.


Interview with Employee C (Registered Nurse) at 3:15 PM on 5/17/18, confirmed staff failed to monitor Patient #1 on 3/19/18 and on 4/5/18, and stated it needed to be done. (Photocopy of the Observation Monitoring Log sheet was provided).

Based on interview and record review, the facility failed to ensure a safe discharge was implemented and the discharge planning evaluation included the possibility of the patient being cared for in the environment upon discharge, for one of 10 patients. (Patient 1)


The findings include:


Interview with the complainant on 5/15/18 at 5:10 PM revealed Patient #1 was discharged to a place that was not appropriate on 5/2/18. She explained that the Case Manager was rude and instead of helping place Patient #1 in a nursing home facility, the Case Manager decided to discharge Patient #1 after hours, to an Adult Crisis Alternative Program/ACAP on 5/2/18. Stated: "They called me and left me a message that day of discharge; that they found a place that accepted him. They will take him short term. You can work on long term placement. They did not do what we needed to do. Geriatric nursing home was our plan. This was not appropriate. ACAP is respite care. I'm not sure what they said to ACAP for them to take him. They knew someone over there. Patient #1 cannot communicate."


Review of the medical record for Patient #1 revealed he was 76 years old, admitted to the facility on 3/3/18 with bizarre behavior. He had a diagnosis of Major Neuro Cognitive Disorder/Alzheimer's. He came from an Assisted Living Facility (ALF). Initial discharge plans on 3/3/18 were to have the patient transferred to a skilled nursing home facility.

According to Patient #1's 3008 Form used for discharge instructions, it revealed the facility identified Patient #1 as an Elopement Patient Risk Alert (Section G); He ambulates independently (Section S) and Q5 minute observations.


Further review of the medical record for Patient #1 revealed that on 3/12/18, "Therapist received a call from Kepro indicating that Patient #1 did not meet PASRR Level 2 requirements, since his primary diagnosis was dementia and not mental illness."


A review of the Physician's discharge note, dated 5/2/18 was conducted. The document indicated Patient #1's admitting diagnosis was Major Cognitive Disorder Alzheimer's Type 4/5 dementia type. Patient had poor social support. The patient was very convivial. He had an MSE of 13/30, which speaks high of a high intensity dementia. Very poor speech and aphasia present. The patient was not able to repeat or to write or read any words, and he performed very poorly. Zilch judgement and zilch insight.


A review of the discharge planning notes, documented on the Master Treatment Plan updated on 4/27/18 indicated
"Discharge plan to nursing facility with Memory Unit target date 5/7/18."


The medical record revealed Patient#1 was discharged on 5/2/18 to an Adult Crisis Alternative Program (ACAP) who provide services for people with mental illness. The ACAP Program is voluntary and is used for adults who are experiencing a mental health crisis. ACAP was unable to meet the needs of the patient upon discharge on 5/2/18 as per the "Progress note dated 5/2/18 Intervention: Discharged to Clay County ACAP via non-emergent transport. On 5/2/18 at 1800 hours, received call from receiving facility stating they are unable to keep Patient #1 at their facility due to Patient #1 not talking with them and not signing the admission paperwork. As per Wekiva admission and DON, there is no criteria to readmit Patient #1. Call placed to family who directed to call guardian. No answer; message left."


There was no documented evidence that Patient #1 was provided with post-hospitalization instructions for follow-up and the necessity for continued care, at the time of his release. All discharge paperwork noted, "Patient unable to sign." Noted Patient #1 was "not capable to follow discharge planning instructions independently. Unable to obtain meds and take meds without supervision. Unable to sign discharge plan" (Nurse signed only and the MD did not sign) dated 5/2/18. The discharge medication summary dated 5/2/18 noted that Patient is unable to sign.
Patient #1 was also sent to the ACAP with only one discharge arrangement, which was a walk-in appointment to Clay Behavioral Health postdated for 5/3/18 at 8:00 AM.


On 5/17/18 at 2:00 PM, the Case Manager (Employee A) was interviewed and stated, "He is just shy. ACAP provides respite care and they accepted him. His Case Manager can then work on placement. We had to discharge him. When asked about ACAP, Employee A described it as a mental health facility providing respite care. She stated that ACAP can allow patients to walk out if the patient wanted to leave the facility. She explained that any patient could walk out of the facility, because it was not a locked unit. She further stated that Patient #1was just quiet and shy. It takes time to get to know him.


On 5/18/18 at 11:55 AM, the Physician (Employee B) was interviewed and stated, "Patient#1 has demented behavior. Medication treatment is well tolerated. Dementia treated with palliative. He has Alzheimer's. He is able to stand and walk. He is demented with all the symptoms of dementia. He was fine here. Awaiting for placement. The Social Worker told me he had social economic hardships. Skinny income to place him. The Case Manager said nobody wants to take him. Finally, he was discharged. I don't know where he ended up. He could elope if he needed to. He was not wheelchair bound. Very demented."

Based on interview and record review, the facility failed to ensure a safe discharge was implemented for 1 of 10 patients. (Patient #1)


The findings include:

Interview with the complainant on 5/15/18 at 5:10 PM revealed Patient #1 was discharged to a place that was not appropriate on 5/2/18. She explained that the Case Manager was rude and instead of helping place Patient#1 in a nursing home facility, the Case Manager decided to discharge Patient #1 after hours to an Adult Crisis Alternative Program/ACAP on 5/2/18. Complainant further stated "They called me and left me a message that day of discharge that they found a place that accepted him. They will take him short-term. You can work on long term placement. They did not do what we needed to do. Geriatric nursing home was our plan. This is not appropriate. ACAP is respite care. I'm not sure what they said to ACAP for them to take him. They knew someone over there. Patient #1 cannot communicate."


Review of the medical record for Patient #1 revealed he was 76-years-old, admitted to the facility on 3/3/18 with bizarre behavior. He had a diagnosis of Major Neuro Cognitive Disorder/Alzheimer's. He came from an Assisted Living Facility (ALF). Initial discharge plans on 3/3/18 were to have the patient transferred to a skilled nursing home facility.


According to Patient #1's 3008 Form used for discharge instructions, it revealed the facility identified Patient #1 as an Elopement Patient Risk Alert (Section G). He ambulates independently (Section S) and Q5 minute observations.


Further review of the medical record for Patient #1 revealed on 3/12/18, "Therapist received a call from Kepro indicating that Patient#1 did not meet PASRR Level 2 requirements since his primary diagnosis was dementia and not mental illness."


A review of the Physician's discharge note dated 5/2/18 was conducted. The document indicated Patient #1's admitting diagnosis was Major Cognitive Disorder Alzheimer's type 4/5 dementia type. Patient has poor social support. The patient is very convivial. He has an MSE of 13/30, which speaks high of a high intensity dementia. Very poor speech, aphasia was present. The patient was not able to repeat, write or read any words, and he performed very poorly. Zilch judgement and zilch insight.


A review of the discharge planning notes documented on the Master Treatment Plan updated on 4/27/18 indicated "Discharge plan to nursing facility with Memory Unit target date 5/7/18."

The medical record revealed Patient#1 was discharged on 5/2/18 to an Adult Crisis Alternative Program (ACAP), which provides services for people with mental illnesses. The ACAP Program is voluntary and is used for adults who are experiencing a mental health crisis. ACAP was unable to meet the needs of the patient upon discharge on 5/2/18, as per the "Progress Note dated 5/2/18 Intervention: Discharged to Clay County ACAP via non-emergent transport. On 5/2/18 at 1800 hours, received call from receiving facility stating they were unable to keep Patient #1 at their facility due to Patient #1 not talking with them and not signing the admission paperwork. As per Wekiva admission and DON, there is no criteria to readmit Patient #1. Call placed to family, who directed to call guardian. No answer, message left."


There was no documented evidence that Patient #1 was provided with post-hospitalization instructions for follow-up and the necessity for continued care, at the time of his release. All discharge paperwork noted, "Patient unable to sign." Noted Patient #1 was "Not capable to follow discharge planning instructions independently. Unable to obtain meds and take meds without supervision. Unable to sign discharge plan". (Nurse signed only, and the MD did not sign) dated 5/2/18. The discharge medication summary dated 5/2/18 noted that Patient was unable to sign.
Patient #1 was also sent to the ACAP with only one discharge arrangement, which was a walk-in appointment to Clay Behavioral Health, postdated for 5/3/18 at 8am.


On 5/17/18 at 2:00 PM, the Case Manager (Employee A) was interviewed and stated, "He is just shy. ACAP provides respite care and they accepted him. His Case Manager can then work on placement. We had to discharge him". When asked about ACAP, Employee A described it as a mental health facility providing respite care. She stated that ACAP can allow patients to walk out if the patient wanted to leave the facility. She explained that any patient could walk out of the facility, because it was not a locked unit. She further stated that Patient #1 was just quiet and shy. It takes time to get to know him.


On 5/18/18 at 11:55 AM, the Physician (Employee B) was interviewed and stated, "Patient #1 has demented behavior. Medication treatment is well tolerated. Dementia treated with palliative. He has Alzheimer's. He is able to stand and walk. He is demented with all the symptoms of dementia. He was fine here. Awaiting for placement. The Social Worker told me he had social economic hardships. Skinny income to place him. The Case Manager said nobody wants to take him. Finally, he was discharged. I don't know where he ended up. He could elope if he needed to. He was not wheelchair bound. Very demented."