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Based on review of facility internal documents, medical record review, and staff interviews, drugs were not administered in accordance with the orders of practitioners responsible for the patient's care and accepted standards of practice. Specifically, medical errors were identified in several areas, including a medical floor's failure to administer the medication Lactulose, administration of additional doses of the medication Ancef, and pump calculation errors within the Intensive Care Unit. These failures created the potential for negative patient outcomes.

The findings were:

The facility's policy/procedure titled Medication Administration, Order Verification, and Documentation Guidelines, dated 03/2010, stated the following, in pertinent part: "Clinical associates administering medications are the final 'gatekeepers' for the hospitalized patient. There are no additional opportunities to detect potential medication errors beyond this step. Therefore, clinicians administering medications must be especially vigilant to prevent medication errors..."

1. A review of the facility's internal variance reports, revealed that two patients were identified to have had missed doses of the medication Lactulose, a drug which prevents absorption of ammonia in the colon by acidifying stool and is often used for portal-systemic encephalopathy in patients with hepatic (liver) disease (Mosby's Nursing Drug Reference, 2010, 23rd Edition). Mosby's states to assess stools and blood ammonia levels (normally 15 - 60 mcg/dL). The initial patient variance was a patient did not get three doses of Lactulose due to, per verbal report, diarrhea, however, no bowel movements were documented within the chart. The physician's ordered stated "goal is to have 2-3 loose BMs a day," and the patient's ammonia level was over 100. The second variance was a patient that missed nine doses of Lactulose "due to reason of diarrhea." The variance stated, "It is concluded that staff did not understand diagnosis or treatment plan for this to occur... Only 2 stools documented..." Both incidents occurred on the same general surgical floor during the same week. Review of the patients' medical records, revealed each patient was admitted with encephalopathy.

An interview with the Nurse Manager of that floor was conducted on 8/8/11, at approximately 2:00 p.m. When asked about the variances, it was discovered that the floor is usually split into two units (North and South), however, one of the units was currently closed for construction. Therefore, hepatic encephalopathy patients that would normally receive the medication Lactulose were now "overflowed" to a unit with nurses that don't usually care for that type of patient as often. When asked about the first variance, the Nurse Manager stated that it was a single nurse and that nurse "was provided education." S/he also stated, "there were days when [the patient] refused everything and then [s/he] was ok the next day... We talked [with the nurse] about coaxing skills..." When asked about the second variance, the Nurse Manager stated there was "poor documentation of actual BMs (bowel movements) occurring... It appeared in report [s/he] had been stooling, so Lactulose was held and so it just kept being held... I asked other [staff], 'what did you get in report?' [One staff nurse] just thought [s/he] was supposed to hold it..." The Nurse Manager confirmed that all the staff involved in the variance were educated on the importance of the medication and referred to the unit's Educator for the education plan. When asked about the nurses on that unit and how it could be ensured not to happen a third time with nurses that had not yet been educated, s/he stated, "It got around at that point... There is no formal education yet, but it is on [the Educator's] list to update CIWA (Clinical Institute Withdrawal Assessment used to assess alcohol withdrawal) protocol and hepatic encephalopathy will also be done... The [Nurse Managers] are all aware of this now, so if we have similar patients, they are heightened to issues... We thought about sending an email update but knew that [education] was coming out... No other issues have been noted since then..." When asked when this education would occur, s/he stated, "I'd say in the next two months." The Nurse Manager stated that the unit which was closed for construction was planned to re-open at the end of September. The education power points on hepatic encephalopathy and the use of Lactulose that was to be presented to staff was provided to surveyors on 8/9/11 by the floor's Educator.

Additionally, medical record review conducted on 8/10/11, at approximately 8:40 a.m., revealed sample patient #11 missed approximately three Lactulose doses. A nurse's note, dated 4/17/11 at 08:19, stated the following: "Lactulose was missed 2200 [on 4/16] and 0000 due to emergency situation with another pt. Lactulose dose 0400 was missed because pt was sleeping." The patient's Lactulose order was changed several times: on 4/13, 4/14, and 4/17. The order from 4/14 at 1330, that the nurse would have been following, stated to give 30 grams of the medication every two hours and hold if three bowel movements in 24 hours. From 6:00 a.m. on 4/15/11, to 6:00 a.m. on 4/16/11, the patient had only one documented bowel movement. From 6:00 a.m. on 4/16, to 6:00 a.m. on 4/17, the patient had zero documented bowel movements. Although the nurse was aware of the missed doses, the medication order was still not followed correctly to best benefit the patient.

An interview with the Chief Nursing Officer was conducted on 8/10/11, at approximately 11:45 a.m. When asked when this education would be conducted, s/he stated "The CIWA education [will be later]... It is too long to wait... I'm going to ask them [the Educators] to do it in the month of September for all Med/Surg units (five total). They will come up to the floor and do education in small groups, there will be a sign in sheet, and it will be mandatory."

Although the facility implemented a plan during the survey, there was no evidence or projected dates of education prior to the medication issues being addressed by surveyors, considering the current logistics of these types of patients on a different unit and possibly with unfamiliar staff caring for them.

2. A review of the facility's internal variance reports, revealed a patient (sample #19) "received an additional 5 doses of Ancef post-operatively... med apparently entered without a stop date or timed for 3 doses only..." The variance documentation revealed that proper checks by nursing staff had been completed, however, the error had not been discovered. A review of the medical record revealed the order "1 gram Ancef Q 8 [hours] x 3 doses," ordered on 6/29/11 at 8:30 a.m. Documentation revealed the first dose was given in surgery at 9:30 a.m. Further review of the nursing Medication Administration Record, revealed that eight total doses were given by nurses, plus the additional one given by anesthesia staff in surgery, equaling a total of nine doses, despite that the order was written for only three.

An interview with the Director of Pharmacy was conducted on 8/10/11, at approximately 10:00 a.m. When asked about the variance, s/he stated it was an order entry error by a pharmacist and that the pharmacist had been "talked to by me as follow-up." The Director stated there had not been past issues with that pharmacist. When asked how this error could have been prevented, s/he stated, "A previous system I worked in had Pharmacy Techs do order entry, then the Pharmacist would check, then the Nurse would check... That is not done in Meditech (the facility's computer system). When asked further about why there was not an automatic stop order in place to prevent such an error, s/he stated, The corporate hospital system had "eliminated automatic stop dates because too many times something automatically stopped per policy and the physician didn't know and now the patient was at risk because they didn't get the drug." The Director further stated that the facility had a specific stop order for Toradol and TPN (Total Parenteral Nutrition), but otherwise functioned under the "no stop orders" policy of the corporate hospital system.

Review on 8/10/11 of the facility's policy/procedure titled "Automatic Stop Orders for Medication," last revised 2/10, revealed the following, in pertinent part: "[Corporate hospital system] will not be using the automatic STOP on orders due to the problems with order entry (leading to errors). Medications such as antibiotics, narcotics, Toradol injections (there is a label comment on all Toradol orders that states 'therapy should not exceed 5 days') will be monitored on a clinical basis at [the hospital]."

Despite the Pharmacy Director's counsel to the Pharmacist that incorrectly entered the medication order, the facility had made no further changes to prevent such an occurrence in the future.

3. A review of the facility's internal variance reports, revealed sample patient #20 had an incorrectly dosed continuously infused sedation medication (propofol) for over a day. The physician's order for the propofol drip (continuous infusion) was written on 7/12/11 at 2345. The medication had already begun, as it was emergently needed on 7/12 at 2245. Internal investigation and reporting by staff, revealed that the fourth nurse caring for the patient discovered the incorrect calculation on 7/14/11 at 0924. No adverse events occurred to the patient due to this incorrect pump calculation. During medical record review, it was difficult to clearly determine when the miscalculation had been discovered as each nurse did not document the pump's drug dosage, as well as infusion per hour and instead most just documented the dosage.

An interview with the manager of the Intensive Care Unit was conducted on 8/10/11, at approximately 2:00 p.m. When asked about the plan for change after the pump error, s/he referenced another error that had occurred prior to sample patient #20's. S/he stated that previous error had occurred partially due to staffing issues as the nurse's other patient was very busy. S/he continued that after that error, the ICU had initiated a trial. The trial included getting two RNs in the room to double check and chart the medication bags in Meditech. However, s/he stated "the trial failed because of the difficulty of getting two RNs in there (the patients' rooms)." The Manager stated other initiatives that had been trialed after that failure, including bedside nurse report at change of shift. Then in July, after sample patient #20's pump error, s/he stated, "We realized we have a process that is not working... We are going to continue with color labels (for different medications) and an email went out Monday (8/8) that staff will check pumps with two RNs when they hang a new bag, make a program change, and have a different concentration..." When asked further why nurses were independently failing to check their pump medication calculations, s/he stated, "The double check of the correct concentration is not happening consistently... I honestly don't know why this is happening now..." The difficulty of this new process of two nurse checking every pump change was discussed and the Manager was asked if the ICU currently uses smart pumps, which have calculations of medications pre-programmed within them. S/he stated, "We are currently doing all manual calculations on our pumps in the ICU."

When asked why such was the case, as other facility's within their corporation have pumps with "smart" technology, the Chief Nursing Officer and ICU Manager stated that they were informed there was some type of contractual obligation with the pumps and that upgrades were not available for another year and a half. Additionally, all of the current triple pumps in the facility's ICU were first generation and not able to be upgraded. The plan was to wait for "true smart pumps" with the corporate system-wide roll-out. When asked if the facility could look at this change independently, the Chief Nursing Officer stated, "Our board does not have budgetary authority."

Although the facility, specifically the Intensive Care Unit, was attempting to decrease errors and improve patient care during the use of medication pumps, the facility was implementing a process of double-checking medications that could potentially be more labor intensive and taxing to Intensive Care Unit nurses. The possibility of improved medication pump technology was not an option due to the facility's lack of budgetary authority.

Based on medical record review and staff interview, the facility failed to ensure blood transfusions were done so timely. Specifically, one (#2) of 20 sample medical records had a blood transfusion that began five hours and 37 minutes after the Blood Bank had completed preparation of the blood, a total of eight hours and 46 minutes after the physician's order was written to transfuse. This failure created the potential for a negative patient outcome.

The findings were:

Review of patient sample #2's medical record, revealed that the patient was admitted after a fall. While hospitalized, the patient was treated for leg wounds, acute renal failure, chronic anemia, rheumatoid arthritis, lower extremity blood clots in both legs, and weakness. On 4/17/11 at 5:10 a.m., the patient's hemoglobin and hematocrit were 7.8 and 25.6, down from the previous day's 8.1 and 27.2 levels. At 3:44 p.m., one of the patient's critical care physicians ordered "Transfuse 2 Units pRBC," indicating for the patient to have two units of packed red blood cells transfused. It was noted that the nursing documentation, which evidenced the time the units of blood were started and stopped was done so on two separate "DOWNTIME BLOOD TRANSFUSION RECORD." "Downtown" occurred when the facility's computer medical record documentation system was not working and documentation had to be done on paper. The first form was dated 4/18/11, and stated that the preinfusion vital signs were done at "0030" and the postinfusion vital signs, to be done "within 1 hr," were done at "0220." The second form was also dated 4/18/11, and stated that the preinfusion vital signs were done at "0300" and the postinfusion vital signs were done at "0430." Additional documentation within the Meditech computer charting system confirmed that those times were the "Blood start time" and "Blood unit stop time" for each unit. An interview with the Regulatory Readiness Coordinator on 8/9/11, at approximately 12:40 p.m., confirmed there was no nursing note explaining the delay in the blood transfusion.

An interview with the Blood Bank Coordinator was conducted on 8/9/11, at approximately 1:00 p.m. Using the Meditech computer charting system, s/he confirmed that the blood had been ordered on 4/17/11 at "1605" and ordered as "routine." S/he stated that the patient had "no antibodies and was O negative." S/he stated that both units were "screened at 1850 and crossmatched at 1853." S/he stated that the crossmatch time is when "they were ready" and that both units were ready at the same time. When s/he was asked if Meditech's downtime would affect the processing and preparation of blood, s/he stated it would not, as the Blood Bank has downtime sheets they use during those events.

An interview with the Chief Nursing Officer was conducted on 8/9/11, at approximately 4:50 p.m. S/he stated that the Meditech computer charting system was in "downtime" from "11 p.m. to 7:30 a.m... so this had nothing to do with the downtime."

An interview with the Director of Quality Management (QM) was conducted on 8/9/11, at approximately 2:20 p.m. S/he stated, "At this point, we don't have an explanation for the delay [in transfusion]." An additional interview was conducted on 08/09/11, at approximately 5:00 p.m. S/he stated that s/he had spoken with the Manager of the floor the patient was on during this blood transfusion. The Director of QM stated, "[The Manager] said it is not our standard of practice to take that long to give blood... Lab calls and says the blood is ready, the RN sends a pink slip down, and then lab sends up [via the tube system] the blood..." The Director of QM stated the Manager expressed this nurse had not had issues like this in past. When asked if this type of delay would generate an incident report within the facility, s/he stated, "...Blood is not timed so it is not a formal delay..."

The facility's clinical policy titled "Blood and Blood Products," last revised 3/21/2011, did not specify how soon after an order blood products should be transfused.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Discharge Planning.

The findings were:

Cross Reference to A0809: Self Care Patient Evaluation - for findings related to the facility's failure to ensure that it conducted an accurate and multi-disciplinary discharge planning evaluation, which included the likelihood of a patient's capacity for self-care in the environment from which s/he entered the hospital. Specifically, in one of 20 sample medical records, the patient was discharged home with minimal assistance and services when such were needed due to the patient's condition at the time of discharge.

Cross Reference to A0822: Preparation For Discharge - for findings related to the facility's failure to ensure that interested persons in the patient's care were counseled/educated to prepare them for the patient's post-hospital care.

Cross Reference to A0843: Reassessment Of Discharge Planning Process - for findings related to the facility's failure to ensure its reassessment of discharge plans determined the plans were responsive to patients' discharge needs.

Based on medical record review, staff interviews, and review of facility policies/procedures, the facility failed to ensure that it conducted an accurate and multi-disciplinary discharge planning evaluation, which included the likelihood of a patient's capacity for self-care in the environment from which s/he entered the hospital. Specifically, in one of 20 sample medical records, the patient was discharged home with minimal assistance and services when such were needed due to the patient's condition at the time of discharge. This failure created the potential for a negative patient outcome and did not ensure the facility maintained a safe, efficient, and mult-disciplinary discharge planning process and system. Additionally, despite the facility's awareness of concerns about the patient's discharge, minimal process changes were evidenced.

The findings were:

A. Medical Record Review

1. Sample medical record #2 was reviewed on 8/8/11. The patient was admitted on 4/12/11, and discharged on 5/2/11. The discharge summary stated, in pertinent part: "This is a[n adult patient] ...who was admitted to the hospital after [s/he] was profoundly disheveled with dirty [household items] and inadequate food... Unfortunately, [s/he] is uninsured and has not sought help with Medicare, Medicaid or COBRA. [S/he] has fairly significant debility. Unfortunately, there was no facility that will accept [him/her] for rehab. Ultimately, [s/he] is being discharged home with a friend of [his/hers] named... who will change [his/her] dressings every other day. [Patient's friend] has also found [him/her] an apartment in [town's name] that is single level as [his/her] previous home was multilevel. Clinically, [s/he] is markedly improved. [His/her] legs have improved and [s/he] has worked with therapies. [His/her] mobility has also improved. [S/he] is discharged in stable condition.... I did speak with [PCP physician] who will see the patient in clinic today for outpatient followup. [S/he] needs ...[his/her] dressings changed every 48 hours which [his/her] friend... is going to do."

However, further review of the medical record revealed that there were concerns about the patient's discharge to home expressed by physical therapy, occupational therapy, a sister facility's rehabilitation department, as well as all home health agencies that the facility contacted except one. Additionally, the patient had a psychological exam completed, which identified that the patient was not realistic of his/her needs, capabilities, and situation. However, the medical record did not evidence that this evaluation was taken into consideration when discharging the patient. It is unknown if all avenues of assistance were fully explored for this patient as the patient was deemed not eligible for Medicaid due to his/her income and because the patient did not have dependents, the former of which was never officially verified by the facility. Lastly, there was no evidence that the patient's caretaker ever received education on wound care or transfers or that the patient had the proper equipment at home prior to discharge, such as a wheelchair, bed, walker, or commode.

2. The "Psychological Assessment" was conducted on 4/25/11, by a Behavioral Health Registered Nurse. It stated the following, in pertinent part: "...Since that time [s/he] has apparently been on a downhill course. [His/her] home is reportedly very uncared for as well as [s/he] has several ulcerations some of which have been around for a long time. [S/he] presents with a passive dependent style while saying [s/he] is quite independent and is saying [s/he] is more able to care for [him/her]self than [s/he] really is. [S/he] reports lots of friends and [family members] who [s/he] talks to all the time... Collateral Information: I was able to speak with [the patient's friend]... [S/he] differed with many of the things [the patient] told me today." The patient's friend stated that the patient did not have much social support or resources, that the patient's statements were not always accurate, that the patient had not been very mobile for 1 1/2 years, and that the patient's finances were in not in stable shape. The evaluation continued, "[Patient's Social Worker] says [s/he] has contacted [the patient's family members] and even though they know the shape [s/he] is in, they have not stepped forward to help and have refused to come to Colorado... Apparently [s/he] is also dishonest about what is really going on with [him/her]..."

3. The Social Worker's documentation evidenced much work towards the patient's discharge disposition, despite that the patient was discharged home with only the assistance of a friend who planned to come by periodically and two home health visits. There was not evidence that education and necessary equipment were in place prior to the patient's discharge from the facility.

On 4/11/11, the Social Worker documented that a medicaid application would get started on the patient, however, on 4/15 the Social Worker documented that the facility's Health Benefits Advisor stated "because of the patient's income" s/he would not be eligible for medicaid. A financial trust was recommended by one of the facility's contracted company's that assists with patient financial needs, however the Social Worker documented on 4/20 that s/he was not able to get any facilities to set up a trust. The Social Worker spoke with the patient's out of state family members frequently, who stated they would not be able to be in state until May 9th. On 4/27, the Social Worker documented that s/he asked one of the patient's family members "so is the plan to make [the patient's friend] the one that will have to do everything and [patient's family member] stated yes..." The facility's sister rehab unit's staff liaison reviewed the patient's medical record on 4/22, to determine if the patient was a candidate for their unit. The rehab liaison documented the following, in pertinent part: "Even if we got pt mobile would [s/he,] could [s/he] take care of herself and be able to return home independently... If pt unable to return home then where would this pt go..." The rehab liaison spoke with two of their physicians on 4/26, who were concerned about the patient's ability to be admitted to their unit and Skilled Nursing Facility placement was ultimately recommended.

On 4/26, the Social Worker documented the following, in pertinent part: "...Worker then went to talk to the patient and his/her friend... about the fact that this patient is not going to be approved by [for Rehab center. Patient started to cry and stated that [s/he] can't be put out on the street. Worker let the patient know that the hospital worked very hard to get [him/her] insurance and to a facility. Patient at this time has no private monies... [P]atient has a very close friend... that was in the room who really wants to help the patient out with [his/her] plans... Worker let the patient and [his/her] friend know that there is a good chance that the patient would be d/c by the end of the week..."

On 4/29, the Social Worker documented the following, in pertinent part: "Patient today has been refused by all of the homecare agencies because they feel that [s/he] should be in a higher level of care. Worker has faxed scripts and charity forms regarding getting the patient a semi-electric Hill Rom foam beds... PT will be evaluating the patient because the current bed is to[o] high... Worker has asked the friend come it to learn how to do the every other day wound care with the patients nurse..."

The final notes documented by the Social Worker on 5/2, indicated that the patient was being discharged to a doctor's office for appointment so the patient could then have two visits of home health care, which the facility was paying for. The patient's friend was able to find a new apartment close to him/her and the friend stated that s/he would be getting the patient a wheelchair and a commode. As of 5/2, the patient's friend had not yet come in to learn "how to dress" the patient's wounds, but the Social Worker documented, "...Worker was told that the patient is very knowledgeable about [his/her] care needs. Patient's nurse states that [s/he] feels the patient will be able to direct [his/her] friend..." Additionally, the Social Worker documented the following regarding the discharge plan: "...Patient at this time has been referred for a bed, but we have not yet heard back about the status of this bed. Patient's friend will be checking on the patient a few times a day..." On 5/2, the Social Worker worked contacted Adult Protective Services to have someone assigned to the patient.

4. Throughout the patient's hospitalization, the physical and occupational therapists continually recommended the patient be discharged to a Skilled Nursing Facility or Acute Rehabilitation Center. Progress notes towards the end of the patient's hospitalization, when it was clear the patient was not accepted into a skilled care facility, still recommended home therapies and evidenced the patient's weakness. Despite interviews wherein staff stated these recommendations were taken into consideration, it is not evidenced within the medical record. The final Physical Therapy and Occupational Therapy Progress Notes stated the following, in pertinent part:
5/1: OT Progress Note "...Assessment - pt plans to d/c to new apt, friend will assist 4 x day. question pts ability to manage, friend to purchase needed dme [durable medical equipment], continue to recom [recommend] acute rehab..."
5/1: PT Progress Note "...pt reports [s/he] is feeling better about going home tomorrow... anticipate home with home p.t. [Physical Therapy] @ d/c..."
5/2: OT Progress Note "...reviewed w/c [wheelchair] specs rec for rental w/c, reviewed purchasing options for bsc [bedside commode], provided lending options, pt refused oob [out of bed]... Assessment - question pts safety at home, reviewed dme [durable medical equipment]..."
5/2 PT Progress Note "...no a.m. p.t. as pt states [s/he] does not want to do any transfers as [s/he] wants to save [his/her] energy for going to M.D. appt. then home..."

5. The primary physician group's progress note, dated 4/30/11, stated the following, in pertinent part: "- [bilateral lower extremity] ulcers slowly better... Dispo home on Monday c HHC [Home Health Care], establish Ppc... D/C to appt at [MD's office], weakness: therapies..." The physician's progress note, dated 5/1/11, stated the same in regards "weakness: therapies," despite that the patient was not going to be getting therapies (physical or occupational) at home.

6. The patient's "Discharge Orders and Instructions," dated 5/2/11, stated "(change) drsngs bil LL q 48 (hours)," instructing the patient to change both of her lower extremity dressings every 48 hours. It did not specify with what or how the dressings changes were to be done.

B. Staff Interviews

Many interviews were conducted in regards to the patient's care and quality assessment/performance improvements after the patient's care had been alerted as a concern. The interviews further displayed how many individuals were involved in the patient's care, how there was not necessarily a lead in the discharge planning process except for the physician, and that communication and interdisciplinary processes were not clear. Furthermore, the interviews evidenced that the patient's primary social worker was not fully apprised of the patient's safety needs upon discharge and that no concrete changes have been implemented within the facility since the patient's hospitalization. Although a "meeting" was frequently referenced, the meeting already took place prior to the patient's admission and no minutes of such meetings were maintained.

1. An interview with the Chief Nursing Officer, was conducted on 8/8/11 at approximately 1:15 p.m. When asked about the patient in the complaint, s/he stated, "...We had worked with PT/OT trying to find a safe discharge for [him/her]... It was a difficult discharge, that's for sure." When asked who did the post-discharge evaluation of the patient's care, [s/he] stated it was the CMO, CNO, Director of Quality, and Director of Discharge Planning. "We met about looking at it... 'did we miss anything?'" At approximately 1:50 p.m., when asked what changes had been made since then, s/he stated, "Administration made up plans. The challenges for discharge are sent to us by the Directors... We are doing case conferencing... The Social Worker pulls directors in on these complex cases and they take this back to us..." At approximately 8:30 a.m. on 8/9/11, the CNO stated, "We have a new re-admission team. We meet every other week for re-admission... We are looking at follow-up phone calls within 24 hours with a nurse after discharge and checking follow-up physician appointments... Had someone gone out and called the patient in 24 hours, it may have been prevented..." When asked, the CNO stated that the facility was not currently doing post-discharge phone calls yet on each floor.

2. An interview with the Director of Discharge Planning was conducted on 8/9/11, at approximately 8:00 a.m. When asked who makes the determination as to if the patient is to be discharged, she stated, "Ultimately the physician." When asked about documentation is the patient's chart, which stated the patient was likely to be discharged "this week," s/he stated, "We talk to the physician and nurse practitioner on an ongoing basis so we know the patient will be discharged based on medical reasons and progress with PT." When asked about the documentation, which stated the patient's income was too high to get Medicaid, s/he stated, "I believe it was confirmed... We use Health Benefits or Charity to determine Medicare/Medicaid... Health Benefits would do the Medicaid application... Conifer is the outsourced company that comes in and reviews everything for the (Medicare/ Medicaid) application... It is two fold... They would help the patient complete the application. Health Benefits and Conifer would have determined [his/her] SSI income." When asked about the Medicaid application documentation, she stated, "They work in a different system. Everyone that comes to us as self pay, they review and evaluate..." When asked about the documentation from [outside hospital's] Rehab staff, s/he stated, "...There is a liaison nurse for [them]... We make a consult for them, they do the initial assessment, talk to the physician and team... [S/he] stated that they thought the patient wasn't capable of doing three hours of rehab per day, as [that is what is required there.]" When asked about the documentation, which stated the patient's family was to be involved, s/he stated, "They told [the Discharge Planner] they were planning to visit, but we had no confirmation of that..." When asked about the patient's progression towards discharge, s/he stated, "In discussions with the physicians, they felt they were ready to go... [S/he] was motivated to participate and at other times not..." When asked if the patient still had needs prior to discharge, s/he stated, "As I look back, the challenge was to keep motivated and return home... Perhaps everything wasn't perfect, but we felt it was good enough. [S/he] had her PCP appointment, transfer, two home care visits... [The friend] was agreeable, the patient was agreeable..." When asked the role of 'Home Care,' another separate entity from Social Work/Discharge Planning, s/he stated, "To make sure it's all wrapped up and totally a package..." When asked how this new discharge meeting is different that in the past, s/he stated, "There is more involvement... We are all on the same page... We understand the complexity... We are having more complex discharges that we've had in the past..." S/he stated that there were no minutes maintained from this meeting. The Director stated that weekly follow-up with the lead Social Worker now occurred. S/he stated, "We requested [s/he] take more leadership role with Social Work and that [s/he] meet with all Social Workers... It is done informally at least once a week..." The Director stated that interdisciplinary rounds occur and that it is the nurse's responsibility to chart who is present, the barriers/challenges to discharge, and what should take place. Interdisciplinary rounds in sample patient #2's medical record did not clearly evidence a multi-disciplinary approach to discharge planning.

3. An interview with the patient's primary Social Worker/facility's Lead Case Manager was conducted on 8/9/11, at approximately 8:45 a.m. When asked about the patient's presentation and history, s/he stated, "[S/he] came in poor shape with multiple wounds and not ambulating, had become bed bound... [S/he] was not really connected to a physician. A few months prior, [s/he] had insurance" but had lost it. When asked about the patient's discharge planning, s/he stated, "The primary player was [his/her] friend... [His/her] family was in [another state]..." When asked why the patient was not transferred to a Long Term Acute Care Hospital (LTAC), s/he stated, "There was a lack of insurance and finances didn't pan out. We were told by the LTAC there was a high cost factor..." When asked about [the facility's Sister hospital's Rehab Unit,] s/he stated, "They didn't feel they could provide services because [s/he] had lots of wounds... PT (Physical Therapy) was seeing [him/her] twice a day to rehab [him/her] the best we could... We applied for 'Getting Us Covered,' which is for people who have high insurance costs and can't get covered. If you apply for it after the 15th of the month, you won't get it until the following month, not that month... The application did get done; It was done by [contracted staff member] of Conifer... At one point, we were told [the patient had money] in resources, then a week to two weeks later we were told that money had to go to bills... So that made [him/her] Medicaid applicable: [the contracted staff member] helped apply to Medicaid..." When asked about the status of his/her Medicaid application, s/he stated, "I don't know what happened with that because of the length of time it takes to get approved." When asked about the statement that the patient was getting a certain amount of money per month in [assistance], s/he stated, "I think it was verified..." When asked about Home Care, s/he stated, "[S/he] didn't qualify for their charity... We decided to send [him/her] to the [a specific] Clinic to see a Doctor, then we were sending in a nurse for two visits to do dressing changes... Our ultimate goal is to teach someone to do wound care for anyone who goes home with a wound... [The patient] felt comfortable due to [his/her] professional knowledge [in the medical field] and as [s/he] saw them done..." When asked about post-discharge home equipment, s/he stated, "The hospital ordered a bed... The patient knew [s/he'd] be responsible for the cost of the bed." When asked about team communication, s/he stated, "We do interdisciplinary rounds on every patient on the unit... I work very closely with Home Care... I was aware of PT/OT's perspective... [The friend] was aware... The plan was that [the friend] would be there to do treatment... [S/he] got an apartment [that was close. The patient's friend's job required her to] be gone a short time in the morning and in the afternoon..." When asked if the patient's psych evaluation was taken into consideration for his/her discharge, s/he stated, "The psych eval was brought up in team meetings... I'm pretty sure [the Psych Nurse Specialist] gave resources for [him/her] to get in touch with a therapist... [S/he] was alert and oriented and able to make her own decisions... We were not making decisions for [him/her,] just aiding her." When asked about Adult Protective Services' involvement, s/he stated, "When [s/he] came, ...County APS was involved. Once hospitalized, they feel they are safe and never stepped it... Hospital's responsibility to be kept in the link. When [s/he] left, I called ...County and had [the other county's] APS speak with them..." When asked about guardianship, s/he stated, "I don't know if [the family member] ever did come in (to town). We never saw paperwork that [the patient's friend] was the POA, but [s/he] mentioned that she was... The [family] had resistance to come here, of course, I was trying to get them to come..." When asked if s/he felt push from the physicians to discharge the patient, s/he stated, "It wasn't a push... [S/he] was ready a few weeks prior, the hospital felt. We wanted to make sure we had everything in place we could... We don't like to discharge patient with long problems until after the weekend..." When asked if the patient had a contact s/he could refer to after discharge, s/he stated, "Home care would be their one contact. Also, that is why we were connecting [him/her] to a physician... [The patient's friend] was willing to drive [him/her] back and forth..." When asked who makes the call about patient's discharge, s/he stated, "The doctors felt that [s/he] was ready. We are an assistant to them." When asked about the future for the Discharge Planning Department, s/he stated, "We have meetings every Tuesday with all the Social Workers. We meet with UR (Utilization Review), go over cases, and figure out how to process. We go over cases every week: my responsibility is to assist..." S/he also stated there was a hospital initiative to "have someone as a designated position to do follow-up on every patient..." That initiative had not yet been put into action.
An additional interview was conducted with the Social Worker at approximately 12:00 p.m. When asked about wound care education for the patient or the patient's friend, s/he stated, "I think they tried to get [the patient's friend] to come in and have the wound care team teach, but perhaps [s/he] was never able to make it." When asked if the patient or friend had been provided transfer training, s/he stated, "I don't know." When asked if the patient had ever received a speciality bed, as was recommended by PT/OT, s/he stated, "We had ordered the bed. The doctor from [the clinic] would be the one to write the script had it been ordered. I think we placed an order, but it was contingent on getting the script." When asked his/her understanding as to if the patient got a wheelchair or a commode, s/he stated, "[The friend] was going to be getting it for [him/her.]"

4. An interview with one of the "Health Benefits Advisor," was conducted on 8/9/11, at approximately 9:20 a.m. S/he stated, "I was involved in the financial part... am a financial counselor... Conifer/ MEC (contracted company) goes up and interviews the patient. [The staff member who works for Conifer/ MEC] went up there to look for all outlets to help this patient..." When asked if patients' financial income was verified, s/he stated, "We rely on the patient because a lot of the times they are real defensive and so we say: 'on what you tell us, [that amount of money] is over for disability.' If no minors, we know they aren't going to get on Medicaid... After [Conifer staff member] is done, I go up and say 'I understand you don't qualify for State programs, but you may get on our programs.' Had [s/he] not been getting [that amount of money, s/he] may have been eligible for disability but not straight Medicaid." When asked further about Medicaid eligibility, s/he stated, "If [s/he'd] had minors or if very low income... It is contingent on how may kids." S/he continued, "There are two forms of disability: SSDI and SSI, but because of the money amount, [s/he] was not eligible at the time of this interview... We normally give the phone number to disability so we don't stop them from applying..."

An additional interview was conducted with the Health Benefits Advisor at approximately 2:25 p.m. When asked about the patient's financial assistance, s/he stated, "[S/he] was not approved for Medicare or Medicaid. [S/he] got approved for our charity." When asked if the facility explored other non-governmental assistance options, s/he listed other programs and stated, "We give them the source to get in, but don't follow-up and hold [their] hand." When asked again about the patient's Medicaid application, s/he stated, "It they qualify, we are just the go between. We help with the applications. I don't do that, [the Conifer staff member] does that. [S/he] faxes the application to the county, gets information back stating we need financials, birth certificates, etc."

5. An interview with the Chief Medical Officer was conducted on 8/9/11, at approximately 10:25 a.m. When asked what happened after the facility was alerted of the patient's care, s/he stated that several individuals "looked at the case. What was put in place: it obviously ended up failing. We were wanting to look at what we could do differently and improve in the future..." When asked further about performance improvement processes thereafter, s/he stated, "It is somewhat of an evolving process. We have had more patients with difficult discharges for a wide variety of reasons... not all the same problem... In the past, I've met with [the facility's Utilization Review staff member] and the Case Manager frequently and went through the process with a particular patient; the best way to handle barriers. What we've said would be better is if we schedule regular meeting to go over... We've had regular meetings within the last few weeks... We were doing them before, but not on a schedule." When asked about the role of Utilization Review, s/he stated, "One issue we frequently have, it is very common for physicians to go ahead and evaluate other unrelated things they discover or the patient may tell them about while the patient is waiting to get better from pneumonia, for example. Part of this question is when we have issues that are not an inpatient type issues, how can we get them out of the hospital? One thing that has become much clearer to me over the past few years is the move to care of hospitalist. They are good at managing acute care, but not outpatient doctors anymore... They are not good at taking care of long term problems, nor is the hospital stay. The point of that is that getting patients out of the hospital into a setting more likely to have skills to get through the next few weeks of recovery... Simply keeping [sample patient #2] for a longer period is not helpful to getting [him/her] into hands...." The CMO continued, "There were times when [s/he] was more willing to work with therapy staff. [S/he] was not someone that was being straight forward. When I talked to the Nurse Practitioner and asked if [s/he] was comfortable with this plan, [s/he] said [s/he] was..." When asked if the patient was safe for discharge, s/he stated, "It is always a matter of balancing risk as opposed to benefit... With [him/her], if we couldn't come up with something that would allow [him/her] to get out of there, [s/he] was as going to be here... We aren't skilled at long term... I think they worked hard to come up with something that everyone thought was going to work... It would not have been our ideal choice." When asked who is responsible for determining discharge, s/he stated, "Ultimately the physician is in charge of discharge planning... Physicians are particularly concerned with whatever plan we put in place... A lot of communication that goes on is not reflected in the chart." When asked about this new meeting that had been referenced often, s/he stated, "Most of these patients are kind of ongoing... It could start at the time of admission... Most of the patients we've talked about in the past have been here for a while." When asked specifically about [sample patient #2], s/he stated, "Part of the challenge was telling if [s/he] was reliable..."

6. An interview with the Director of Quality Management was conducted concurrently with the latter interview with the CMO. S/he stated, "We have a team looking at re-admissions. We can't say 'we are putting x, y, and z in response,' we are looking at a broader scope... We are spending a lot of time looking at the bigger system. There is a smaller group meeting more regularly that is really looking at creative placement options." When asked about the patient's equipment needs at home, s/he stated, "We did not specifically look at equipment in our review." When asked about the patient's psych evaluation, s/he stated, "My understanding was [s/he] was more capable than [s/he] would admit." When asked about the possibility of home visits prior to discharge, s/he stated, "We don't have the capacity to do home visits. OT does home visits..." S/he was not aware if one was done for this patient. The QM Director later checked with OT and stated that a follow-up call/ visit was not done with the patient.

7. An interview was conducted with the patient's primary Occupational Therapist on 8/9/11, at approximately 12:40 p.m. When asked about the involvement of the patient's friend, s/he stated, "[S/he] found an apartment for [the patient. [S/he] generally seemed sincere. I questioned the reality of [the friend] being able to come in four times per day. I questioned the safety of that. I originally thought [the patient] would get a hospital bed and that if [the patient] would be toileting in the morning... that would be tolerable... [The patient] was safe in a wheelchair.... [The patient] was progressing... I was disappointed we didn't get a hospital bed: [the patient] was more independent getting out of bed with a speciality bed... I encouraged [the patient's friend] to bring the equipment here and [s/he did not do] that... I think [s/he] got the wheelchair and commode, but it has been a while. I gave a list of places that loan out medical equipment." When asked if the patient could get to and from the toilet independently, as the patient's friend would be working for several hours in the morning and again in the afternoon, s/he stated, "[S/he] couldn't get there with a walker safely. I believe [s/he] was minimal assist from the bed to the wheelchair...'" The OT stated the patient was on "contact guard" upon [his/her] discharge. When asked the definition of that, s/he stated, "I physically felt I needed to hold on to [him/her.] I didn't feel safe letting go." When asked about his/her recommendation for this patient, s/he stated, "Initially and all the way along it was SNF (Skilled Nursing Facility). But when that didn't come through, we worked on making [him/her] independent for home..." When asked about the patient at discharge, s/he stated, "With the level of care that the friend said [s/he] could provide, I thought it was ok. I had reservations. It was not ideal. In my gut I was questioning it... I knew about the friend's job... [The friend] was there for a lot of the therapy sessions, but there was no set education (on transfers). The patient was aware and the friend had seen all the transfers. Because [the patient] was improving, I thought [s/he] could have benefited from more therapy. [S/he] was a tough case..."

8. An interview with the patient's Nurse Case Manager was conducted on 8/9/11, at approximately 1:35 p.m. When asked his/her involvement with the patient's care, s/he stated, "[The Social Worker] asked me to see if we could get a Hill Rom bed approved for the patient... The current one with us was too high... Hill Rom then called back and said [s/he] did not meet poverty level with charity for a bed...." When asked when someone in his/her role, a Nurse Case Manager, would be contacted to become involved in a patient's care, s/he stated, "Usually with medical necessity, insurance, or approvals... Usually a Social Worker (instead of RN Case Manager) is involved with long term patients or difficult dispositions. We get involved with low risk, younger patients..."

9. An interview with the Home Service Coordinator was conducted at approximately on 8/9/11, at approximately 1:45 p.m. S/he stated there were three total Home Service Coordinators at the facility, but it was discovered they were a contracted service. When asked how s/he would get involved in a patient's care, s/he stated, "Through Case Management or Social Work after an evaluation of a patient they will give me a call or through a PT recommendation. If there are no referrals from either, I get a p

Based on medical record review and staff interview, the facility failed to ensure that interested persons in the patient's care were counseled/educated to prepare them for the patient's post-hospital care. The facility relied on the fact that the patient was previously in a medical profession, however the medical record evidenced that the patient was not necessarily a reliable historian or as able to care for him/herself as the patient felt. Additionally, although the patient's interested person was willing, it was not clear that person was able to provide the care necessary for that patient. This failure created the potential for a negative outcome.

The findings were:

An interview was conducted with the patient's primary Occupational Therapist on 8/9/11, at approximately 12:40 p.m. When asked about the involvement of the patient's friend, s/he stated, "[S/he] found an apartment for [the patient. S/he] generally seemed sincere. I questioned the reality of [the friend] being able to come in four times per day. I questioned the safety of that. I originally thought [the patient] would get a hospital bed and that if [the patient] would be toileting in the morning... that would be tolerable... [The patient] was safe in a wheelchair.... [The patient] was progressing... I was disappointed we didn't get a hospital bed: [the patient] was more independent getting out of bed with a speciality bed... I encouraged [the patient's friend] to bring the equipment here and [s/he did not do] that... I think [s/he] got the wheelchair and commode, but it has been a while. I gave a list of places that loan out medical equipment." When asked if the patient could get to and from the toilet independently, as the patient's friend would be working for several hours in the morning and again in the afternoon, s/he stated, "[S/he] couldn't get there with a walker safely. I believe [s/he] was minimal assist from the bed to the wheelchair...'" The OT stated the patient was on "contact guard" upon [his/her] discharge. When asked the definition of that, s/he stated, "I physically felt I needed to hold on to [him/her.] I didn't feel safe letting go." When asked about his/her recommendation for this patient, s/he stated, "Initially and all the way along it was SNF (Skilled Nursing Facility). But when that didn't come through, we worked on making [him/her] independent for home..." When asked about the patient at discharge, s/he stated, "With the level of care that the friend said [s/he] could provide, I thought it was ok. I had reservations. It was not ideal. In my gut I was questioning it... I knew about the friend's job... [The friend] was there for a lot of the therapy sessions, but there was no set education (on transfers). The patient was aware and the friend had seen all the transfers. Because [the patient] was improving, I thought [s/he] could have benefited from more therapy. [S/he] was a tough case..."

Medical record review was conducted on 8/8/11 and revealed the following:

The "Psychological Assessment" was conducted on 4/25/11, by a Behavioral Health Registered Nurse. It stated the following, in pertinent part: "...[S/he] presents with a passive dependent style while saying [s/he] is quite independent and is saying [s/he] is more able to care for [him/her]self than [s/he] really is..."

"Case Management DC Assessment/Plan" documentation in the medical record was as follows, in pertinent part:
5/2: "Patient is being d/c today to [his/her] doctor[']s office... Patient at this time has a bed that is from [his/her] prior apartment and the friend will be getting the patient a wheelchair and will get [him/her] a commode. Patient will be getting two visits from [Home Healthcare Agency] starting on Wednesday that the hospital will be paying the bill... between the doctor[']s apt and the patient having two nursing visits that we are insuring that this patients wounds are progressing. Worker spoke to [patient's friend] this morning who states that [s/he] has not yet come in to learn the dressing changes. Worker spoke to the patient['s] nurse... today who states that this patient is able to direct [his/her] friend on how to dress [his/her] wounds. Worker was told that the patient is very knowledgeable about [his/her] care needs. Patient's nurse states that [s/he] feels the patient will be able to direct [his/her] friend and this is also the reason that we are getting homecare into the home. Worker has spoken to [patient's friend] who states that [s/he] feels very comfortable with this plan. Patient will be given supplies to take home with [his/her] to get the wound dressed. Patient will be responsible to get [his/her] own supplies. Patient at this time has been referred for a bed, but we have not yet heard back about the status of this bed. Patient[']s friend will be checking on the patient a few times a day..."

The primary physician group's progress note, dated 4/30/11, stated the following, in pertinent part: "...weakness: therapies..." The physician's progress note, dated 5/1/11, stated the same in regards "weakness: therapies," despite that the patient was not going to be getting physical or occupational therapies at home.

The patient's "Discharge Orders and Instructions," dated 5/2/11, stated "(change) drsngs bil LL q 48 (hours)," instructing the patient to change both of her lower extremity dressings every 48 hours. It did not specify with what or how the dressings changes were to be done.

Based on internal facility documents and staff interviews, the facility failed to ensure its reassessment of discharge plans determined that the plans were responsive to patients' discharge needs. Additionally, there was not concrete evidence that a quality assessment and performance improvement process had effective follow-through during the review of one (#2) of thirty sample medical records. This failure created the potential for a negative patient outcome.

The findings were:

1. Despite that the facility was aware of a patient's negative outcome only days after discharge, the facility deemed that their discharge process had been appropriate.

Meeting minutes from the "Utilization Review Committee" were reviewed. The meeting revealed that the patient's case was addressed at the meeting dated 5/2/11, the day of the patient's discharge. The minutes stated the following, in pertinent part: "[The CMO] suggested that if there is a case in the future where discharge planning is complicated because the patient is self pay that the circumstances and treatment plan be reviewed to determine if it is possible to discharge the patient from the hospital and provide the required treatment on an outpatient basis. [The CMO] wants everyone to understand that the hospital can get creative with treatment plans when the cost is shouldered by the hospital..."

The patient's case was also addressed at the following meeting, dated 5/11/11, which stated, in pertinent part: "We had a very challenging discharge and [the Director of Discharge Planning] is very proud of how the Team handled it... though it was a challenging... the outcome was good."

2. Despite that the below "recommendation for improvement" was identified after the patient's hospitalization and review of care, per staff interviews and document review, there was no clear evidence that the recommendations had been implemented.

A summary in regards to the patient's care was compiled by the Director of Case Management and dated 5/9/11. The summary stated, in pertinent part:
"Documentation Challenges/ Learning:
- Lack of monetary resources
- Documentation concerns...
* Finance concerns
* Lack of coordinating efforts: Not clear of communications with therapies...
Recommendation for Improvements:
- Needed a more consistent high level care conference even when a great amount of work was taking place. Process improved by weekly discharge meetings that are now set up. Also, have had scheduled calls with legal involved in some cases. Emails sent to CNO, CMO, and Directors more consistently to keep all informed. Weekly follow-ups with lead SW regarding complex cases.
- Need to include therapy in Home Care plan at discharge. Process continues to sure documentation includes all home care planing done with home care coordinators. The hospital did pay for [the patient's] home care visits at discharge.
- One questions was to keep the patient another week until family arrived. However, we had no confirmation that the family would come... This discharge plan would not have changed because the [family] had arrived. The patient had acquired a new apartment with the help of [his/her] friend. Recognizing a 'true' financial state of affairs earlier. Had differing opinions from patient. Our HBS's had begun applying for Medicaid, but [s/he] was not eligible. Then process began for Getting US Covered.
- More consistent documentation of interdisciplinary taking place. The floor nurses are to document in the Interdisciplinary Rounds Intervention. Perhaps can re-educate."

3. Lastly, the facility's discharge planning system was evidenced to be very complex and without clear lines of communication, but this element had not been identified in the facility's reassessment of its discharge planning process. For example, in the care of sample patient #2, six disciplines were involved in a portion of the patient's direct discharge planning, who included the primary Social Worker, the Health Benefits Advisor, the Nurse Case Manager, two Home Service Coordinators, the Sister Hospital's Rehab Center Liaison, and a staff member from the outside contracted company who assist with Medicaid/Medicare applications. Additionally, the team of Physical and Occupational therapy were a crucial role in sample patient #2's discharge planning, however clear communication and a cohesive process between all of these roles was not evidenced. Interviews from several individuals referenced the physician as the lead of discharge planning, but it was not evidenced that the physician tied all of these roles together to make a successful discharge for sample patient number two.

An interview with the facility's Director of Nursing was conducted on 8/9/11, at approximately 2:30 p.m. The DON provided an organizational chart of the facility's Discharge Planning Program. Two bold leads were on the chart, which were the facility's Chief Financial Officer and the Chief Executive Officer of "Centura Health at Home," confirmed with the DON as a contracted service.
Under "Centura Health at Home" were the Home Care Coordinators, who were stationed physically at separate entities than the hospital. The Home Care Coordinators were connected with a dotted line over to the RN Case Managers and Licensed Social Workers at the facility.
Under the facility's CFO were two branches. The branch to the right showed the Patient Access Services section, which included the contracted company "Conifer/ MEC," who assisted with the Medicare/Medicaid application process. Patient Access Services was then over the Health Benefits Advisors, who assisted with financial assistance. The left branch showed the Utilization Review staff member, titled as "Revenue Management," over the Case Management Director, who was over all the Licensed Social Workers and RN Case Managers.

Cross Reference to A0809: Self Care Patient Evaluation - for findings related to the facility's failure to ensure it conducted an accurate and multi-disciplinary discharge planning evaluation, which included the likelihood of a patient's capacity for self-care in the environment from which s/he entered the hospital.