HospitalInspections.org

Based on a review of policy and procedures, medical records, and staff interviews it was determined that the facility failed to ensure that patients' rights were promoted and protected when four (P#1, P#2, P#3, and P#4) of four sampled patients (P#1, P#2, P#3, and P#4) were not given the opportunity to formulate an advanced directive upon admission.

Findings Included:

A review of the facility's policy titled "Advance Directives for Healthcare (Durable Power of Attorney for Healthcare and Living Will)", effective 7/8/2018, revealed that the facility recognized the right of an adult patient to execute an Advance Directive for Health Care. That facility staff shall notify adult patients upon admission of their rights to formulate an advance directive.

A review of the facility's policy titled "Patient's Rights and Responsibilities", no number, last reviewed 9/8/21, revealed that the facility would establish guidelines for patient care that recognizes each patient as an individual with unique healthcare needs, values, and cultural perspectives. To respect, promote, and protect the basic human rights of each individual.

* Formulate advance directives and expect hospital staff will honor these directives.
* Receive information in a manner that meets their needs when they are impaired by vision, speech, hearing or cognitive impairments.

A review of Patient (P) #1's medical record failed to reveal documentation that that P#1 and/or a representative received information or given the opportunity to formulate an advanced directive.

A review of three additional medical records (P#2, P#3, P#4) failed to reveal documentation that the patient or representative received information about advanced directives or were provided the opportunity to formulate an advanced directive.

During an interview on 8/6/24 at 11:10 a.m. with the Director of Patient Access (DPS) FF, in a conference room, DPS FF stated that Patient Access (PA) staff were required to obtain patient signatures for all consents and patient rights responsibilities. DPS FF explained that clinical staff were responsible for inquiring about advanced directives and documentation of such in the record.
DPS FF added that when a patient provided the clinical team with an advanced directive, it was sent to PA staff to be uploaded to the patient's medical record.

During an interview on 8/6/24 at 1:56 p.m. with Emergency Department Unit Nursing Director (UND) KK, in a conference room, UND KK stated that ensuring that patients are asked about their advanced directive is a collaborative effort between the clinical staff and the PA staff.

Based on review of Medical Staff Bylaws, Quality Assessment Performance Improvement (QAPI) Plan, Medical Executive Committee meeting minutes, Quality Improvement Committee meeting minutes, Governing Body meeting Minutes and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective, ongoing, data-driven quality assessment and performance improvement program for the Emergency Department (ED) In addition, the facility failed to ensure performance improvement data was collected, tracked, and analyzed in order to implement changes that effected improvements in quality of care and patient safety in the ED.

Cross refer to A0283 as it relates to the facility's failure to ensure that ED specific performance improvement data was collected, analyzed and tracked and activities implemented to improve health outcomes and patient safety.

Cross refer to A0308 as it relates to the Governing Body's failure to ensure that ED specific quality improvement performance improvement projects were developed and implemented.

Findings Included:

Based on review of the Quality and Patient Safety Plan, committee meeting minutes, and interviews with staff it was determined that the facility failed to collect and monitor ED specific data to identify opportunities for improvement; implement activities to improve health outcomes, patient safety, or quality of care.

Findings included:

A review of "Quality and Patient Safety Plan Emory Healthcare Fiscal Year 2024" revealed that the facility quality plan's strategic priority areas for 2024 are inclusive of patient experience, patient safety, patient, access, infection prevention, community outreach, and clinical quality. Further review revealed that quality metrics related to the Emergency Department included patient experience and length of stay. The plan failed to include additional metrics related to the Emergency Department or EMTALA.

Further review of the plan revealed that the Patient Quality Committee of the EHC Board (PQC) is responsible for oversight and governance of quality and patient safety at EHC. System and entity-specific activities are reported to the PQC through various committees and teams. Senior Executive Management Groups include entity and system Executive Operating Teams. These groups are responsible for the direct management oversight of quality and patient safety activities across the system.

A review of the Medical Executive Committee (MEC) meeting minutes dated, 1/16/24, 2/20/24, 4/16/24, and 5/21/24; Quality Council Committee meeting minutes dated, 9/26/23, 10/24/23, 11/28/23, 1/23/24, and 5/28/24; and Governing Body meeting minutes dated, 8/10/23, 10/17/23, 12/23/23, and 2/28/24, failed to reveal quality improvement discussions including quality indicators, data-driven assessments, and quality performance improvement activities related to the ED.

During an interview on 8/6/24 at 8:30 a.m. with the Corporate Director of Quality Operations (CDQ) OO, Chief Medical Officer (CMO) PP, CMO QQ, and CMO RR, all of whom are members of the Corporate Patient Quality Committee PQC). CMO QQ stated that the purpose of PQC is to review facility-wide scorecards that measure quality metrics which include patient experience, employee retention, financial data, root cause analysis (RCA) data, and infections of various departments. CMO QQ said that the PQC meets one to two times a year. CMQ explained that PQC's most recent quality improvement (QI) projects have been high-performance reviews, Magnet status, and credentialing balancing scorecards. He added that the information they discuss was relayed to the MEC during their meetings. CMO PP further added that PCQ has been reviewing facility-wide policies, health equity, and patient experience in the Emergency Department. When this surveyor asked the PQC members if the Emergency Department was being monitored by the PCQ through quality indicators, data-driven assessments, or quality performance improvement activities, CDQ OO said that patient experience and length of stay in the Emergency Department were being monitored. The PQC members failed to provide any further information regarding how the committee was monitoring patient health outcomes in the Emergency Department. The PQC members acknowledged that they are responsible for implementing, monitoring, and reporting performance quality improvement measures to the Medical Executive Committee and Governing Body. The PQC members acknowledged that they are responsible for implementing, monitoring, and reporting performance quality improvement measures to the Medical Executive Committee and Governing Body. CDQ OO was a member of the Medical Executive Committee.

During an interview on 8/6/24 at 1:37 p.m. with ED Medical Director (EMD) LL, in a conference room, EMD LL explained that she conducted medical record audits when there was a patient complaint made regarding care. EMD LL was asked to explain what quality indicators were being tracked and trended in the Emergency Department. EMD LL said she was unsure because she had been on maternity leave. When EMD LL was asked by this surveyor to explain how she conducts physician oversight to ensure patients are receiving appropriate care, EMD LL said that she just knows her physicians are always doing what they are supposed to. She added that she knows 100 percent (%) that the providers are conducting appropriate MSEs, discharging patients, and appropriately transferring patients 100% of the time. When this surveyor asked EMD LL to tell us how she could be 100% sure without any oversight or surveillance projects that track and trend quality performance, EMD LL said because the physicians take online EMTALA training annually.

Based on a review of Governing Board Bylaws, Medical Staff Bylaws, meeting minutes, quality reports, and staff interviews it was determined that the Governing Body failed to ensure that the Emergency Department was being monitored as part of the facility Quality Assessment and Performance Improvement Program (QAPI).

Findings Included:

A review of the facility's Governing Body Bylaws, last amended 2/28/24, revealed that Article III, Meetings of Directors, 3.1, Duties, the Corporation shall:

The Board of Directors is responsible for the conduct of the business of the Corporation and is authorized to exercise all powers inherent in the Corporation.

4.A.3. Functions of Clinical Services:
Clinical services are organized for the purpose of implementing processes: (i) to monitor and evaluate the quality and appropriateness of the care of patients served by the service; (ii) to monitor the practice of individuals with Clinical Privileges in a given service; and (iii) to provide appropriate specialty coverage in the Emergency Department, consistent with the provisions in these Bylaws and related documents.

The Medical Executive Committee is delegated the primary authority over activities related to the Medical Staff and to Performance Improvement activities. The Medical Executive Committee is responsible for the following:
(5) participation of the Medical Staff in Hospital Performance Improvement activities and the quality of professional services being provided by the Medical Staff;
(c) consulting with Hospital administration on quality-related aspects of contracts for patient care services;
(d) providing oversight and guidance with respect to Continuing Medical Education activities;
(e) reviewing or delegating the review of quality indicators to facilitate uniformity regarding patient care services;
(f) providing leadership in activities related to patient safety;
(g) providing oversight in the process of analyzing and improving patient satisfaction;

5.C. PERFORMANCE IMPROVEMENT FUNCTIONS
(1) The Medical Staff is actively involved in the measurement, assessment, and improvement of at least the following:
(a) medication management oversight;
(d) utilization review;
(e) medical record review; and
(f) quality management system.
(2) A description of the committees that carry out monitoring and Performance Improvement functions, including their composition, duties, and reporting requirements, is contained in the Medical Staff Organization Manual.

5.D. CREATION OF STANDING COMMITTEES AND SPECIAL COMMITTEES
(2) Any function required to be performed by these Bylaws that is not assigned to an individual, a standing committee, or a special committee shall be performed by the Medical Executive Committee.

A review of "Quality and Patient Safety Plan Emory Healthcare Fiscal Year 2024" revealed that the facility quality plan's strategic priority areas for 2024 are inclusive of patient experience, patient safety, patient, access, infection prevention, community outreach, and clinical quality.

Further review revealed that quality metrics related to the Emergency Department included patient experience and length of stay. No other metrics related to the Emergency Department or EMTALA were revealed.

Further review revealed that the Patient Quality Committee of the EHC Board (PQC) is responsible for oversight and governance of quality and patient safety at EHC. System and entity-specific activities are reported to the PQC through various committees and teams. The Patient Quality Committee (PQC) meets four times per year, preferably on a quarterly basis depending on Emory Healthcare Board Member and EHC Quality Division leadership availability. The meeting agenda typically includes a Story of Harm, updates on strategic initiatives and results on the Balanced Scorecard (BSC), a review of minutes from Clinical Safety Steering Committee (CSSCo) meetings, and a Review of Patient and Employee Survey Results.

Entity Medical Executive Committees (MECs) are responsible for credentialing & privileging physician assistants & advanced practice nurses who practice within the hospital. These approvals are presented to and approved by the PQC.

Senior Executive Management Groups include entity and system Executive Operating Teams. These groups are responsible for the direct management oversight of quality and patient safety activities across the system.

A review of the Medical Executive Committee (MEC) meeting minutes dated, 1/16/24, 2/20/24, 4/16/24, and 5/21/24; Quality Council Committee meeting minutes dated, 9/26/23, 10/24/23, 11/28/23, 1/23/24, and 5/28/24; and Governing Body meeting minutes dated, 8/10/23, 10/17/23, 12/23/23, and 2/28/24, failed to reveal quality improvement discussions including quality indicators, data-driven assessments, and quality performance improvement activities related to the ED.

During an interview on 8/6/24 at 8:30 a.m. with the Corporate Director of Quality Operations (CDQ) OO, Chief Medical Officer (CMO) PP, CMO QQ, and CMO RR, all of whom are members of the Corporate Patient Quality Committee PQC. When this surveyor asked the PQC members if the Emergency Department was being monitored by the PCQ through quality indicators, data-driven assessments, or quality performance improvement activities, CDQ OO said that patient experience and length of stay in the Emergency Department were being monitored. The PQC members failed to provide any further information regarding how the committee was monitoring patient health outcomes in the Emergency Department. The PQC members acknowledged that they are responsible for implementing, monitoring, and reporting performance quality improvement measures to the Medical Executive Committee and Governing Body. The PQC members acknowledged that they are responsible for implementing, monitoring, and reporting performance quality improvement measures to the Medical Executive Committee and Governing Body. CDQ OO is also a member of the Medical Executive Committee.

Based on a review of facility policies and procedure, medical records, and staff interviews, it was determined that the facility failed to implement appropriate discharge planning when two (P#6 and P#15) of 24 sampled (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18, P#19, P#20, P#21, P#22, P#23, and P#24) patients reviewed failed to receive discharge education. Specifically, P#6 and P#15 medical records failed to reveal documented information in the discharge education regarding necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, treatment preferences to the appropriate post-acute care services providers or agencies, and ancillary care.

Findings included:

A review of the facility's policy titled "Discharge of Patients", effective 5/17/23, revealed that the purpose of the policy was to ensure a smooth and safe discharge process for patients, minimize risks, prevent unplanned readmissions, and maintain compliance with regulatory guidelines.

PROCEDURE:
1.The attending physician or designee is responsible for discharging the patient, performing a medication reconciliation, and providing a summary of the patient's medical condition and care plan.

2.All patients will receive written and verbal post-discharge care instructions, including prescriptions, supplies, and follow-up appointment details, through the EeMR After Visit Summary (AVS).

3.Responsibilities of the nursing staff at discharge include:
c. Provide and explain discharge instructions, including discharge prescriptions and supplies/DME and any follow-up appointment details.
e. Complete all required documentation, both electronic and on paper as applicable, and discharge the patient from EeMR once the patient is physically out of the unit. A manual discharge requires the completion of the date, time, and discharge disposition.
i. If transport is requested at discharge, the discharge disposition must be entered prior to requesting transport. The date/time will auto-populate when the transporter completes the transfer in EeMR.
g. Inform and encourage the patient to enroll in MyChart.

A review of P#6's medical record revealed that P#6 presented to the facility's ED on 7/11/24 at 12:51 a.m. with a chief complaint of suicide. P#6 was assigned an acuity level of two. A review of an "Attending Physician Note" on 7/11/24 at 2:38 a.m. revealed that P#6 had suicidal ideations without a plan.

Continued review revealed that P#6 became verbally aggressive with the physician and security was notified. P#6 was escorted off the premises. Continued review of the medical record failed to reveal further psychiatric or mental status examination by a providerP#6 was set for discharge from the facility on 7/11/24 at 2:42 a.m.

A review of P#15's medical record revealed that P#15 presented the facility's ED on 3/14/24 at 4:02 p.m. with a chief complaint of suicide. P#15 was assigned an acuity level of two. Review of the medical record revealed that P#15 had visual hallucinations and suicidal ideations, positive for alcohol use, and requested information for alcohol rehabilitation. Continued review of the medical record revealed that P#15 wished to be dead in the past month, had non-specific active suicidal thoughts in the past month, and suicidal behavior. P#15 had a Columbia Suicide Severity Rating Scale (CSSRS) risk as moderate. Continued review of the medical record failed to a psychiatric or mental status examination by a provider.

P#15 was discharged from the facility on 3/14/24 at 6:11 p.m. with discharge instructions about alcohol use. Continued review failed to reveal any rehabilitation recommendations or additional outpatient services.

During an interview on 7/31/24 at 3:30 p.m., with Security Officer (SO) EE, in a conference room, SO EE
explained that although not ideal, the ED staff had to discharge behavioral health patients due to aggressive behavior for the safety of the staff. He explained that staff had been injured by aggressive patients in the past.

During a telephone interview on 8/1/24 at 10:30 a.m. with Registered Nurse (RN) CC, RN CC explained that the manner behavioral health patients were discharged depended on the situation. Providers signed a 1013 hold if the patient exhibited true expressions of suicidal or homicidal ideations. . If a patient was overly aggressive or not cooperating with the provider, the patient was discharged.

During an interview on 8/6/24 at 1:28 p.m. with ED Unit Nursing Director (UND) KK, in a hallway, UND KK explained that all discharge education instructions should be printed out and include resource phone numbers, follow-up instructions, prescription information, and diagnosis information. He added that a QR code prints on the last page of the discharge instructions. UND KK was asked to explain under what circumstances a patient's discharge instructions would not include specific discharge education but only a QR code. UND KK added that it should never happen unless the patient eloped or left without treatment. He said that it would surprise him if patients were not receiving discharge education and only a QR code.