HospitalInspections.org

Based on a review of hospital policy and procedures along with 6 open and 6 closed records, it was determined that the hospital failed to provide a Medicare Outpatient Observation Notice (MOON) notice to patient #3 (P3) and failed to include P3 in discharge planning.

Patient #3 (P3) was a 90+ patient who presented to the emergency department (ED) following a fall in which P3 broke an ankle. P3 was determined in the ED to require further evaluation by an orthopedist and physical therapy. P3 was initially noted to be oriented to 3 spheres (person, place, and time) but later had some confusion.

A review of P3's record revealed a MOON notice timed at 0141 when P3 was placed into an observation bed. The MOON notice revealed a written note of "Unable to sign." No further information was found in the record regarding hospital attempts to deliver the MOON to P3. Documentation indicated that for observation days 1, 2, 3, 4 and 5, P3 was oriented to 3 spheres. Further, no physician certification of incapacity was found which could have indicated that P3 was unable to understand or participate in care.

Case management notes revealed in part, "Initial Assessment completed with patient's (family) who reports (__) has POA (Power of Attorney) for patient and will bring it in on (__) next visit this evening," ... and, "Agreed to follow up with patient's (family) after (physical therapy) sees patient to further discuss." Further review revealed that physical therapy recommended a Skilled Nursing Facility for rehabilitation; that P3 did not have secondary insurance to cover the costs, and that the case manager would attempt to find a rehab placement pending Medicaid reimbursement. One referral did indicate they might accept P3 pending Medicaid reimbursement, though P3's family refused the option. No evidence was found that P3 was queried related to discharge planning and the potential rehab option under Medicaid.

A "Patient Discharge Instruction" signature page was signed by P3, though P3 was not included in decision-making for P3's discharge disposition. Ultimately, P3 was discharged to a family member's home with some home health care services.

While it was clear that P3's family understood that P3 was in observation status and would not receive Medicare rehabilitation authorization, no evidence indicated that P3 ever received a MOON, was informed of, or made decisions regarding a rehab facility pending Medicaid vs. home care. This meant that the hospital failed to include P3 in care planning.

Based on an onsite review of the behavioral health unit, it was determined that many digital video discs (DVDs) which could be broken and used as weapons for harm to self and other, were kept in open cabinets.

Tour of the behavioral health unit revealed a number of locked and open cabinets in the day room where patients could congregate for leisure and gaming pursuits. It was noted that one double-door cabinet was found unlocked and contained approximately 20 or more DVD's.

This meant that patients had free access to DVDs which could be broken and then used to harm due to the sharp edges produced when DVDs are broken. Staff had not identified the DVDs as potential objects of harm.