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Based on interviews and record review (RR), the Hospital (H)1 did not ensure an effective transition at the time of discharge for one patient (P)1 of a sample size of four. On discharge, 02/06/2024, P1 was not competent to provide self-care for his diabetes management, which included checking blood sugars and administering insulin injections. H1 did not confirm P1 had support/caregiver(s) agreeable to provide these services and did not provide in-hospital training to anyone prior to discharge. In addition, H1 did not provide specific instructions how to obtain the glucometer to test blood sugar and the two types of insulin. As a result of this deficient practice, P1 did not receive several the insulin post discharge and suffered harm. He was readmitted to H1 on 02/09/2024 and readmitted for hyperglycemia (high blood sugar). If discharge plans are not reevaluated, revised and implemented appropriately, there is the potential patients may have adverse outcomes or even death. Due to the nature of the deficiencies, this resulted in a Condition Level deficiency in Discharge Planning.

Findings include:

1) The Office of Healthcare Assurance (OHCA) received a report from an external agency on 02/14/2024, that included: "1. A vulnerable adult's (P1) inability or failure, due to physical or mental impairment, to perform tasks essential to caring for oneself. ... "A. P1 was admitted to H1 for cardiogenic shock from 01/24/2024 to 02/06/2024 and discharged home with a referral to the Transitional Care Program (TCP); The TCP followed up with P1 and determined P1 was unable to check his own blood sugars or administer his insulin. ...P1 did not have a lot of family support and did not have any family members who were able to consistently assist P1 with checking his blood sugars/administering his insulin. ..." "2. The vulnerable adult (P1) appears to lack sufficient understanding or capacity to make or communicate responsible decisions and appears to be exposed to a situation or condition that poses an immediate risk of death or serious physical harm. "

2) P1 is a 65-year-old male with diabetes, dementia, and other long standing medical problems. He was admitted to the hospital (H)1 on 01/24/2024 with diagnosis that included, but not limited to cardiogenic shock, acute kidney injury (decline in kidney function) and diabetic keto acidosis (life threatening condition when body produces too many ketones and too little insulin). RR revealed he had not been taking his diabetic medications for some time. P1 had dementia and was not competent to make decisions regarding his medical care, so Family Member (FM)1 became his surrogate. FM1 worked, and did not live on or near the property where P1 lived, but was the individual that provided transport to appointments and assisted when she could. FM1 requested P1 go to the a skilled nursing facility (SNF) if at all possible prior to going home due to his condition and lack of support. His discharge plan included the potential to be discharged to SNF for additional physical therapy pending insurance approval. The insurance ultimately denied the in-patient rehabilitation and P1 was discharged home on 02/06/2024.

3) RR review of P1's medical records revealed the following:
On 02/06/2024 at 03:51 PM, Advance Practice Registered Nurse (Diabetes Nurse Practitioner) entered Progress Notes that included but not limited to: " ... To be DC (discharge) to SNF today. ... Pt (P1) says he lives alone in his brother's apartment. ...alert and oriented x2 (cognitively aware of self and place only), fair judgement. ... Pt with poor insight on his medical conditions. Pt reports not taking any DM (diabetic) medications. Fasting sugar 227. Daytime sugars 75-312. Will plan to DC pt on Lantus (injectable insulin) 36 units daily and NovoLog (injectable insulin) 10 units tid ac (three times a day before meals)." The note included a table that indicated "updates/what needs to be done." The table documented: "Glucose Meter Teaching: TBD (to be determined), Insulin Teaching: TBD, and Script for meter and supplies TBD. ..."

02/06/2024 at 05:51 PM. Nursing note entered by Registered Nurse (RN)1 read: "Discharge instructions provided to patient and to surrogate over the phone. Reviewed AVS (After Visit Summary), Prescriptions, and transport. The Cab called to transport home, set up by CM (Case Manager). Notifying family of patient transport." The instructions were actually provided to another family member, not the surrogate (FM1).

Reviewed the "After Visit Summary" for admission "01/25/2024-02/06/2024," The AVS included: "Destination: ... Nursing Home" "Ask: Ask how to get these medications 1. Insulin asparat (injectable pen) U-100, 2. Insulin glargine U-100, and 3. thiamine mononitrate (Vit B10 (oral))." "Do: Pick up these medications from Longs Drug Store: Atorvastatin" "Pick up these medications from Queens POB1 Pharmacy: Cefuroxime" "Pick up 6 medications from the Queens Medical Center-Outpatient Pharmacy." These specific medications were not listed on the AVS.

RR of the Medication Administration Record (MAR) revealed the last time P1 received insulin was after his blood sugar (BS) was checked at 11:01 AM, prior to eating his lunch. The MAR schedule indicated P1 would be due for a BS check and insulin at 05:00 PM. He was discharged home by taxi at approximately 06:00 PM. He did not have a BS check, receive insulin or eat dinner prior to leaving.

There was no clinical pharmacist documentation of review of medications, and there was no documentation of training anyone that agreed to be responsible for P1's BS checks and insulin injections three times a day.

02/07/2024 at 08:19 AM, Transitional Case Management Program (TCMP) documentation of phone call with P1's family: "FM1 reports that they do not know how to check blood sugar/administer insulin, client is unable to complete due to dementia and limited vision and there is no one to administer prescribed insulin 3x/day. CM notified PCP's (Primary Care Physician) office ...and RN Care Coordinator (CC) reported that he would notify their supervisor and they would f/u (follow up) with client/family." The progress note medication reconciliation of current outpatient medications included: "Patient not taking (or using)" the blood glucose meter, lancets, test strips, Lantus Solarstar, NovoLOG, albuterol inhaler, or taking the Vitamin B1.
02/08/2024 at 02:15 PM, TCMP note: Indicated P had been referred to West Diabetes Management. "Informed CC (Care Coordinator) that client has not been taking insulin since d/c (02/06/2024) and not checking his BS due to poor vision. Although he has some family support nearby, they have not been trained on it. ..."
02/09/2024 at 01:32 PM, TCMP note: Received phone call from CC. "She stated she spoke to FM1 to assess situation and offer outreach to provide diabetes education and insulin administration teaching for family. ...reports that family is on longer willing to learn how to administer medication and check BG (blood glucose/BS). Per CC, client lives alone, and family are not able to provide very much support. CC stated that client has hx (history) of wandering due to his dementia. FM1 also expressed concern that client does not look well today (flushed in face)." CC advised family to take P1 back to H1.

On 02/09/2024 P1 returned to H1 Emergency Department. At 03:36 PM, the ED Provider note documented "Was recently discharged 3 days ago. Per RM1, someone called them to come back and be admitted. ..." P1's BS was 401 on admission. The note included "Consideration of management or escalation of hospital-level of care given concerns regarding outpatient environment and safety concerns. ...Clinical impression included acute hyperglycemia (too much sugar in the blood)."

4) On 4/19/2024 at 11:22 AM, interviewed RN1 and the Nurse Manager (NM). NM said nursing attend daily rounds with the CM and SW to discuss patient's discharge status. He said if something in the plan changes after rounds, they use tiger text to update everyone. The facility will often have a pharmacist come to the patient to discuss medications prior to discharge. The NM explained after the Provider puts in the discharge orders, it goes to the pharmacist, who will come to educate the patient or family and determine where to pick up the medications. He said there are some patients we will not sent home without medications in hand to ensure they have it, and others will be sent to a pharmacy of their choice to pick them up. At that time, RN1 said her shift on 02/06/2024 was 11 AM to 7:00 PM, so she was not there for the initial rounds to discuss the discharge plans. She said when she got report, she was told P1 was going to be discharged to the LTC facility. RN1 went on to say Physical Therapy went into see him (P1) and said he didn't qualify anymore but was not going to be discharged today. Later, about 04:00 PM or 05:00 PM, she was informed P1 had a home to go to, was doing well and had people to go home to. RN1 said "medications came up from pharmacy in a brown paper bag. I went over them with him and his niece on the phone." She did not recall which specific medications were in the bag that were reviewed. RN1 said "CM told me to call the niece, as FM1 was reluctant to talk to me." RN1 said the discharged process was "very rushed." She confirmed she personally did not do any education regarding insulin injection and blood sugar testing with anyone, and said P1 "wouldn't have been able to do it himself."

5) On 04/19/2024 at 12:15 PM, the facility reported after following up with the pharmacy, they identified the pharmacist had dispensed six medications (clopidogrel, ASA, Digoxin, Midodrine, senna docusate and albuterol inhaler) on 02/06/2024 at the time of discharge, which were provided to nursing to send home with P1. P1 was discharged home by cab with the bag of medications and AVS, which had been reviewed over the phone with R1's niece.

It is unknown if P1 or his family picked up the insulins, B1 oral medication or the equipment to test his sugar (glucometer and test strips).

6) Cross Reference 802
P1's discharge plan included the potential admission to a Skilled Nursing Facility (SNF) for continued physical therapy. The day of the planned transfer (02/06/2024) to the SNF, based on the information the insurance company had of P1's condition, the SNF admission was denied. The discharge plan changed, and P1 was discharged home. H1 failed to adequately reassess P1's needs for the discharge home to ensure he had a safe discharge.

Based on interviews and record review (RR), the hospital (H)1 failed to adequately reassess one patient's (P1) discharge plan of a sample of four, to ensure his needs could be met when he was discharged home. P1's discharge plan included the potential admission to a Skilled Nursing Facility (SNF) for continued physical therapy. The day of the planned transfer (02/06/2024) to the SNF, based on the information the insurance company had of P1's condition, the SNF admission was denied. The discharge plan changed to discharge P1 home. P1 was not competent to provide self-care that included testing his blood sugar and administer insulin three times a day, but the hospital did not reassess the support he had at home to provide the services needed. As a result of this deficient practice P1 suffered harm and was readmitted on 02/09/2024 with acute hyperglycemia (too much sugar in blood). Discharge plans must be reassessed, revised as needed and implemented appropriately, or there is the potential discharged patients may have adverse outcomes or even death.

Findings include:

1) P1 is a 65-year-old male with diabetes, dementia, and other long standing medical problems. He was admitted to the hospital (H)1 on 01/24/2024 with admitting diagnosis that included, but not limited to cardiogenic shock, acute kidney injury (decline in kidney function) and diabetic keto acidosis (life threatening condition when body produces too many ketones and too little insulin). RR revealed he had not been taking his diabetic medications for some time. P1 lived on the second story of a house owned by Family Member (FM)2. Although FM2 and other family lived next door, they did not care for him. Other FM's reportedly were in the same house as P1, but also did not participate in his care. P1 had dementia and was not competent to make decisions regarding his medical care, so FM1 became his surrogate. FM1 worked, and did not live on or near the properties, but was the individual that provided transport to appointments and assisted when she could. FM1 requested P1's go to the SNF if at all possible prior to going home due to his condition and lack of support. His discharge plan included the potential to be discharged to a skilled nursing facility (SNF) for additional physical therapy pending insurance approval. The insurance ultimately denied the admission for in-patient short-term rehabilitation and P1 was discharged home on 02/06/2024.

2) Review of Social Work (SW) and Care Management (CM) and discharge planning notes revealed the following: 01/25/24 SW1: " ...SW was informed that pt is confused and appears to need a health care decision maker. ...After RN's call with FM1 was informed limited support at home for pt. RN reported pt lives with his niece at this FM2's house however, pt is at home alone during the day and his niece does to provide care for pt. RN shared pt's baseline is confused and FM2 brings food and checks on him often. ..." 01/25/2024 CM Initial assessment: "...Does patient have a designated caregiver: No. ..."
02/01/2024 SW note: " ...SW received call back from pt's (P1) FM1. She expressed her concerns about the PT (Physical Therapy) recommendations of "discharge with assist" and shared her thought pt would go to an SNF (skilled Nursing Facility). SW explained this is not the current recommendation and FM1 verbalized understanding. SW explained pt would benefit from increased family support ... FM1 shared "if he returns home, he will die. There is no one to take care of him, no family." She explained although he lives with his niece and brother, who lives downstairs, they do not care for pt and they did not notice pt's decline (prior to admission) and she is the only one who checks on pt, but she cannot manage his care as pt is now and does not live close by ...."
2/2/24 11:00 AM SW2 note: "Pt lives with brother and niece who do not provide care for pt. FM1 is not able to provide care for him. Pt's FM2 and FM1 cannot provide care or accommodation. ..."
2/2/24 03:08 PM SW2 note: "SW met with brother and sister-in-law. ...Pt's FM2 and sister-in-law shared that pt lives alone upstairs and their son lives downstairs at their house while they live next door to pt and their son. Pt's brother and sister-in-law confirmed to take pt home however, would like him to go to SNF since there are 17 stairs at home. ...Shared that they would like him to go to LTC (long term care placement if it was an option. Explained the LTC placement process and Medicaid LTC application referral process. Pt's family says if pt can go to SNF first with disposition to return home with support from pts nephew they are fine with that. ...Pt appears to have discharge location with support from his family members and they verbalized their needs to care for pt at home. They appear to understand the LTC placement process and Medicaid LTC application referral process.
2/5/2024 at 09:49 AM, CM3 documented the "Important Message from Medicare (IM) notice was discussed with P1's Surrogate (FM1) over the phone. The notice included: anticipated discharge 2/5/24-2/6/24, and notification of financial liability will start on 02/06/2024-02/07/2024. . 02/05/2024 at 09:57 AM CM2 DC Plan Note included: "Plan for today: SNF referrals ... Anticipated Disposition: Skilled nursing facility (STR (Short term rehabilitation)) ...Notified DCC (discharge care coordinator) that patient is med clear for SNF and requested to start SNF referrals. ...Also confirmed that she (FM1) prefers SNF for patient prior to going home as patient does not have assistance 24/7 or as needed. FM1 checks up on patient but does not live in the same house. ...Received update from DCC-pending insurance auth (authorization).
02/05/2024 at 10:30 AM SWA (Social Work Associate)1: Skilled Nursing Facility Referral Note: "Discharge to Skilled Nursing Facility. Per CM, patient is recommended for discharge to SNF for STR (physical therapy) when medially cleared. Per CM, pt is medically cleared today (02/05) ... Potential barriers: none noted. 02/05/2024 at 01:53 PM SWA2 Skilled Nursing Facility Acceptance Note. ...Nursing Home (LTC)1 tentatively tomorrow at noon ..." The approval required approved authorization from P1's insurance. 02/06/2024 SWA1: Transportation details made (to LTC facility). Still awaiting insurance to be approved. "Colleague ...assisting with insurance informed ... is being reviewed by medical director to be either declined or escalated to peer-to-peer review. " 02/06/2024 SWA1 at 10:18 AM: Writer attempted to f.u with insurance for update on ...PA. Per Representative, informed writer... has been moved forward for medical director to evaluate but no medical director has been assigned ...yet. Advised to cancel transport due to insurance most likely not be be resolved before DC time, (12PM). Addendum 1 PM: Writer was informed that attending MD will have to call and leave a message for the peer-to-peer review. Per insurance, peer to peer review deadline is Wednesday (02/06) @ 9AM HST. Addendum 2:20 PM: Received call was denied. If pt/pts family wants to appeal, they can call. Writer informed team. DC plan pending."
02/06/2024 at 02:15 PM CM1: " ... PT/OT Discharge Disposition Recommendations: Home Health PT (If pt goes home, needs standby assist with mobility and ambulation including on stairs with rails. Anticipated Discharge Facility/Level of Care Needs: ...Skilled nursing facility l(STR) (pending insurance authorization) ...Current Discharge Risk (Barriers): deconditioned, cognitively impaired. FM1 requested CM to speak with daughter due to language barrier. FM1 seams [sic] to speak English and comprehend but requested CM speak with her daughter. She is hopeful patient will get into SNF but is aware that patient may need to discharge to home even though it is not the most ideal situation. CM provided Private hire care list in case they are unable to make a schedule to assist patient at home. CM left a message for Service Coordinator requesting more assist at home and or day care services while family is working. Daughter also stated patient does not currently have a fww (front wheel walker) at home. CM expressed concern that it is unlikely he will get the authorization for SNF but we will wait for the insurance to decide prior to entering Home health and DME (Durable medical equipment). ..."
02/06/2024 at 03:29 PM Transitional Social work referral made
02/06/2024 at 04:56 PM CM1 Discharge Screening Note: PT/OT Discharge Disposition Recommendations: Home Health PT (If pt goes home, needs standby assist with mobility and ambulation including on stairs with rails. FM1's daughter is aware patient will be on his way once cleared. Patient is to be discharged today. No other discharge needs are assessed.

3) Despite multiple entries from different staff that P1 did not have resources available to him and that he could not self-care, the team did not reevaluate the discharge home plan to ensure this was a safe discharge that met P1's needs.