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DOOR COUNTRY MEDICAL CENTER 323 SOUTH 18TH AVENUE STURGEON BAY, WI 54235 Dec. 11, 2017
VIOLATION: PATIENT CARE POLICIES Tag No: C1014
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to provide discharge planning per policy for 2 of 10 patients reviewed (Patient #1, Patient #10). Lack of discharge planning has potentially contributed to the readmission of Patient #1 and Patient #10.

Findings include:

Review of facility policy "Case Management Policy/Discharge Planning ADM-033" dated 4/27/2017 revealed: "3. [Facility] implements discharge planning for all patients admitted to [Facility]. A discharge plan is initiated as soon as possible after admission. 4. Case Manager/Social Worker is responsible for the coordination of the discharge planning process and does so in collaboration with the RN's responsible for the patient's nursing care plan... Procedure: I. For every inpatient, the Care Manager will: A. Review the patient's medical record for physician orders, course of treatment, functional status, therapies, and teaching needs of the patient. B. Consult with the physician, therapist and other healthcare personnel involved in the patient's care to identify his/her medical/nursing/rehabilitive needs. C. Interview the patient and/or patient's family to identify the patient's psychosocial, medical and nursing needs. ...II. The Discharge Planner/Social Worker will: ...B. Contact other health professionals in the community when indicated (i.e. ...home care services...). C. Coordinate the resources most appropriate to meet the individual patient needs."

During an interview on 12/6/2017 at 10:30 AM, Social Worker H stated the discharge planning process begins by seeing every inpatient and observation patient within 24 hours of admission. Per H, "we complete an assessment that addresses needs" and narrative notes are entered as needed after the initial assessment. H stated the goal of discharge planning is "making sure the patients have what they need after the hospital." For patients needing home health care services post discharge, H stated "we are limited on options, we check to see if the patient is agreeable and complete the form" for the home health agency agreed upon.

Per medical record review on 12/6/2017 at 10:45 AM, Patient #1 was admitted to the facility on [DATE] for delirium. The admission history and physical report, dated 4/14/2017, documents "Wife reports that for the last 3 days [Patient #1] has had increasing obsession with blood sugars and has been unable to load insulin syringes. The patient apparently had a blood sugar of 600 last week..." The assessment/plan states "Delirium. Unclear etiology." Patient #1's medical history upon admission includes Type 1 Diabetes Mellitus and Long-term (current) use of insulin. Patient #1's blood glucose on 4/14/2017 at 10:05 AM resulted as critically high at 430 mg/dL. A home medication intake assessment on 4/14/2017 at 1:32 PM srevealed "Insulin doses are ?? as patient is very confused, and describing insulin changes that do not make sense. Spouse is aware of all meds except for insulins."

A Nutrition Assessment on 4/15/2017 at 10:43 AM revealed: "Inability to manage self cares (including insulin dosing) related to delirium ...Patient interviewed, however, he continues to talk about things unrelated to the questions asked. ...Will assist patient with any diet instruction as needed when his confusion has cleared. Will monitor." There are no additional instructions documented in Patient #1's medical record.

On 4/17/2017 at 8:00 AM, the shift assessment documents Patient #1 as "confused (baseline)" with a "rambling, excessive" speech pattern and behaviors of "appropriate, anxious, distractible, talkative." Neurological comments state: "Patient did not know year or date, Patient to have some alcohol induced memory loss." Communication documentation states: "Difficulty following commands" with an affect description of "suspicious, anxious, labile ...Patient is argumentative with medication administration."

Physician progress notes dated 4/15/2017 at 9:31 AM reveal "Subjective: Patient seen today in followup for delirium. ...His mental status is not improved." Under Exam: "Psychology: Present: Alert and Oriented x 3, Other (Patient is confused on his follow up dates for doctor's appointments. He obsesses over his blood sugar). Absent: Intact judgement." Physician progress notes dated 4/16/2017 at 4:32 PM state "Subjective: Patient seen today in followup for delirium. ...His mental status is improved." Under Exam: "Psychology: Present: Alert and Oriented x 3, Other (Patient is confused on his follow up dates for doctor's appointments. He obsesses over his blood sugar). Absent: Intact judgement." There is no documentation to support the subjective change in mental status from "not improved" on 4/15/2017 to "improved" on 4/16/2017. There is no physician documentation on 4/17/2017, the date of Patient #1's discharge.

A care plan for Knowledge Deficit: Diabetes Mellitus was started on 4/14/2017 at 4:08 PM with goals to: "-Follow treatment regimen as prescribed; -Demonstrate correct procedure for blood glucose testing; -Monitors blood glucose as per plan; -Treats symptoms of [DIAGNOSES REDACTED]" There are no interventions listed to assist Patient #1 in meeting goals. On 4/15/2017 at 8:08 AM, outcome progress is documented as "not met" with a comment "ongoing, wife is involved in patient care." On 4/16/2017 at 8:08 AM, outcome progress is documented as "partially met" with a comment "ongoing, patient is confused." Outcome progress for the plan of care related to Knowledge Deficit: Diabetes Mellitus is documented as "not met" on 4/17/2017 at 8:00 AM and reveals: "Patient has illogical train of thought, unable to comprehend information presented as well as being obsessed with blood sugar monitoring and information related to insulin. Patient does become argumentative with information being presented with POC."

Case management notes on 4/15/2017 reveal: "[Patient #1] lives with wife...so far they have been very self sufficient. Wife states [Patient #1] has been obsessed with blood sugars...plans to return home at discharge." There is no initial assessment form in the medical record. Case management notes on 4/17/2017 state: "[Patient #1] denies any needs at home or concerns about going home. ...No discharge needs were determined." Review of nursing assessment notes reveal confusion throughout the inpatient stay. Nursing notes on 4/14/2017 at 5:31 PM state: "Continues to ramble on and on with concerns and at times makes sense and other times pt just carries on and on about blood sugar numbers and insulin amounts." A nursing note on 4/17/2017 at 12:19 PM reveals "Pt refusing insulin of 10 units pre lunch sliding scale need based on blood sugar of 353. ...refusing any insulin injection at this time." Patient #1 was discharged on [DATE] at 1:56 PM. On 4/17/2017 at 4:45 PM a progress note reveals: "Discharge/Diab Concerns: [RN] from clinic calling. [Patient #1]'s wife called clinic with concerns of insulin management. [Patient #1] has always handled own insulin in past and wife is unaware how to handle it."

During an interview on 12/11/2017 at 11:35 AM, Chief Nursing Officer A stated "nursing typically administers insulin" during inpatient stay. There is no documentation that Patient #1 or Patient #1's wife were assessed to ensure competence in blood sugar management or that education was provided specific to the admission concerns of blood sugar management and insulin administration. Patient #1 returned to the Emergency Department on 4/18/2017, less than 24 hours after discharge, and was transferred to another facility for inpatient treatment.

Per medical record review on 12/6/2017 at 1:30 PM, Patient #10 was admitted to the facility on [DATE] for hypotension and urinary tract infection. Patient #10 was discharged on [DATE]. The discharge summary, dated 10/14/2017, reveals: "Patient is discharged with home PT, OT and skilled nursing... Plan for home health service: Skilled Nursing, Physical Therapy, Occupational Therapy, Home Health Aide." Discharge instructions provided to the patient reveal: "Other instructions: Home Health Services: Skilled Nursing, Physical Therapy, Occupational Therapy, Home Health Aide." Review of case management notes do not include any initial assessments pertaining to discharge planning.

Patient #10 was readmitted on [DATE], 6 days after discharge, for confusion, urinary tract infection and acute kidney injury. Patient #10 was discharged on [DATE]. The discharge summary, dated 10/24/2017, reveals: "The patient recently been discharged for similar issues. The patient had been set up for home health skilled nursing and physical therapy but for reasons unclear these were not in place when the patient was readmitted ." Case Management notes dated 10/21/2017 reveal: "[Patient #10] shared that [Patient #10's son] is 'looking into getting more help because sometimes I can't get to the bathroom.' ...stated that goal is to return to son's home at discharge. ...Home health was also discussed and both [Patient #10] and [Patient #10's son] were agreeable. The plan will be to order home health [sic] at discharge."

During an interview on 12/6/2017 at 2:30 PM, Social Worker H stated the process is to "fax the paperwork to the home health agency." H was unable to confirm that the process for home health referral had been completed for Patient #10's 10/14/2017 discharge or why home health care services were not provided. When asked why there was not an initial assessment from the case management staff, H stated "I don't know."
VIOLATION: NURSING SERVICES Tag No: C1050
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview facility staff failed to identify and provide interventions as part of the patient plan of care in 1 of 10 patients reviewed (Patient #1).

Findings include:

Review of facility policy "Medical Surgical Unit Practice Guidelines" dated 11/29/2017 reveals: "IV. Plan of Care: ...C. Problems/potential problems will be identified. D. Realistic goals for the patient will be established. E. Nursing actions based on the potential or identified problem, and directed towards achievement of the goal will be clearly identified. F. Actions will be evaluated for effectiveness. ...VIII. Patient Education: ...5. Teaching of self-care measures will be conducted when appropriate."

Per medical record review on 12/6/2017 at 10:45 AM, Patient #1 was admitted to the intensive care unit from the ED on 4/14/2017 with diagnoses of [DIAGNOSES REDACTED]" A care plan for Knowledge Deficit: Diabetes Mellitus was started on 4/14/2017 at 4:08 PM with goals to: "-Follow treatment regimen as prescribed; -Demonstrate correct procedure for blood glucose testing; -Monitors blood glucose as per plan; -Treats symptoms of [DIAGNOSES REDACTED]" There are no interventions listed to assist Patient #1 in meeting goals. On 4/15/2017 at 8:08 AM, outcome progress is documented as "not met" with a comment "ongoing, wife is involved in patient care." On 4/16/2017 at 8:08 AM, outcome progress is documented as "partially met" with a comment "ongoing, patient is confused." Outcome progress for the plan of care related to Knowledge Deficit: Diabetes Mellitus is documented as "not met" on 4/17/2017 at 8:00 AM and states "Patient has illogical train of thought, unable to comprehend information presented as well as being obsessed with blood sugar monitoring and information related to insulin. Patient does become argumentative with information being presented with POC." There are no documented nursing actions or interventions designed to help Patient #1 meet the outcomes and goals of the Knowledge Deficit: Diabetes Mellitus plan of care.

During an interview on 12/11/2017 at 11:35 AM, when asked if staff are expected to document interventions as part of the care plan, Chief Nursing Officer A stated "yes, absolutely."
VIOLATION: RECORDS SYSTEM Tag No: C1104
Based on record review and interview, facility staff failed to ensure accurate and legible medical records in 1 of 10 medical records reviewed (Patient #1).

Findings include:

Review of facility policy "Patient Health Records -- Maintaining Accuracy and Integrity, RC HIM-021-DC" dated 9/6/2017 reveals: "3. ...In general, documentation in the patient health record should always be: A. Accurate. ...C. Complete. ...E. Consistent. F. Legible. ...8. Authentication of Health Record Entries: Authentication of a patient health record shows authorship and assigns responsibility for the entry. ...G. Electronic Signatures: ...When electronic signatures are used in the EHR [electronic health record], the software program or technology should provide message integrity--assurance that the message sent or entry made by a user is the same as the one received or maintained by the system."

Per medical record review on 12/6/2017 at 10:45 AM, Patient #1's ED record dated 3/27/2017 reveals "...was treated with normal saline fluid bolus and toes discovered that his sodium was low." Patient #1's ED record dated 4/14/2017 reveals: "Normally [Patient #1] articulates well cares for himself administers his own insolent. The patient is having difficulty with the equipment to administer insolent check his blood sugar. A criminal which she is well familiar with." This finding was verified at the time of the review with ED Director D. When asked what that statement meant, D stated "I think maybe it was supposed to say 'today?' I'm really not sure." When asked about the "insolent" and "criminal" documentation dated 4/14/2017, Director D stated "that [insolent] should state insulin. I'm not sure where the criminal comes from or what that is supposed to mean."

During an interview on 12/6/2017 at 3:15 PM, Health Information Management Director F stated "most of our providers use Dragon, a voice recognition software system. We have limited transcription, our standard for transcription is 99.7% accuracy which we are meeting." Per F, "the doctor is responsible for the integrity of the record" when using the Dragon voice recognition software. Director F stated Patient #1's medical records were dictated using the voice recognition software and stated that all physicians are aware and educated regularly about their responsibilities in ensuring the integrity and accuracy of medical records when using the system. Director F stated that there is no standard or quality review to ensure medical record accuracy for records dictated using the voice recognition system and described the software as "sloppy at best."
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
Based on record review and interview, facility staff failed to investigate patient grievances per policy in 3 of 3 grievances reviewed (Patient #1, Patient #2, Patient #3).

Findings include:

Review of facility policy "Patient Complaints Process, ADM-162, dated 5/25/2017, reveals: "...Leader/Designee will conduct complete investigation into all issues, and will involve any and all appropriate staff or departments in the investigation. Leader/Designee will document an investigation report which includes the following components: -Investigation results for each complaint; -Action plans or adjustments recommended for resolution; -Any service recovery initiated. ...f. The Quality Department will generate a resolution follow up letter stating outcome of investigation and actions agreed upon within 45 days of receipt. g. In the event the investigation can not be completed within 45 days of receipt of the complaint...will generate a status letter, to the Complainant advising them of the status of the investigation, plan for completion and estimated time frame of completion."

On 8/11/2017 the facility received a complaint regarding care provided to Patient #1 from 4/15/2017 through 4/17/2017. The complainant alleges inadequate discharge planning, stating case management "did not meet with me [on 4/15/2017]" as indicated in Patient #1's medical record. The complainant also alleges that case management met with Patient #1 to discuss discharge needs and that Patient #1 was admitted for delirium and was unable to provide accurate information. The investigation report activities are as follows: on 8/11/2017 an acknowledgement letter was sent to the complainant; on 8/15/2017 the inpatient Med-Surg Director documented "Reviewed and noted, no further additions at this time." On 9/5/2017, Quality Director C called and left a message with the complainant and on 9/7/2017 B documents "Received call from [complainant], explained that I had reviewed concerns in depth and fell that the case management/discharge planning was appropriate. I apologized that we did not meet expectations." There is no evidence of investigative activities documented. A grievance resolution letter was sent on 9/7/2017, more than 45 days after receipt of the complaint. The letter revealed "We recognize that your satisfaction is based not only on quality medical care but also the expectation of timely, compassionate, and respectful care. In our current health care environment, we realize that you have many options. As a critical access hospital, our goal is to provide quality care that keeps you in the community. We apologize for not meeting your expectation." There is no mention of investigation activities or outcomes related to the complaint. An entry on the report activities reveals on 10/11/2017: "Letter from patient's wife regarding medical records attached." There is no follow up documented.

During an interview on 12/11/2017 at 11:00 AM, Quality Director C stated "[Quality Analyst B] did a review with the entire chart. The discharge planner was out on maternity leave. I couldn't find evidence that there were any concerns [with discharge]." C went on to state "The doctor documented in the discharge summary that [Patient #1] was alert and oriented and had intact judgement." When it was pointed out that the documentation stated "Absent: Intact judgement" C stated "oh, I read that wrong." When asked about the documentation related to the complaint investigation, Director C stated "I could have documented my investigation further." When asked about the actions in response to the complaint filed on 10/11/2017 regarding medical record documentation, C stated "there isn't any, I didn't view it as a problem that needed to be addressed."

On 5/8/2017 the facility received a complaint regarding care provided to Patient #2 on 5/7/2017 in the Emergency Department. A grievance resolution letter was sent on 6/27/2017, more than 45 days after receipt of the complaint. The letter revealed "We recognize that your satisfaction is based not only on quality medical care but also the expectation of timely, compassionate, and respectful care. In our current health care environment, we realize that you have many options. As a critical access hospital, our goal is to provide quality care that keeps you in the community. We apologize for not meeting your expectation." There is no mention of investigation activities or outcomes related to the complaint.

During an interview on 12/11/2017 at 11:00 AM, Quality Director C stated "we usually do a summary of the conversation in the letter. We had to address this on a high level because the complaint was not filed by the patient."

On 6/1/2017 the facility received a complaint regarding care provided to Patient #3 on 5/5/2017 in the Emergency Department. A grievance resolution letter was sent on 8/8/2017, more than 45 days after receipt of the complaint. The letter revealed "We recognize that your satisfaction is based not only on quality medical care but also the expectation of timely, compassionate, and respectful care. In our current health care environment, we realize that you have many options. As a critical access hospital, our goal is to provide quality care that keeps you in the community. We apologize for not meeting your expectation." There is no mention of investigation activities or outcomes related to the complaint. The investigation report does not include documentation of the investigation results or action plans.

During an interview on 12/11/2017 at 11:00 AM, Quality Director C stated "we should have included more information [in the resolution letter], there is no reason why it wasn't done." Regarding the delay in sending the resolution letters to Patient #2 and Patient #3, C stated "we strive to adhere to the timelines outlined in the policy, we didn't meet the time requirements."