The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PORTNEUF MEDICAL CENTER 777 HOSPITAL WAY POCATELLO, ID 83201 Sept. 14, 2016
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, review of Idaho state laws, hospital policies, and medical records, it was determined the hospital failed to ensure the rights of 2 of 2 patients, who were placed on involuntary holds (#2 and #9) and whose records were reviewed, were protected. The hospital failed to allow them to refuse treatment and failed to follow state statutes. This resulted in the unlawful detainment of patients and the failure to protect patients' right to due process. Findings include:

Idaho state law at Title 66 Chapter 3, 66-320 states a "...person may be detained at a hospital...[if a] peace officer or a physician...has reason to believe that the person is gravely disabled due to mental illness or the person's continued liberty poses an imminent danger to that person or others, as evidenced by a threat of substantial physical harm...Whenever a person is taken into custody or detained under this section without court order, the evidence supporting the claim of grave disability due to mental illness or imminent danger must be presented to a duly authorized court within twenty-four (24) hours from the time the individual was placed in custody or detained." The law then states a court will assign a designated examiner to review the case.

Idaho state law at Title 66 Chapter 3, 66-320 further states "(3) if the director of the facility [hospital] determines that the patient should be hospitalized under the provisions of this chapter, the patient may be detained up to three (3) days, excluding Saturdays, Sundays and legal holidays, for the purpose of examination by a designated examiner and the filing of an application for continued care and treatment...(d) A patient admitted for examination pursuant to section 20-520 or 18-211, Idaho Code, may not be released except for purposes of transportation back to the court ordering, or party authorizing, the examination."

State law was not followed by the hospital in relation to 2 of 2 patients (#2 and #9) who were placed on involuntary holds by the hospital and were not allowed to leave the hospital against medical advice. Examples include:

1. Patient #9 was a [AGE] year old male who was admitted to the Rehabilitation Unit 8/25/16 following treatment for TBI and multiple facial fractures. He was discharged on [DATE] at 4:30 PM.

The H&P by the physiatrist, dated 8/22/16 at 5:01 PM, determined Patient #9 was appropriate for admission to the Rehabilitation Unit. It stated Patient #9 was "...alert, mildly agitated, easily distractible. He knew the year and month, not the day. He was oriented to self." The H&P stated Patient #9 had 1 episode of combativeness while in the Intensive Care Unit, where he was treated for alcohol detoxification.

Following admission to the Rehabilitation Unit, the first physician progress note, dated 8/25/16 at 2:09 PM, stated "TBI [prior to admission], agitated requiring 1:1." The note did not describe behaviors of Patient #9. A physician progress note, dated 8/26/16 at 2:29 PM, stated "TBI [prior to admission], agitated requiring 1:1 on medical hold." Again, the note did not describe Patient #9's behavior or why he was placed on a medical hold.

A physician order, dated 8/26/16 at 2:38 PM, stated "Medical Hold please. [Diagnosis] TBI. Agitated/confused." There was no documentation of specific behaviors that indicated how Patient #9 was a danger to himself or others.

After the order to place Patient #9 on a medical hold, no further mention of the hold was documented. Nursing notes stated Patient #9 remained with 1:1 staff until his discharge on 9/29/16. The implementation of a legal process was not documented after Patient #9 was placed on a hold. There was no record that the court was notified of the hold or that a Designated Examiner was notified and a request for examination was made.

A "Visual Observation Sheet" for 8/26/16, listed behaviors for Patient #9 every 15 minutes recorded by the 1:1 staff member. The sheet stated Patient #9 was angry from midnight to 12:30 AM, from 6:45 to 7:00 AM, and from 8:45 to 10:30 AM. The sheet stated he was "Pacing off and on throughout the day." No other behaviors were noted on the sheet.

Patient #9's nursing notes stated he exhibited confusion at times but said he communicated with staff, followed directions, and was cooperative. A nursing note on 8/26/16 at 7:20 AM stated Patient #9 was pleasant and compliant. A nursing note on 8/26/16 at 9:00 AM stated Patient #9 was calm and cooperative. A nursing note on 8/26/16 at 2:00 PM stated Patient #9 was up in a chair doing occupational therapy homework. One nursing note, dated 8/27/16 at 3:05 PM, stated security was called for Patient #9 due to "increased agitation/aggression. Pt walking with security at this time." Specific behaviors were not documented. A nursing note, dated 8/27/16 at 8:30 PM, stated Patient #9 was angry when he was not allowed to walk onto an elevator. Otherwise, no negative or threatening behaviors were mentioned in nursing notes.

Following the involuntary hold order, a physical therapy note on 8/26/16 at 4:55 PM stated Patient #9 "..was agitated early a.m. but participated well this p.m. [Patient #9] reported plan to leave to smoke and return before [nursing] notices he is gone. Discussed need to stay in rehab until [discharged by the physician]." No negative behaviors were mentioned in therapy notes.

A nursing note, dated 8/26/16 at 11:00 PM, stated Patient #9 "...was wanting to leave again. Redirection done. Pt requested to have security officers to tell him that it's not ok for him to leave. Security officers in and explained the situation." A nursing note, dated 8/27/16 at 12:01 AM, stated Patient #9 was "...starting to ramp up. Wanting to go home. Multiple redirection done with multiple approaches. Pt still perseverates in going home & or wanting to go to the store to smoke." The note stated Patient #9 was given antipsychotic medication in response to his requests to go home. A nursing note, dated 8/27/16 at 3:14 AM, stated Patient #9 "...started to ramp up. Stating that he wants to go home. Security requested for redirection."

The documented behaviors exhibited by Patient #9 all related to his desire to smoke.

Patient #9 was discharged on [DATE] at 4:30 PM accompanied by his wife. The hold was not rescinded by the court prior to discharge.

No documentation was present in Patient #9's medical record that stated he was a danger to himself or others. Justification for denying Patient #9's freedom was not documented. No efforts to protect Patient #9's rights or to allow him to refuse care were documented. No efforts to follow a legal process were documented after Patient #9 was placed on a hold prior to his discharge. The court was not notified of the hold. No efforts to allow Patient #9 the opportunity to refute the hold in court were documented.

After Patient #9 was placed on the hold, no determination was documented that Patient #9 was not a danger to himself or others prior to his discharge.

The policy "AMA/ELOPEMENT & REFUSAL OF TREATMENT AGAINST MEDICAL ADVICE," revised 9/12, stated "The [hospital] seeks court intervention in accordance with State or Federal statutes could result in death or serious harm in situations when...the patient's mental competence is in question..." The same policy also stated if a patient represented "...a significant threat of harm to him or herself or others, every attempt is made to convince the patient to stay including...Initiating Protective Custody proceedings." An accompanying procedure defining the process to determine whether the patient represented a threat of serious harm to himself or others was not present. An accompanying procedure defining the process to seek court intervention was not present. A policy and procedure providing direction to staff in the above situations was not present.

The Director of Behavioral Health was interviewed on 9/13/16 beginning at 8:15 AM. He stated the hospital had not developed a policy or procedure for involuntary holds because holds were defined in Idaho law. He stated there were holds by law enforcement officers and administrative holds. He stated he did not know what the term "medical hold" meant. He stated a physician must examine a patient and document the reasons to place a patient on an administrative hold.

Patient #9's physician was interviewed on 9/13/16 beginning at 8:55 AM. He stated the term "medical hold" meant a patient was detained involuntarily and could not leave the hospital against medical advice. He stated patients were placed on medical holds if they were a danger to self or others. He stated the hold meant nurses were notified of this and if the patient attempted to leave the hospital security force would physically prevent the patient from leaving. He stated he was not familiar with the policy but said he thought one existed.

The RN who noted the order when Patient #9 was placed on the medical hold was interviewed on 9/13/16 beginning at 4:00 PM. She stated Patient #9 was pleasant and all of his behaviors related to him wanting a cigarette. She stated when a patient was placed on a medical hold, the nurse notified other nursing staff and security of the hold. She stated if the patient then tried to leave against medical advice, security would detain them and prevent them from leaving. The RN reviewed Patient #9's medical record. She stated Patient #9's POC was not updated when he was placed on a medical hold. She also stated the POC did not direct nursing staff in addressing Patient #9's behaviors. She stated she was not aware if the hospital had a policy for medical holds.

The hospital did not allow Patient #9 to refuse treatment. The hospital deprived Patient #9 of his physical freedom and his ability to participate in his care. When he requested to leave, the hospital detained him and then failed to notify the court which prevented him from receiving due process. The hospital then discharged Patient #9 before a judgement to determine that he was not a danger to himself or others.

In addition, the hospital failed to develop policies and procedures to direct staff in the application of involuntary holds.





2. Patient #2 was a [AGE] year old female admitted on [DATE], for injuries caused by a motorcycle accident. Injuries included a TBI, fractured ribs, fractured left scapula, pneumothorax, probable splenic laceration and multiple skin lacerations. She required 2 surgeries and intubation during her stay in the ICU. She was transferred to the Rehabilitation Unit on 9/09/15.

Patient #2's record stated she was suffering from emotional lability, impaired judgement and impulsiveness secondary to her TBI. She had documented episodes of confusion, agitation and aggressive behavior. Examples include:

- A nursing note dated 9/11/15 at 9:57 PM stated "Pt was agitated and throwing shoes on her friend. [sic] Kept saying 'let's go, let's go right now' patient was confused and wandering in hallway Redirected but not effective this time. PRN med given."

- A nursing note dated 9/12/15, at 6:06 PM stated "at the window pt thought her brother's trailer was outside and she became agitated and verbally aggressive when she was told he was not there...7:05 PM Ativan given for agitation...7:15 PM Haldol given for increasing agitation toward SO"

- A nursing note dated 9/14/15 at 7:00 AM stated "pt came out of the room, very agitated, swearing difficult to redirected [sic], yelling at her SO and nurses at the desk, Haldol given...7:02 AM Pt becoming more angry and agitated, aggressive [sic] and yelling at person in the hall, unable to redirect, yelling at passerby in hall and getting combative, Haldol [sic] given continues 1:1... 8:44 AM pt very agitated, swearing at S.O. and nurses, ativan, hydro [sic] for generalized pain, haldol given for agitation"

- A nursing note dated 9/14/15, at 7:12 PM stated "Pt up in hallway very agitated restless
confused wanting to go home-pt began yelling trying to leave1:1 w/pt security also called and present, pt escalating yelling at girlfriend that she wants to leave, reassured pt that she will be [discharged ] on Wednesday, pt redirectable. Support offered. Unable to distact [sic] pt. pt back to room yelling again at SO, turned and picked up chair raised into air and threw it at security guard. Pt. given haldol."

- A nursing note dated 9/14/15 at 9:10 PM stated " Unable to distract pt, pt back to room yelling again at SO, turned an picked up chair raised and threw it at security guard [sic] Pt given haldol."

- A nursing note dated 9/15/15 at 12:40 PM stated "Pt came out of room agitated. Pt demanding to go off unit. Refused verbal redirection. Multiple staff tried to redirect. Pt behavior escalated. Pt state 'you don't want to [expletive] with me right now' Pt made threats security was called for pt safety...Patient placed on medical hold."

- A nursing note dated 9/16/15, the morning patient was scheduled for discharge, at 7:08 AM, stated Patient #2 had paranoia about being attacked by bees and stated she was medicated with hydrocodone (for pain) and Haldol (for agitation), at 8:30 AM "with much coercion."

A nursing note dated 9/15/15 stated Patient #2's rehabilitation physician was called at 12:40 PM. An order for "Medical Hold' was taken by the Staff RN from the physician at 12:45 PM. There was no further mention of a medical hold in the nurses notes, care plan or case management notes. A physician note timed 1:07 PM stated "called by NS [nurses] patient agitated confused angry-sig other not present ambulating well security called for medical hold...Plan DC [discharge] 9/16/15."

Patient #2's record did not include documentation that the courts were notified she was placed on a hold.

Patient #2's record stated she was discharged with her SO on 9/16/15 at an unspecified time. There was no documentation the hold was recinded by the court prior to discharge.

Patient #2's Physician was interviewed on 9/13/16 beginning at 8:55 AM. He stated he put patients on medical hold when someone wanted to leave against medical advice or was a danger to themselves or others. He stated the medical hold order meant that nursing was put on alert to call security to help redirect the patient to stay. He stated he was not familiar with any policy related to a medical hold. The Physician stated it was a judgement call. He stated he wanted to make sure that things were "organized" before Patient #2 left the rehabilitation unit.

The Staff Nurse caring for Patient #2 on 9/15/15 that took the medical hold order was interviewed on 9/13/16 at 3:10 PM. She stated she remembered the patient came out in the hallway yelling and screaming. She stated staff tried to redirect but they needed to call security as the patient did not calm down. She stated she remembered she called and explained the specific situation to the physician and he ordered a medical hold to keep the paitient in the hospital for Patient #2's safety. She stated she was not familiar with a policy regarding medical holds.

The hospital did not follow State law regarding Patient #2's hold. The hospital detained her and failed to notify the court which prevented her from receiving due process. The hospital discharged Patient #2 before a judgement to determine that she was not a danger to herself or others had been rendered by the court.

In addition, the hospital failed to develop policies and procedures to direct staff in the application of involuntary holds.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records, hospital policies, and staff and caregiver interviews, it was determined that the hospital failed to prepare the patient's caregivers for post hospital care for 1 of 9 patients (Patient #2) whose records were reviewed. This resulted in a patient being discharged without their caregivers having the knowledge and ability to meet their post-hospitalization needs. Findings include:

The hospital's policy "Discharge Planning," revised on 4/11, stated "... As needed, the patient and family members are counseled to prepare them for post-acute care." The policy also stated "Case Management transfers and refers patients along with necessary medical information to appropriate facilities, agencies or outpatient services, as needed, for follow-up or ancillary care."

Patient #2 was admitted on [DATE], for care related to injuries caused by a motorcycle accident. Injuries included a TBI, fractured ribs, fractured left scapula, pneumothorax, probable splenic laceration and multiple skin lacerations. She required 2 surgeries and intubation during her stay in the ICU. She was transferred to the Rehabilitation Unit on 9/09/15.

Patient #2's record included a Case Manager's documentation, dated 9/10/15 at 3:39 PM, stated "Currently, therapy attempting to complete full assessments and their hopes to collaborate with patient have proved problematic d/t [due to] symptoms of impulsivity and poor attention."

Further documentation by the Case Manager, dated 9/10/15 at 5:42 PM, stated the expectation was for the patient to be discharged home the week of 9/14/15 "and receive outpatient therapy." The documentation stated Patient #2's SO was making plans for Medicaid coverage and transfer to a hospital in another state to continue rehabilitation. Additionally, Patient #2's record stated she was denied admission to inpatient rehabilitation due to self-pay status.

The Case Manager documented at 1:01 PM he contacted the out of state hospital again to inquire about Patient #2 being transferred as an inpatient. The Case Manager documented clinical notes were sent and questions were answered regarding a possible transfer. He documented at 1:36 PM, the out of state hospital reported back that they declined placement. The Case Manager documented "Plans underway to facilitate [discharge] 9/16 with 24/7, SO [name] to setup CNA support and find PCP, no DME needs and [name] will ensure outpt [sic] therapy is obtained through [hospital name] as recommended."

Case Management notes dated 9/16/16 at 12:06 PM stated "PCP selected and patient will follow up with the [hospital name] for outpatient OT/ST. Plan to enlist CNA our [sic] ongoing. No other CM interventions required at this time."

There was no further documentation in the Case Manager's notes or the nursing discharge instructions related to arrangements for Patient #2 to be an out-patient at the out of state hospital. There was no documentation of specific arrangements for follow up with the patient's new PCP.

Patient #2 was discharged on [DATE] at an unspecified time. The discharge instructions included a list of medications, directions on wound care, signs of depression, and status at discharge, including the direction someone was to be at patient #2's side 24 hours a day. The discharge instructions stated they were to make an appointment with Patient #2's PCP. There was no contact information listed for the PCP. There was no contact listed for the out of state hospital.

During an interview on 9/13/16, at 9:30 PM, the LPN who discharged Patient #2 reviewed her record and stated what was documented were all the discharge instructions given to Patient #2's significant other. She stated Patient #2's significant other had medications as ordered but she was not aware of any paperwork related to a transfer or referral. She stated there was no discussion of patient transfer to another facility that she could remember. She agreed there was nothing documented regarding Patient #2's referral to another facility.

During a telephone interview on 9/13/16, at 3:45 PM, Patient #2's significant other was interviewed by phone. She stated Patient #2 was transported to another state the day of discharge in a private car. She stated she understood she would take Patient #2 to the out of state hospital the next day, walk in, and she "would be listed in the computer and they would admit her for continued rehabilitation." She stated there was a "colossal miscommunication" because the out of state hospital had no information regarding an anticipated admission, outpatient or inpatient. Patient #2 was admitted to the out of state hospital through the ED by her significant other due to her emotional lability and aggressive behavior.

The hospital failed to ensure Patient #2's referral information was complete and her caregiver fully understood the discharge plan and had the necessary resources.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records and policies, staff and caregiver interviews, it was determined that the hospital failed to reassess discharge plans for 2 of 9 patients (#2 and #9) whose records were reviewed. This had the potential to result in patients being inadequetely prepared for discharge. Findings include:

The hospital's policy "Discharge Planning", revised on 4/11, stated "case management reassesses the discharge planning process at periodic intervals to evaluate the appropriateness of previous assessments and plans ...patients are reevaluated at discharge to ensure plans still appropriate and in place."

1. Patient #2 was a [AGE] year old female, admitted on [DATE], for care related to injuries caused by a motorcycle accident. Injuries included a TBI, fractured ribs, fractured left scapula, pneumothorax, probable splenic laceration and multiple skin lacerations. She required 2 surgeries and intubation during her stay in the ICU. She was transferred to the Rehabilitation Unit on 9/09/15.

a. The Case Manager's documentation on 9/10/15, at 3:39 PM stated "Currently, therapy attempting to complete full assessments and their hopes to collaborate with patient have provided [sic] problematic d/t [due to] symptoms of impulsivity and poor attention."

Further documentation by the Case Manager on 9/10/15, at 5:42 PM, stated the expectation was for the patient to be discharged home the week of 9/14/15, and receive outpatient therapy "as plan is developed for safety." The Case Manager also documented Patient #2's significant other was making plans for Medicaid coverage and transfer to a hospital in another state to continue rehabilitation. The Case Manager documented Patient #2 was denied admission due to self-pay status.

The Case Manager's note dated 9/14/15, at 1:01 PM, stated he contacted the out of state hospital again to inquire about Patient #2 being transferred as an inpatient. He documented that clinical notes were sent and questions answered regarding possible transfer. At 1:36 PM, the Case Manager documented the out of state hospital reported back that they declined Patient #2 as an inpatient, but would consider her as an outpatient. The Case Manager documented "Plans underway to facilitate [discharge] 9/16 with 24/7, SO [name] to setup CNA support and find PCP, no DME needs and [name] will ensure outpt [sic] therapy is obtained through [hospital name] as recommended." There was no documentation her significant other was notified of the changes.

On 9/16/15 at 12:06 PM, the Case Manager notes discussed Patient #2's brother's concerns regarding discharge. It was noted "PCP selected and patient will follow up with the [hospital name] for outpatient OT/ST."

There was no documentation in the Case Manager's notes related to Patient #2's aggressive behavior, and how it was considered in her discharge plan.

b. Patient #2's chart included documentation in the nursing notes of multiple events of confusion and agitation due to her TBI during her rehabilitation stay. These events included aggressive and violent behavior. Examples included:

- A nursing note dated 9/11/15 at 9:57 PM stated "Pt was agitated and throwing shoes on her friend. Kept saying 'let's go, let's go right now' patient was confused and wandering in hallway Redirected but not effective this time. PRN med given."

- A nursing note dated 9/12/15 at 6:06 PM stated "at the window pt thought her brother's trailer was outside and she became agitated and verbally aggressive when she was told he was not there... 7:05 PM Ativan given for agitation... 7:15 PM Haldol given for increasing agitation toward SO"

- A nursing note dated 9/14/15 at 7:00 AM stated "pt came out of the room, very agitated, swearing difficult to redirected [sic], yelling at her SO and nurses at the desk, Haldol given... 7:02 Pt becoming more angry and agitated, aggressive [sic] and yelling at person in the hall, unable to redirect, yelling at passerby in hall and getting combative, Haldol [sic] given continues 1:1... 8:44 pt very agitated, swearing at S.O. and nurses, ativan, hydro [sic] for generalized pain, haldol given for agitation"

- A nursing note dated 9/14/15 at 9:10 PM stated " Unable to distract pt, pt back to room yelling again at SO, turned an picked up chair raised and threw it at security guard [sic] Pt given haldol."

- A nursing note dated 9/15/15 at 12:40 PM stated "Pt came out of room agitated. Pt demanding to go off unit. Refused verbal redirection. Multiple staff tried to redirect. Pt behavior escalated. Pt state 'you don't want to [expletive] with me right now' Pt made threats security was called for pt safety." Patient placed on "medical hold".

- A nursing note dated 9/16/15 at 7:08 AM, the morning patient was scheduled for discharge, stated Patient #2 had paranoia about being attacked by bees. She was medicated with hydrocodone (for pain), and Haldol (for agitation), at 8:30 AM "with much coercion."

Patient #2 was discharged on [DATE] at an unspecified time and placed in a private vehicle with her significant other and a friend, who were instructed by the physician to use the child locks to keep her in the car. Patient #2's discharge instructions included the medications Haldol 5mg by mouth every hour as needed until response, and Ativan 1 mg by mouth every 4 hours as needed for agitation. Her discharge instructions included directions on wound care, signs of depression, and status at discharge, which included someone was to be at patients side 24 hours a day. The directions stated they were to make an appointment with Patient #2's physician. There was no documentation of an evaluation of the Patient #2's behaviors as listed above, her remaining on medical hold, or the safety of her being transported by private vehicle.

On 9/13/16, at 3:45 PM, Patient #2's significant other was interviewed by phone. She confirmed that she was transported to another state the day of discharge in their car. She stated she was concerned about Patient #2's safety as well as her own. She stated she had a friend fly down to drive back with she and Patient #2 to help keep them safe. She stated the first 5 hours of the 11 hour trip were peaceful, as patient #2 was very sedated. She stated she and her friend gave Patient #2 "as much medication as they dared" but the second half of the trip Patient #2 became disoriented, yelling and screaming, grabbing their hair and continually trying to leave the car. She stated Patient #2 continued to be difficult to manage after arrival to their home city and was admitted through the ED the day after discharge from the hospital. She stated Patient #2 remained in isolation in the ED for a few days as the hospital had no beds.

During an interview on 9/13/16, at 11:50 AM, the Clinical Director of Rehabilitation stated she remembered Patient #2's outbursts. She stated Patient #2 was "angry at the nurses" and "using profanity" and one nurse stated she had "thrown a chair."

During an interview on 9/13/16 at 3:10 PM, the staff nurse that had cared for Patient #2 on 9/15/15, stated "she was yelling and screaming in the hallway" and that security was called to keep the staff and patient safe. She stated she had called the physician and he had ordered a medical hold to keep the patient in the hospital.

During an interview on 9/13/16, at 9:30 PM, the LPN that discharged patient #2 stated Patient #2's significant other had medications as ordered. She stated she was unaware of Patient #2 having a medical hold ordered the day before due to aggressive behavior. She stated she and another nurse were concerned regarding Patient #2 sitting in the back seat of the car "with lots of their stuff."

During an interview with the Case Manager on 9/13/16, at 11:15 AM, he stated that Patient #2's aggressive behavior was never documented in the IDG (interdisciplinary group) notes or discharge planning notes. He stated he never saw her outbursts of aggressive behavior though he was "aware of some." He stated "(SO name) did a good job of managing patient." He stated he was unaware of the medical hold.

Patient #2's discharge plan was not reassessed and updated to address her potentially dangerous aggressive behavior and safety after discharge.





2. Patient #9 was a [AGE] year old male who was admitted to the Rehabilitation Unit 8/25/16 following treatment for TBI and multiple facial fractures. He was discharged on [DATE] at 4:30 PM.

The H&P by the physiatrist was dated 8/22/16 at 5:01 PM. It stated Patient #9 was "...alert, mildly agitated, easily distractible. The H&P stated Patient #9 had 1 episode of combativeness while in the Intensive Care Unit. The H&P stated Patient #9 was in an alcohol related motorcycle accident. He was treated for alcohol intoxication on admission.

A physician progress note, dated 8/26/16 at 2:29 PM, stated "TBI [prior to admission], agitated requiring 1:1 on medical hold." The note did not describe Patient #9's behavior or why he was placed on a medical hold.

An order dated 8/26/16 at 2:38 PM stated "Medical Hold please. [Diagnosis] TBI. Agitated/confused."

Patient #9 was discharged on [DATE] at 4:30 PM accompanied by his wife. The hold was not rescinded prior to discharge.

The CM's initial assessment for discharge planning was dated 8/26/16, after Patient #9 was placed on an involuntary hold. The assessment did not document that Patient #9 had been placed on a hold. The only other discharge planning note was dated 8/29/16 at 5:20 PM, after the patient's discharge. This note stated Patient #9 required "24/7 family oversight." The note did not mention the hold nor did it specifically mention ways to keep Patient #9 safe.

Patient #9's discharge planning assessment and discharge plan were reviewed with the Data Abstractor on 9/13/16 beginning at 3:35 PM. She stated Patient #9's discharge planning notes did not address his involuntary hold or his specific behaviors.

The hospital did not reassess Patient #9's discharge plan to address his involuntary hold status and specific ways to keep him safe.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on staff interview and review of QAPI documents, it was determined the hospital failed to ensure its discharge planning process was reassessed including a review of discharge plans to ensure that they were responsive to discharge needs. This resulted in the inability of the hospital to fully assess its discharge planning process. Findings include:

The hospital gathered some data related to discharge planning, including the percentage of initial assessments completed within 24 hours and patient satisfaction data. However, no documentation indicated staff reviewed discharge planning evaluations and discharge plans to ensure the plans addressed needs identified by the evaluations.

The Director of Case Management was interviewed on 9/14/16 beginning at 9:05 AM. She stated discharge plans were reviewed but she was not able to provide documentation of this.

The hospital did not have evidence its discharge planning process was evaluated including a review of discharge plans.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on staff and caregiver interview, review of medical records and hospital policies, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in the failure of the hospital to ensure basic human rights were protected in accordance with state laws. Findings include:

1. Refer to A131 as it relates to the failure of the hospital to ensure the rights of patients who were placed on Medical Holds were protected and state laws were followed.

The cumulative effects of these negative systemic practices seriously impeded the ability of the hospital to protect patient rights.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital failed to ensure the discharge planning evaluation included an evaluation of the likelihood of 1 of 9 patients (Patient #9) needing post-hospital services and of the availability of the services. This resulted in a lack of resources for patients following discharge. Findings include:

Patient #9 was a [AGE] year old male who was admitted to the Rehabilitation Unit 8/25/16 following treatment for TBI and multiple facial fractures. He was discharged on [DATE] at 4:30 PM.

The H&P by the physiatrist, which determined Patient #9 was appropriate for admission to the Rehabilitation Unit, was dated 8/22/16 at 5:01 PM. It stated Patient #9 was "...alert, mildly agitated, easily distractible." The H&P stated Patient #9 had 1 episode of combativeness while in the Intensive Care Unit. The H&P stated Patient #9 was in an alcohol related motorcycle accident. The H&P stated Patient #9's blood alcohol level was over 3 times the legal limit. The H&P stated Patient #9 was treated for alcohol intoxication on admission.

Patient #9's initial occupational therapy evaluation was dated 8/25/16 at 3:06 PM. It stated the motor vehicle accident that resulted in Patient #9's admission was his third motor vehicle accident in 2016. It stated Patient #9 had a problem with alcohol abuse.

Patient #9's initial discharge planning assessment was dated 8/26/16 at 1:30 PM. The assessment did not mention Patient #9's alcohol abuse and his need for substance abuse treatment. Patient #9's discharge plan did not mention the addiction nor did it include referrals or other information regarding treatment of substance abuse.

Patient #9's discharge planning evaluation and discharge plan were reviewed with the Data Abstractor on 9/13/16 beginning at 3:35 PM. She stated Patient #9's discharge planning notes did not address his alcoholism.

The hospital failed to provide Patient #9 with a complete discharge planning evaluation.