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.

CHRISTUS ST FRANCES CABRINI HOSPITAL 3330 MASONIC DRIVE ALEXANDRIA, LA 71301 June 3, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

1) Failing to ensure physician orders were implemented for educating Patient #1 on the procedure of emptying a Jackson-Pratt (J.P.) drain twice a day and encouraging incentive spirometry hourly for 1 (#1) of 5 (#1 - #5) patient records reviewed for implementation of physician orders by the RN from a total sample of 9 patients.

2) Failing to ensure a nurse clarified the physician's pain medication order when 2 different medications were ordered for the same level of pain for 1 (#1) of 5 (#1 - #5) patient records reviewed for medication administration from a total sample of 9 patients.

3) Failing to notify the physician when a patient's oxygen saturation dropped to 90% (per cent) (#2) and a patient (#3) complained of difficulty breathing for 2 (#2, #3) of 5 (#1 - #5) patient records reviewed for notification of the physician with a change in condition or complaints voiced by a patient from a total sample of 9 patients.

4) Failing to ensure Patient #1's discharge planning screening was performed by the RN as required by hospital policy as evidenced by having the screening delegated to the LPN (Licensed Practical Nurse) for 1 (#1) of 9 (#1 - #9) patient records reviewed for discharge planning screening by the RN from a total of 9 sampled patients.
Findings:

1) Failing to ensure physician orders were implemented for educating Patient #1 on the procedure of emptying a J.P. drain twice a day and encouraging incentive spirometry hourly:
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #1's post-operative physician orders revealed the following orders on 05/31/15 at 11:30 a.m.:
Teach patient to empty and record J.P. drain twice a day;
Encourage patient to use incentive spirometry for 10 breaths a session once each hour while awake.

Review of Patient #1's medical record revealed no documented evidence that the RN instructed Patient #1 on the procedure of emptying and recording the drainage from the J.P. drain that was ordered to be done twice a day. Further review revealed no documented evidence that the RN assured Patient #1 was encouraged to use the incentive spirometer each hour for 10 breaths each session while she was awake.

In an interview on 06/03/15 at 8:05 a.m., S4RN confirmed he did Patient #1's admission assessment when she arrived on the unit. He indicated he should have called Patient #1's physician to clarify the order to instruct Patient #1 on emptying and measuring the drainage from the J.P. drain, because he didn't think patients went home with J.P. drains. Regarding the order to encourage incentive spirometry every hour, S4RN indicated "no one pops in every hour but of course when I'm rounding I do it."

2) Failing to ensure a nurse clarified the physician's pain medication order when 2 different medications were ordered for the same level of pain:
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #1's post-operative physician orders revealed the following orders on 05/31/15 at 11:30 a.m.:
Norco 5/325 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain (4 - 6);
Dilaudid 0.5 mg (milligrams) IV (intravenous) every 2 hours PRN moderate pain (4 - 6);
Norco 10/325 1 tablet by mouth every 4 hours PRN severe pain (7 - 10);
Dilaudid 1 mg IV every 2 hours PRN severe pain (7 - 10).

In an interview on 06/03/15 at 8:05 a.m., S4RN was asked how he determined which of the two medications that were ordered for moderate or severe pain should be given. He indicated that he would "go by what the patient wants." When asked what he meant by that statement, S4RN indicated he explains to the patient that they can get instant satisfaction of an immediate rush by IV or do they want something that will last" by giving oral medication. He then indicated that he would assess the effectiveness of whichever medication was given to determine which to give next time pain medication was requested. He gave no indication that the physician's order should be clarified to obtain an indication when to use each of the medications ordered for the same level of pain.

3) Failing to notify the physician when a patient's oxygen saturation dropped to 90% (#2) and a patient (#3) complained of difficulty breathing:
Review of the hospital policy titled "Admission Of Patient - Initial Assessment And Reassessment", reviewed September 2014 and presented as a current policy by S11Dir (Director) Quality, revealed that each patient is reassessed when a significant change occurs in the patient's condition.

Review of the hospital policy titled "Notification Of Physician/Family Of Patient Regarding: Change In Patient Condition, Delay In Treatment Or Inability To Follow Out Orders:, reviewed September 2014 and presented as a current policy by S11Dir Quality, revealed patients who have a change in condition, delay in treatment, or exhibit an inability to carry out physician's orders will have their physician and family members notified in a timely manner.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #2's physician's orders revealed an order on 05/27/15 at 2:50 p.m. to notify the physician if the oxygen saturation was less than 93%.

Review of Patient #2's nursing notes revealed an entry on 05/29/15 at 11:30 a.m. by S13RN that Patient #2's oxygen saturation (O2 sat) was 93% on room air while sitting up on the side of the bed. Further review revealed that after laying back in bed his O2 sat dropped to 90%. Patient #2 was placed back on oxygen at 4 liters per nasal cannula, and O2 sat increased to 96%. Further review revealed no documented evidence that S13RN reported the drop in O2 sat to the physician. Further review revealed S13RN reported to the physician that Patient #2's heart rate remained above 110 and of far right incision bruising and bleeding on 05/29/15 at 12:40 p.m. with no documented evidence that the physician was notified of the earlier drop in O2 sat.

In an interview on 06/02/15 at 10:00 a.m., S3Clinical Informatics confirmed there was no evidence in Patient #2's medical record that the physician was notified of the drop in O2 sat on 05/29/15 at 11:30 a.m. She indicated that order written after surgery to notify the physician of an O2 sat below 93% was canceled when Patient #2 was transferred from ICU (intensive care unit) to the nursing unit, and another order was not given for notification.

Patient #3
Review of Patient #3's medical record revealed she was a [AGE] year old female admitted to Observation on 04/13/15 with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #3's pre-operative data revealed she had a history of cardiac disorders, Coronary Artery Disease, Hypertension, Congestive Heart Failure, Coronary Stent, and Irregular heart Beat.

Review of Patient #3's vital signs documented on 04/14/15 at 4:21 a.m. revealed her temperature was 100 degrees Fahrenheit.

Review of Patient #3's "Nursing Rounds" documented by S6RN on 04/14/15 at 6:00 a.m. revealed Patient #3 was resting in bed and stated she couldn't breathe well and was short of breath. Further review revealed S6RN applied oxygen at 2 liters per nasal cannula, and her O2 sat was 97 -98 %. S6RN instructed Patient #3 to cough and deep breathe, and incentive spirometer was given with instructions on use. Further review revealed "after a few minutes" Patient #3 stated she felt able to breathe without difficulties. Her head of bed was elevated, and she was encouraged on frequent use of the incentive spirometer and deep breathing. There was no documented evidence that S6RN reported Patient #3's reports of shortness of breath and difficulty breathing to her physician or the oncoming RN.

In an interview on 06/01/15 at 9:50 a.m., S7RN indicated she didn't remember if S6RN told her about Patient #3's complaints of shortness of breath. She further indicated she thinks if she had been told, she would have followed up on it and would have documented her assessment and notified the doctor immediately. She confirmed that she didn't see any documentation by her in Patient #3's chart about shortness of breath or physician notification.

In an interview on 06/03/15 at 7:45 a.m., S6RN confirmed she documented Patient #3's complaints of shortness of breath on 04/14/15. She further indicated, that based on what she documented, sometimes patients, especially females, who are in bed all night will complain of shortness of breath, so she gives the patient an incentive spirometer and elevated the head of bed. She further indicated that if the patient's complaints improve after those interventions, she doesn't report it to the physician. S6RN indicated she document that she reported the complaints to the oncoming nurse. S6RN indicated they keep fans on the unit for patients who complain of being hot after having had female surgery, but she doesn't remember if she gave Patient #3 a fan. She confirmed that she doesn't always document when she gives a fan to a patient. S6RN indicated she wouldn't call the physician to report a temperature of 100 degrees Fahrenheit, because the physician order was to notify if greater than 101 degrees.

4) Failing to ensure Patient #1's discharge planning screening was performed by the RN as required by hospital policy:

Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of the admission assessment performed for Patient #1 by S4RN on 05/31/15 at 3:45 a.m. revealed no documented evidence that the discharge planning screening was addressed during the admission assessment.

Review of Patient #1's admission data obtained by S12LPN revealed S12LPN conducted the discharge planning screening during her assessment of Patient #1.

In an interview on 06/03/15 at 8:05 a.m., S4RN confirmed he didn't perform Patient #1's discharge planning screening during the admission assessment that he performed.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure:

1) The discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of the patient's capacity for self-care, the possibility of the patient being cared for in the environment from which he/she entered the hospital for 5 (#2, #6, #7, #8, #9) of 5 patient records reviewed for discharge planning evaluations from a sample of 9 patients.

2) A process was developed and implemented for notifying patients that they may request a discharge planning evaluation and that the hospital will conduct an evaluation upon request.
Findings:

1) The discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of the patient's capacity for self-care, the possibility of the patient being cared for in the environment from which he/she entered the hospital:
Review of the hospital policy titled "Discharge Planning", revised March 2015 and presented as a current policy by S11Dir Quality (Director of Quality), revealed that specific services are provided based on individual needs and available resources. The "High Risk Screening and Referral Guide" is utilized by the Case Management Department as a tool to assist in identifying those patients whose diagnosis, health problems, or psychosocial circumstances may indicated the need for additional services at discharge. Further review revealed that the primary nurse performs an initial assessment upon admission to include physical status, self-care needs, and psychosocial needs. Discharge needs or potential barriers to discharge are identified by the primary nurse during the initial assessment and throughout hospitalization will be referred to Case Management according to the Case Management Plan. Each case manager will review the medical record of assigned patients to assess high risk for discharge needs. A full assessment with patient interview will occur on all patients that meet criteria for "high risk" according to the High Risk Screening and Referral Guide (See Case Management Plan). Patients not meeting "high risk" criteria according to the High Risk Screening and Referral Guide will be reassessed at intervals during hospitalization for potential discharge needs.

Review of the hospital policy titled "Discharge Planning Assessment Screen", revised July 2014 and presented as a current policy by S11Dir Quality, revealed that each patient admitted to the hospital will be screened for discharge needs by the admitting RN. Further review revealed patients with complex discharge issues or who do not have an adequate social support system will be triaged to a social worker for assessment and/or intervention. This should include cases with complex psycho-social situations with complex discharge planning needs and/or patient/family conflicts; cases with clinical counseling/support as a primary need or concurrent issues; cases with neglect, abuse, domestic violence, adoption or factors involving legal statuses; cases with repeat admissions that may be the result of failure of a prior discharge plan.

Review of the discharge planning evaluation performed for Patient #8 revealed no documented evidence that her assessment included an assessment of whether her post-discharge care needs could be met in the environment from which she entered the hospital.

Review of the discharge planning evaluation performed for Patients #2, #6, #7, and #8 revealed no documented evidence that their assessment included an assessment of their ability to perform ADLs (activities of daily living). Further review of Patient #2's and #8's evaluation revealed no documented evidence that their evaluation included an assessment of their or their support person's ability to provide self-care/care.

Review of the discharge planning evaluation performed for Patients #6, #7, and #8 revealed no documented evidence that the assessment included whether specialized equipment was needed and if the equipment was available and whether home and/or physical environment modifications were needed and if the modifications could be made to safely discharge the patient to that setting.

Review of the discharge planning evaluation performed for Patient #2 revealed no documented evidence that the assessment included whether home and/or physical environment modifications were needed and if the modifications could be made to safely discharge the patient to that setting.

Review of Patient #8's discharge planning evaluation revealed no documented evidence that the assessment included an assessment of his insurance coverage and how that coverage might or might not provide for necessary services post-hospitalization .

Patient #9 was admitted on [DATE] and had been admitted to the hospital within the last 30 days. As of 06/03/15, Patient #9 did not have a discharge planning evaluation performed by the social worker or case manager.

In an interview on 06/03/15 at 9:15 a.m., S14Dir Case Mgt (Director of Case Management) confirmed the above-listed patients' discharge planning evaluations did not include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services, an evaluation of the likelihood of the patient's capacity for self-care, the possibility of the patient being cared for in the environment from which he/she entered the hospital, an assessment of whether the patient will require specialized medical equipment and whether the equipment is available, and whether home and/or physical environment modifications are needed and if the modifications can be made to safely discharge the patient to that setting, and an assessment of the patient's insurance coverage and how that coverage might or might not provide for necessary services post-hospitalization

In an interview on 06/03/15 at 1:15 p.m., S14Dir Case Mgt confirmed Patient #9 had not had a discharge planning evaluation performed as of the time of this interview. She indicated that he was a readmission within 30 days, and since he's in ICU (intensive care unit) and there was a social worker assigned to ICU, a discharge planning evaluation should have been performed.

2) A process was developed and implemented for notifying patients that they may request a discharge planning evaluation and that the hospital will conduct an evaluation upon request:
Review of the hospital policies titled "Discharge Planning", "Discharge Planning - Nursing", and "Discharge Planning Assessment Screen", all presented as current policies by S11Dir Quality, revealed no documented evidence that that a process or policy had been developed and implemented for notifying patients that they may request a discharge planning evaluation and that the hospital will conduct an evaluation upon request.

In an interview on 06/03/15 at 9:15 a.m., S14Dir Case Mgt indicated the hospital did not have a policy and procedure or process developed and implemented that addressed patients being educated that they could request a discharge planning evaluation and that the hospital would conduct an evaluation upon request.

In an interview on 06/03/15 at 1:25 p.m., Patient R1 indicated he had a Gastric Sleeve procedure performed on 06/02/15. Patient R1's wife was present during the interview. Both Patient R1 and his wife indicated that discharge planning had not been discussed with them by any hospital staff member (discharge planning was explained to Patient R1 and his wife as an assessment by a RN or social worker to determine if any special equipment or services, such as home health, would be needed after discharge). They both indicated they were not informed by any staff member that they could request a discharge planning evaluation and that an evaluation would be conducted upon request.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient by failing to initiate the nursing care plan within 24 hours of admission that includes patient problems requiring interventions as required by hospital policy for 3 (#1, #2, #3) of 5 (#1 - #5) patient records reviewed for a nursing care plan from a total of 9 sampled patients.
Findings:

Review of the hospital's policy titled "Patient Plan Of care", reviewed September 2014 and presented as a current policy by S11Dir (Director) Quality, revealed that each patient admitted to the hospital will have a Plan of Care based on the admission assessment within 24 hours of admission. The Plan of Care will be developed and initiated by the Registered Nurse (RN). Patient problems are actual alterations requiring staff inquiry, consideration, or intervention. When the admission assessment is completed electronically by the RN, suggested problems are identified. The RN analyzes the data, identifies the patient's problems, and initiates the plan of care. The plan outlines the patient's problems, goals, nursing interventions, and evaluation of care. Goals need to be measurable and time limited.

Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #1's nursing care plan revealed it was initiated on 06/01/15 at 3:09 p.m., 2 days after admission.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #2's nursing care plan revealed it was initiated on 06/01/15, 5 days after admission.

Patient #3
Review of Patient #3's medical record revealed she was a [AGE] year old female admitted to Observation on 04/13/15 with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #3's medical record revealed she had a history of Coronary Artery Disease, Hypertension, Congestive Heart Failure, Coronary Stent, Angina, Irregular Heart Beat, Diabetes, and Seizures. Further review revealed she had physician orders for sliding scale insulin with Accuchecks.

Review of Patient #3's nursing care plan initiated on 04/13/15 revealed no documented evidence that a care plan was developed to address her Seizure Disorder, alteration in elimination related to having an indwelling catheter and vaginal pack, and Diabetes.

In an interview on 06/01/15 at 2:05 p.m., S3Clinical Informatics confirmed no nursing care plan had been developed for Patient #1 as of the time of this interview. She further indicated there were outcomes documented with no identified patient problems. She further indicated "whoever did it (documented outcomes) didn't follow the process."

In an interview on 06/01/15 at 3:15 p.m., S3Clinical Informatics confirmed Patient #2's nursing care plan wasn't developed until 06/01/15 and not within 24 hours of admission as required by hospital policy.

In an interview on 06/03/15 at 2:45 p.m., S2CNE (Chief Nursing Executive) offered no explanation when informed that Patient #3's nursing care plan did not address all problems for which Patient #3 was being treated, specifically Diabetes (Accuchecks with sliding scale insulin orders) and alteration in elimination (foley catheter with vaginal pack).
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure drugs were administered as ordered by the physician as evidenced by Norco not being administered in accordance to the physician's order in relation to the patient's pain level for 1 (#1) of 1 patient record reviewed with physician orders for Norco from a sample of 9 patients. Findings:

Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #1's post-operative physician orders revealed the following orders on 05/31/15 at 11:30 a.m.:
Norco 5/325 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain (4 - 6);
Dilaudid 0.5 mg (milligrams) IV (intravenous) every 2 hours PRN moderate pain (4 - 6);
Norco 10/325 1 tablet by mouth every 4 hours PRN severe pain (7 - 10);
Dilaudid 1 mg IV every 2 hours PRN severe pain (7 - 10).

Review of Patient #1's "Medication Administration Detail Report" revealed she received Norco 5/325 (ordered for moderate pain 4 - 6) on 05/31/15 at 7:43 p.m. when her pain was assessed to be at an intensity of 7 that had Norco 10/325 ordered for pain intensity of 7 - 10. Further review revealed she received Norco 10/325 on 06/01/15 at 12:01 p.m. for pain of 6 that had Norco 5/325 ordered for moderate pain at an intensity of 4 - 6.

In an interview on 06/03/15 at 2:45 p.m., S2CNE (Chief Nursing Executive) offered no explanation when informed that Patient #1's administration of Norco was not in accordance to the physician's order in relation to the nursing assessment based on the pain scale.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there's no adequate discharge planning as evidenced by failure to ensure each patient had a discharge planning assessment screen performed by the RN (registered nurse) at the time of admission as required by hospital policy for 2 (#1, #7) of 9 (#1 - #7) patient records reviewed for discharge planning from a sample of 9 patients.
Findings:

Review of the hospital policy titled "Discharge Planning", revised March 2015 and presented as a current policy by S11Dir Quality (Director of Quality), revealed that specific services are provided based on individual needs and available resources. The "High Risk Screening and Referral Guide" is utilized by the Case Management Department as a tool to assist in identifying those patients whose diagnosis, health problems, or psychosocial circumstances may indicated the need for additional services at discharge. Further review revealed that the primary nurse performs an initial assessment upon admission to include physical status, self-care needs, and psychosocial needs. Discharge needs or potential barriers to discharge are identified by the primary nurse during the initial assessment and throughout hospitalization will be referred to Case Management according to the Case Management Plan. Each case manager will review the medical record of assigned patients to assess high risk for discharge needs. A full assessment with patient interview will occur on all patients that meet criteria for "high risk" according to the High Risk Screening and Referral Guide (See Case Management Plan). Patients not meeting "high risk" criteria according to the High Risk Screening and Referral Guide will be reassessed at intervals during hospitalization for potential discharge needs.

Review of the hospital policy titled "Discharge Planning - Nursing", reviewed September 2014 and presented as current policy by S11Dir Quality, revealed that discharge planning will be initiated upon admission and continued throughout the patient's hospitalization by the RN.

Review of the hospital policy titled "Discharge Planning Assessment Screen", revised July 2014 and presented as a current policy by S11Dir Quality, revealed that each patient admitted to the hospital will be screened for discharge needs by the admitting RN. Information is gathered from chart review, patient interview, family interview, and interdisciplinary team members. If a patient is deemed high-risk, a referral is made to either a case manager or social worker. There was no documented evidence that the policy identified what constituted a patient to be considered high-risk. Further review revealed patients with complex discharge issues or who do not have an adequate social support system will be triaged to a social worker for assessment and/or intervention. This should include cases with complex psycho-social situations with complex discharge planning needs and/or patient/family conflicts; cases with clinical counseling/support as a primary need or concurrent issues; cases with neglect, abuse, domestic violence, adoption or factors involving legal statuses; cases with repeat admissions that may be the result of failure of a prior discharge plan.

Review of the "Document Screening Assessment", presented by S3Clinical Informatics as the computer screen shots included in the nursing admission and data forms completed by nursing at the time of admit, revealed the section titled "Case Management/Social Work Screening" included the following choices to select: None; Emancipated Minot; Failure to Thrive; Fetal/Infant Death; Infant Adoption; Medication Assistance; Mentally Deficit Parent; Needs Support at Home; New NH (nursing home) Placement; No Attachment to newborn; Non-Compliance with Mental health Treatment; Positive drug Screen; Prenatal Care Inadequate; Prenatal Care None; Prenatal Alcohol Use; Prenatal Drug Use; Primary Diagnosis Emotional Behavior Disorder; School Age (length of stay greater than 5 days); School Delinquent/Dropout; Suicide Attempt; Suicide Current Ideation; Teenage Parent (17 or below); Unable to return Home. Further review revealed the section titled "Discharge Planning" included prior living arrangements, living arrangements, support resources, name of agency services, probable disposition or services needed at time of discharge, and a section for comments.

No policy and procedure was presented throughout the survey when the policy related to the "High Risk Screening and Referral Guide" utilized by the Case Management Department was requested.

In an interview on 06/02/15 at 10:00 a.m., S14Dir Case Mgt (Director of Case Management) presented the computer screen of the "Document Screening Assessment" of the section titled "Case Management/Social Work Screening" when a request was made to see the "High Risk Screening and Referral Guide" referred to in the "Discharge Planning" policy. She confirmed that the hospital did not have a policy that addressed the information contained in the "Case Management/Social Work Screening" section of the computer screen shot.

Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of the admission assessment performed for Patient #1 by S4RN on 05/31/15 at 3:45 a.m. revealed no documented evidence that the discharge planning screening was addressed during the admission assessment.

Review of Patient #1's admission data obtained by S12LPN (Licensed Practical Nurse) revealed S12LPN conducted the discharge planning screening during her assessment of Patient #1.

In an interview on 06/03/15 at 8:05 a.m., S4RN confirmed he didn't perform Patient #1's discharge planning screening during the admission assessment that he performed.

Patient #7
Review of Patient #7's medical record revealed she was admitted on [DATE] and discharged on [DATE]. Further review revealed she had a Thoracentesis on 05/20/15 with placement of a PleurX catheter inserted on 05/23/15 that remained in place at discharge. Further review revealed she had no primary care physician (PCP).

Review of Patient #7's Admission Data collected by an LPN revealed no documented evidence that a discharge planning screening was performed by an RN at the time of admission.

In an interview on 06/03/15 at 9:15 a.m., S14Dir Case Mgt confirmed the discharge planning screening performed by the RN on admission did not include not having a PCP as a choice to select for probable disposition or services needed at the time of discharge. She indicated it should be included in the list to select, because this requires the services of the social worker or case manager for discharge planning.

In an interview on 06/03/15 at 11:45 a.m., S3Clinical Informatics confirmed that Patient #7 did not have a discharge planning screening by the RN at the time of her admission.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure the admitting RN (registered nurse) to assess the need for case management or social work screening during the admission assessment as required by hospital policy for 1 (#9) of 5 (#2, #6, #7, #8, #9) patient records reviewed for discharge planning evaluations from a sample of 9 patients. Patient #9 was a current inpatient who had been readmitted within 30 days of discharge.
Findings:

Review of the hospital policy titled "Discharge Planning - Nursing", reviewed September 2014 and presented as current policy by S11Dir Quality, revealed that discharge planning will be initiated upon admission and continued throughout the patient's hospitalization by the RN.

Review of the hospital policy titled "Discharge Planning Assessment Screen", revised July 2014 and presented as a current policy by S11Dir Quality, revealed that each patient admitted to the hospital will be screened for discharge needs by the admitting RN. Information is gathered from chart review, patient interview, family interview, and interdisciplinary team members. If a patient is deemed high-risk, a referral is made to either a case manager or social worker. There was no documented evidence that the policy identified what constituted a patient to be considered high-risk. Further review revealed patients with complex discharge issues or who do not have an adequate social support system will be triaged to a social worker for assessment and/or intervention. This should include cases with complex psycho-social situations with complex discharge planning needs and/or patient/family conflicts; cases with clinical counseling/support as a primary need or concurrent issues; cases with neglect, abuse, domestic violence, adoption or factors involving legal statuses; cases with repeat admissions that may be the result of failure of a prior discharge plan.

Review of Patient #9's medical record revealed he was admitted on [DATE] and had been admitted to the hospital within the last 30 days. As of 06/03/15, Patient #9 did not have a discharge planning evaluation performed by the social worker or case manager. Further review revealed no documented evidence that the section in the computerized admit assessment documentation had been completed by the RN for "Case Management/Social Work Screening".

In an interview on 06/03/15 at 1:15 p.m., S14Dir Case Mgt confirmed Patient #9 had not had a discharge planning evaluation performed as of the time of this interview. She indicated that he was a readmission within 30 days, and since he's in ICU (intensive care unit) and there was a social worker assigned to ICU, a discharge planning evaluation should have been performed.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the patient and family members were counseled to prepare them for post-hospital care as evidenced by:

1) Failing to provide in-hospital education on the use and care of the PleurX drain with which a patient was being discharged for 1 (#7) of 1 patient record reviewed with required in-hospital education from a sample of 5 (#2, #6, #7, #8, #9) patient records reviewed for discharge planning from a total sample of 9 patients and

2) Failing to provide a list of and educate patients on all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications for 4 (#2, #6, #7, #8) of 4 discharged patients whose records were reviewed for discharge planning from a sample of 9 patients.

Findings:

1) Failing to provide in-hospital education on the use and care of the PleurX drain with which a patient was being discharged :
Review of Patient #7's medical record revealed she was admitted on [DATE] and discharged on [DATE]. She had a PleurX catheter inserted on 05/23/15 with which she was discharged . Since Patient #7 had no insurance coverage, the hospital arranged for courtesy home health visits to assist with education on the care and management of the drain. Further review of the social worker's documentation revealed the home health agency requested that the hospital begin educating the patient and her family on the care and management of the drain, and they would continue after discharge. review of Patient #7's medical record revealed no documented evidence that education had been provided by the hospital's nursing personnel prior to discharge.

In an interview on 06/03/15 at 11:45 a.m., S3Clinical Informatics confirmed Patient #7 had no documented evidence in her record that she had received education by hospital personnel on the care and management of the PleurX drain prior to discharge.

2) Failing to provide a list of and educate patients on all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications:
Review of the medical records of Patients #2, #6, #7, and #8 revealed no documented evidence that they received a list of and were educated on the medications they should take after discharge with a clear indication of the changes from their pre-admission medications.

In an interview on 06/03/15 at 1:20 p.m., S3Clinical Informatics indicated the list of medications that the patient receives at discharge doesn't indicate the changes between the medications prescribed at discharge from what the patient was previously taking at home before admission.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on interview the hospital failed to ensure, as part of its reassessment of its discharge planning process, that identified factors that contribute to preventable readmissions resulted in revisions to discharge planning and related processes to address these factors.
Findings:

In an interview on 06/03/15 at 9:15 a.m., S14Dir Case Mgt (Director of Case Management) indicated they had identified that discharge instructions given to patients at the time of discharge could be improved as a means of addressing readmissions of patients within 30 days. She further indicated discussions were held during management meetings, but she had no documentation to present of such meetings. She further indicated no policies or procedures had been revised as a result of identifying this opportunity for improvement.