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 Jan. 10, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure each patient, or when appropriate, the patient's representative, was informed of the patient's discharge rights in advance of discontinuing patient care as evidenced by failure of the rehab unit staff to provide a patient with a copy of the signed "An Important Message from Medicare" in advance of the patient's discharge, but not more than two calendar calendar days before the patient's discharge for 1 (#3) of 2 (#3, #5) closed medical records reviewed for patient notification of his/her discharge rights from a total sample of 5 patients.
Findings:

Review of the hospital policy titled "Notifying Medicare Beneficiaries of Their Discharge Appeal Rights", presented as a current policy by S1COO, revealed that the admitting department will be responsible for the initial delivery of the Important Message from Medicare. The Case Management Department will be responsible for the Follow-up (second notice) Important Message from Medicare. The procedure included that the admitting department will provide the patient with the notice within two calendar days if the patient is having an inpatient admission, or not more than 7 days prior to admission. Further review revealed the admitting department will explain the contents of the notice and assess the patient's ability to comprehend the notice. A signed copy of the Important Message from Medicare will be placed in the patient's medical record with a copy given to the patient. Further review of the policy revealed the Case Management Department will provide the second follow-up notice to the patient as required Monday through Friday. The nursing department assumes the responsibility on weekends and holidays. The second notice is to ensure the beneficiary is aware of his/her discharge appeal rights if he/she needs them. The second notice will be delivered in advance of discharge as possible, but not more than two days prior to the patient's discharge date . The hospital shall not routinely deliver the second notice on the day of discharge. When the patient's discharge date cannot be anticipated, the second notice shall be provided on the day of discharge, as early as possible, but a minimum of four hours before discharge.

Review of Patient #3's medical record revealed she was admitted on [DATE] and discharged on [DATE]. Review of her "An Important Message From Medicare About Your Rights" revealed Patient #3 signed the form on 08/04/16 at 3:45 p.m. and on 08/05/16 at 5:30 p.m. There was no documented evidence that a signed copy was presented to Patient #3 or her representative within two days prior to her discharge or at least 4 hours before discharge.

In an interview on 01/06/17 at 10:50 a.m., S8DMR presented the computerized version of the hard copy of Patient #3's medical record. After review of the computerized medical record, S8DMR confirmed a signed copy of the "An Important Message From Medicare About Your Rights" was not presented to Patient #3 at the time of discharge.

In an interview on 01/10/17 at 9:45 a.m. with S6RD and S20RNM present, S6RD indicated the nurses on the rehab unit are responsible for getting the "An Important Message From Medicare About Your Rights" upon admission to the rehab unit, because the admitting department staff don't come to the rehab unit to get the form signed. She further indicated the case manager is responsible for getting the second signature before discharge. She confirmed the the hospital policy was not followed, and Patient #3 or her representative did not receive a signed copy within 2 days of discharge or within 4 hours of discharge.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record reviews and interviews, the hospital failed to implement its grievance process as evidenced by:
1) Failing to ensure a grievance investigation was conducted in accordance with hospital policy and documented by S27CMO for 1 (#3) of 1 patient grievance reviewed from a total of 3 grievances documented from 08/01/16 to 01/05/17 related to the rehab unit and
2) Failing to handle complaints made by Patient #3's daughter regarding patient care that were discussed with and forwarded to Patient Relations by S21RNHS as a grievance for 1 (#3) of 1 patient's caregiver's documented complaint/grievance reviewed that was not handled as a grievance from a total sample of 5 patients.
Findings:

Review of the hospital policy titled "Patient Complaint And Grievance Policy", presented as a current policy by S1COO, revealed that if a verbal internal complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or required further actions for resolution, the the complaint is a grievance. The grievance process includes the the Patient Relations Manager will communicate with the patient/family to clearly identify their perception of the issue and discuss their expectation to resolve their complaint and ensure the patient/family that reporting of the complaint will not compromise present or future access to healthcare. The Director/Manager will respond to the complaint via MIDAS within 5 business days. An initial letter will be sent to the patient and/or representative acknowledging receipt of the grievance. This letter can either indicate that the concern has been resolved or that the concern is under investigation, depending on the status. Every effort will be made to review and resolve the grievance within 7 days. If an investigation exceeds 7 days or a grievance will not be resolved within 7 days, the hospital will inform the patient or the patient's representative that the hospital is still working on the grievance and the the hospital will follow-up with a written response within 30 days. Review of the entire policy revealed no documented evidence that the policy addressed the steps to be taken to investigate the grievance, including which staff is responsible for the investigation.

1) Failing to ensure a grievance investigation was conducted in accordance with hospital policy and documented by S27CMO:
Review of the Grievance Log from 08/01/16 to 01/05/17, presented by S5PR, revealed the hospital had received 3 grievances. Further review revealed a grievance had been received from the family of Patient #3 with an event date of 08/19/16, the event type listed as "Standards of Behavior", the event parameter listed as "HIPAA (Health Insurance Portability and Accountability Act) Violation Standards - Communication Standards - Physician Skills/Behavior", the outcome listed as "Listen/Support Unable to Contact Phone Call Interdepartmental Resolution Letter", and the status was listed as closed.

Review of the "Grievance Tracker" related to the grievance submitted by Patient #3's daughter, presented by S3ICNE, revealed the grievance was received on 08/19/16, the investigation was initiated on 08/19/16, the 7 day letter was sent on 08/22/16, and the grievance was closed on 09/20/16.

Review of the "Patient Relations Event Worksheet", presented by S3ICNE, revealed a grievance was received on 08/19/16 from Patient #3's family for an event that occurred on 08/18/16. Documentation on 08/19/16 at 10:46 a.m. revealed no documented evidence of the author of the entry that read as follows: daughter of Patient #3 came to speak with S6RD on 08/18/16 at approximately 5:30 p.m. in regards to S10DO calling her mother "crazy" and discussing her care in front of non family members and another patient in the semi-private room; the daughter stated S10DO was very unprofessional by stating "I heard you been acting crazy." Further review revealed the daughter did speak with S10DO immediately about the incident outside the room but wanted to take it further by filing a formal grievance against S10DO. Further review revealed S5PR attempted to call the daughter at the number provided and received a message that the voice mail had not been set up yet. S5PR submitted the concerns to the privacy team and referred it to S27CMO.

Review of the "Patient Relations Event Worksheet" revealed an entry by S5PR on 08/19/16 at 12:25 that read as follows: the initial complaint was a non-patient complaint. The below details are copied from that event. S5PR advised the rehab staff on the proper way to enter these type incidents under the patient name. She also verified with S6RD that it sounded like the family is concerned about privacy and standards of behavior regarding how the physician communicated to the family and patient, and the entry doesn't reveal any care concerns. S5PR referred the case to HIM (Health Information Management) and the Chief Medical Officer for review. Privacy concerns are routed through the privacy officer.

Review of the "Patient Relations Event Worksheet" revealed an entry by S27CMO on 08/22/16 at 11:08 a.m. that read as follows: I have investigated and found this to be a misunderstanding. This was a casual comment not meant in a derogatory manner. Semi-private rooms are at risk for privacy concerns.

Review of the "Patient Relations Event Worksheet" revealed an entry by S5PR on 08/22/16 at 7:05 p.m. that read as follows: grievance letter sent to patient outlining Chief Medical Officer involvement; closing case for grievance on 08/22/16. Will follow-up with S27CMO if any further actions are necessary.

Review of the "Patient Relations Event Worksheet" revealed an entry by S5PR on 08/23/16 at 5:25 p.m. that read as follows: learned on 08/23/16 that patient had been discharged ; attempted to see her and hand deliver the resolution letter but missed her by about 30 minutes; S6RD indicated that patient was aware a formal report had been made but she was ready to go home.

Review of the "Patient Relations Event Worksheet" revealed an entry by S5PR on 09/19/16 at 7:16 a.m. read as follows: S5PR followed up with S27CMO to ensure no follow-up was necessary regarding S10DO for the grievance committee review; he confirmed no follow-up was necessary.

Review of the entire information presented by S3ICNE revealed no documented evidence that S5PR had communicated with Patient #3's daughter as required by the policy, the investigation that took place, and any information from the review by the privacy officer.

In an interview on 01/09/17 at 11:35 a.m. with S6RD and S10DO present, S10DO indicated he had received calls from the nurses on the rehab unit for 2 nights in a row about things going on with Patient #3. He further indicated it didn't sound like Sundowner's or hallucinations, but she did have some confusion. After the second call, S10DO indicated he went to evaluate the patient. He further indicated one or two of Patient #3's daughter were present when he he told Patient #3 "I'm trying to figure out these crazy things going on that nobody can figure out." He further indicated that immediately one of the daughters asked him who had said Patient #3 was crazy. S10DO indicated he told the daughter he had used poor judgment of words and apologized to the daughter and patient.

In an interview on 01/09/17 at 12:50 p.m. with S6RD, S5PR, and S17RDRC present, S5PR indicated she never met with or spoke to Patient #3's daughter. She further indicated that when she went to see them on 08/23/16, the patient had been discharged . She confirmed that the information documented in the worksheet was related to her by S6RD. S5PR indicated physician-related concerns are routed to S27CMO to investigate. She further indicated that S27CMO did not present any documentation of his investigation to her.

In an interview on 01/09/17 at 3:40 p.m. with S27CMO and S6RD present, S27CMO indicated he didn't have any documentation of the investigation he conducted related to the grievance submitted by Patient #3's daughter related to comments made by S10DO. He further indicated sometimes he makes notes for himself when he's talking to persons involved, but he doesn't recall making any separate notes for this grievance. He indicated that generally when there's a physician-related complaint, it is presented to him for review and investigation. He further indicated he looks into it, reviews the record, speaks to the parties involved, and documents back to S5PR what he's found. He further indicated he has a "vague recollection of having spoken with S10DO." S27CMO indicated S10DO said that the daughter said he (S10DO) had said that Patient #3 was acting crazy, but it wasn't said as a "psychiatric crazy." He further indicated that S10DO felt it was taken the wrong way by the family. S27CMO indicated he didn't speak with any nurses who were present during S10DO';s conversation, and he didn't speak with Patient #3's daughter.

2) Failing to handle complaints made by Patient #3's daughter regarding patient care that were discussed with and forwarded to Patient Relations by S21RNHS as a grievance:
Review of a typed report presented by S21RNHS revealed on 08/22/16 at approximately 5:45 p.m., he was called to the rehab unit to speak with Patient #3's daughter who asked to speak in the gym for privacy. Further review revealed Patient #3's daughter discussed the recent unwitnessed fall of her mother on 08/22/16 and reported that her mother had been repeatedly found to have soiled diapers and was in need of frequent toileting breaks. She further reported that sometimes it has been up to 6 hours since her mother was offered a bathroom opportunity. He documented that Patient #3's daughter reported that the nurses were making rounds every 2 hours, but the techs were not. Further review revealed an e-mail was sent by S21RNHS with no documented evidence to whom the e-mail was sent.

In an interview on 01/10/17 at 8:25 a.m. with S21RNHS and S17RDRC present, S21RNHS presented the above-mentioned documentation and indicated he had met with Patient #3's daughter and sent the above-mentioned documentation to S5PR.

In an interview on 01/09/17 at 12:50 p.m. with S6RD, S5PR, and S17RDRC present, S5PR indicated no other grievance was brought to her attention by any staff member while discussing the grievance submitted related to remarks made by S10DO.

In an interview on 01/10/17 at 10:05 a.m. with S5PR, S6RD, and S17RDRC present, S5PR confirmed that she did not handle the above-mentioned documentation from S21RNHS as a grievance. She further indicated she not done so, because she felt that S21RNHS had handled it with the plan that he put in place. She further indicated she didn't view Patient #3's daughter's complaints as a grievance.

In an interview on 01/10/17 at 10:20 a.m., S17RDRC indicated she was not aware of Patient #3's daughter's complaints that were documented by S21RNHS until the documentation was discussed in the above interview with S5PR. She confirmed that the complaints issued by Patient #3's daughter should have been handled as a grievance.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record reviews and interview, the hospital failed to ensure in its resolution of a grievance it provided the patient with written notice of its decision that contains the name of the contact person, the steps taken in behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion as evidenced by failure of the resolution letter submitted to Patient #3 to have the name of the contact person, the steps taken in behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion for 1 (#3) of 1 patient grievance reviewed from a total of 3 grievances documented from 08/01/16 to 01/05/17 related to the rehab unit.
Findings:

Review of the hospital policy titled "Patient Complaint And Grievance Policy", presented as a current policy by S1COO, revealed the Director/Manager will respond to the complaint via MIDAS within 5 business days. An initial letter will be sent to the patient and/or representative acknowledging receipt of the grievance. This letter can either indicate that the concern has been resolved or that the concern is under investigation, depending on the status. Every effort will be made to review and resolve the grievance within 7 days. If an investigation exceeds 7 days or a grievance will not be resolved within 7 days, the hospital will inform the patient or the patient's representative that the hospital is still working on the grievance and the the hospital will follow-up with a written response within 30 days. Review of the entire policy revealed no documented evidence that the policy addressed the required content of the resolution letter including the name of the contact person, the steps taken in behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion.

Review of the resolution letter sent to Patient #3 on 08/22/16 by S5PR revealed no documented evidence that the letter included the name of the contact person, the steps taken in behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion.

In an interview on 01/09/17 at 12:50 p.m. with S5PR, S6RD, and S17RDRC present, S5PR confirmed the hospital's grievance policy did not include what content was to be included in the resolution letter. She confirmed the resolution letter sent to Patient #3 did not include the content required by the federal certification regulations.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by failure of the RN to assess a patient after a fall for 1 (#3) of 2 (#3, #5) patient records reviewed for an RN assessment after a fall from a total sample of 5 patients.
Findings:

Review of the policy titled "Admission Of Patient - Initial Assessment And Reassessment" revealed that each patient is reassessed when a significant change occurs in the patient's condition or diagnosis and following a fall. Rapid Response Nurses are to be notified for changes in vital signs, oxygen saturation, level of consciousness, and changes in condition including falls. Reassessments may be performed by a RN or LPN.

Review of a "Risk Events Summary Rep[ort" revealed Patient #3 had an unwitnessed fall on 08/22/16 at 3:55 p.m. Further review revealed Patient was in her wheelchair with the seat belt on when she told S11LPN and her daughter that she did not want to go back to bed. Both S11LPN and the daughter left the room. S19CNA found patient on the floor. Staff assisted patient back to bed and denied pain. Physician, daughter, house supervisor, rapid response team, charge nurse, and manager were notified.

Review of S11LPN's Nurse Notes on 08/22/16 at 4:06 p.m. revealed she was notified that Patient #3 fell out her wheelchair onto the floor.

Review of S26MD's Progress Note documented on 08/22/16 at 5:37 p.m. revealed patient had a fall reported today. She can't give me any details but denies pain.

Review of a computerized log presented by S3ICNE revealed an entry of "S9RN's name 205 (patient's room number) - pt (patient) fell out of wheel chair in room. No injuries."

Review of Patient #3's entire medical record for 08/22/16 with S6RD revealed no documented evidence that Patient #3 had documentation of an RN assessment after the fall or had any imaging services ordered.

In an interview on 01/06/17 at 9:30 a.m. with S3ICNE and S6RD present, S3ICNE confirmed it has been the practice of the hospital that reassessments for a change in condition and after a fall to be done by either a LPN or an RN. After reviewing patient #3's medical record, S6RD confirmed there was no documented evidence that Patient #3 had been assessed after the fall on 08/22/16 by a LPN or an RN, and no imaging services were ordered after the fall. She further indicated the rapid response nurse who was called is always an RN (an intensive care unit RN).

In an interview on 01/06/17 at 11:15 a.m., S3ICNE indicated she spoke by telephone with S9RN who saw Patient #3 as the rapid response nurse. She further indicated S9RN was out of town and not available for interview. She indicated S9RN reported that he thinks he was called away to another emergency and didn't document an assessment.
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 implement a patient's discharge plan by counseling the patient and family members to prepare them for post-hospital care that included a list of all medications that the patient should be taking after discharge with clear indication of the changes from the patient's pre-admission medications as evidenced by failure to have family education for post-hospital care completed when a patient was abruptly discharged on [DATE] and failure to provide a list of medications that were to be taken after discharge that clearly indicated the changes from the patient's pre-admission medications for 1 (#3) of 2 (#3, #5) closed patient records reviewed for implementation of the discharge plan from a total sample of 5 patients.
Findings:

Review of the policy titled "Discharge Planning For Inpatient Physical Rehab Unit", presented as a current policy by S6RD, revealed that effective and timely discharge planning will be used, and case managers will coordinate discharge planning and work with the interdisciplinary team to identify potential barriers to discharge. A goal of discharge planning is to provide education and information to the patient/family or other caregivers regarding potential discharge services. The Case Manager communicates the expected discharge date to the team during the weekly team conference. Patient teaching, family training, and recommendation for follow-up services and equipment will be incorporated based on the established discharge plan. The Case Manager will coordinate with the patient and family the discharge date and time as well as transportation to assure a smooth transition.

Review of the policies titled "Discharge Planning" and "Discharge Planning For Inpatient Physical Rehab Unit" revealed no documented evidence that an explanation relative to the list of medications prescribed at the time of discharge with a clear indication of the changes from the patient's pre-admission medications was included in either policy.

Review of the policy titled "Independence Day", presented as a current policy by S6RD, revealed that the day before discharge, the patient will be expected to practice all of the skills that they have learned with as much independence as they are able. Associates will assist with any functional care needs the patient is unable to perform independently. Two days prior to discharge, the patient will be encouraged to perform as many ADLs (activities of daily living) and mobility tasks as possible to help prepare them for discharge.

Review of the most recent "Team Conference Family Summary Report" conducted on 08/16/16 revealed Patient #3 had increased confusion in the evening after supper and became more fidgety and tried to get. She required moderate assist with transfers. Her anticipated date of discharge was 08/26/16.

Patient #3 was ordered to be discharged by S26MD on 08/23/16 at 12:33 p.m.

Review of documentation by S16RNCM on 08/23/16 at 9:48 a.m. revealed that S10DO came to the case management office and informed the case managers that Patient #3 would be discharged this day (08/23/16). Options were to be discharged with home health, discharged to a skilled nursing facility, or discharged to another rehab facility. Further review revealed she informed the PT, OT, and SLP, and S12PT offered family training. Patient #3 was a minimal assist and needed 24/7 (24 hours a day 7 days a week) caregiver presence for safety.

Review of S28PT's note on 08/23/16 at 2:30 p.m. revealed Patient #3 was confused and accompanied to therapy with her son. Further review revealed she would be discharged following the therapy session. Patient #3 was able to ambulate 150 feet continuous but was fatigued at the end of the trial and needed minimum to moderate assistance for balance, left side neglect, and steering of the rolling walker.

Review of S14SLP's note on 08/23/16 at 11:15 a.m. revealed Patient #3 was seen for cognitive linguistic reorganization and dysphagia intervention in the therapy room. Multiple family members were present, and Patient #3 was to be discharged this day. S14SLP documented that Patient #3 was "extremely confused today and definitely not acting like herself. Family agreed and stated she is upset that she is leaving." S14SLP administered the mini mental state evaluation, and she scored a 15/30 (severe).

Review of Patient #3's "Discharge Home Medication List" revealed no documented evidence that the list provided a clear indication of the changes from the patient's pre-admission medications.

In an interview on 01/06/17 at 10:30 a.m., S6RD indicated Patient #3's daughter spoke with her about concerns she had regarding a conversation S10DO had with her mother. She further indicated the daughter told her she was filing a grievance against S10DO related to the conversation.

In an interview on 01/09/17 at 11:35 a.m., S10DO indicated after Patient #3's daughter had discussed her concerns about him calling her mother "crazy", he arranged for S26MD to take over the care of Patient #3. He further indicated he did not agree with what S16RNCM documented related to the morning of 08/23/16. He indicated he didn't remember saying what was documented. He further indicated he may have been in the case manager's office discussing other patients when Patient #3 was being discussed.

In an interview on 01/09/17 at 1:10 p.m. with S12PT and S6RD present, S12PT indicated she saw Patient #3 for therapy on the day of her discharge. She further indicated she wasn't aware that she was being discharged at the time of her first session that day, but by the time of her second session, she had been told about the discharge. She further indicated that after reviewing her notes, it looked like the discharge had not been planned for that day. S12PT indicated she did family education with Patient #3's son on the day of discharge, but Patient #3 refused family training that would include her and her family that day, so she trained the son alone. After reviewing her notes, S12PT indicated some observation by family was done on 08/09/16 (son) and 08/21/16 (daughter). She confirmed that there wasn't a lot of education provided to the family prior to the day of discharge. She indicated she wasn't aware of a team meeting to discuss Patient #3's earlier than planned discharge.

In an interview on 01/09/17 at 1:30 p.m. with S13OTR and S6RD present, S13OTR indicated she provided therapy to Patient #3 on the day of her discharge on 08/23/16. She further indicated she wasn't aware that she was being discharged that day. After reviewing the medical record, S13OTR indicated Patient #3's son was present on 01/18/16 for a portion of one of her ADL (activities of daily living) sessions that included grooming tasks and how the patient needed verbal cues on how to place toothpaste on her toothbrush, and some education was provided on 08/05/16, 08/08/16, and 08/12/16. S13OTR indicated normally there's more family education documented before a patient is discharged . After reviewing her discharge summary for Patient #3, S13OTR indicated the following goals were not met at the time of discharge: feeding independently; grooming (still required set up for grooming); bathing with supervision and adaptive equipment (still required assistance with standing for balance); lower body dressing; upper body dressing.

In an interview on 01/09/17 at 1:55 p.m. with S14SLP and S6RD present, S14SLP indicated patient #3's mini mental state evaluation had declined at the time of discharge from the initial one performed. She further indicated she wasn't aware Patient #3 was being discharged on [DATE]. After reviewing Patient #3's discharge summary that she had documented, S14SLP indicated the following: swallowing scored lower this day, because she wouldn't eat anything for the therapist and her son had to feed her; receptive language goal was not met; memory was decreased because of her mini mental state evaluation, and she was confused; problem solving remained at the level of admit (unaware of deficits and limitations and at risk for fall).

In an interview on 01/09/17 at 2:45 p.m. with S15RNCM and S6RD present, S15RNCM indicated she was in the case management office when S10DO entered and informed her and S16RNCM that Patient #3 was being discharged . She further indicated S16RNCM called Patient #3's daughter to notify her of the discharge and then spoke with the therapists to see what assistance would be needed post-discharge. She further indicated usually a team conference is conducted when a patient's discharge changes from what was estimated as the discharge date . S15RNCM indicated a team conference was held on 08/16/16 and again on 08/23/16. She further indicated when Patient #3's name came up at the conference on this day (08/23/16), S10DO said Patient #3 didn't need to be discussed, since she was leaving that day. She further indicated S10DO told her that Patient #3 had plateaued in therapy, but S16RNCM had spoken with all the therapists and noted what they told her.

In an interview on 01/09/17 at 3:05 p.m. with S16RNCM and S6RD present, S16RNCM confirmed she was the person who called Patient #3's daughter to inform her of her mother's discharge on 08/23/16. She further indicated she remembered S10DO coming into the office and saying that Patient #3 was being discharged that day, and at that point S10DO didn't say why she was being discharged before her estimated day of discharge of 08/26/16. She indicated she then went to each therapist to determine what level they were at with Patient #3. The therapists told her Patient #3 required 24/7 family present, follow-up service, and told her what equipment was needed. S16RNCM indicated it was a "hard deal for us in the case management office." She further indicated it was hard to call that daughter, "and I did what I had to do in that situation." She indicated she was she felt she was having difficulty doing what was best for Patient #3. She further indicated she felt that Patient #3 could have benefited by staying longer. S16RNCM indicated she was present when S10DO spoke with Patient #3's daughter. She indicated she remembered that the daughter asked whether mother's discharge was accelerated and asked if it was because of what had occurred between them. S16RNCM indicated S10DO informed the daughter that the therapists had said the therapists had said Patient #3 had plateaued, but it struck her as not the truth, because that's not what anyone had reported to her.

In an interview on 01/09/17 at 3:55 p.m. with S26MD and S6RD present, S26MD indicated he was asked by S10DO to take over the care of Patient #3. He further indicated he wasn't aware her estimated discharge date was 08/23/16. He further indicated he doesn't give the discharge date . S26MD indicated he's not a rehab doctor but an internist. He further indicated he understood there some conflict between the family and S10DO. When informed of Patient #3's status as related in previous interviews with therapists who provided her care, S26MD indicated he wasn't aware of this information. He further indicated he wrote the discharge order, and it;s his responsibility, but as a non-physiatrist, he's dependent on the team to let him know when a patient is ready for discharge. He further indicated he doesn't remember if he spoke with the therapists before he wrote the order for discharge.

In an interview on 01/10/17 at 9:00 a.m., S17RDRC indicated they discuss medication reconciliation verbally with patients, but they do not give a list of prior home medications with the discharge medication list to prevent confusion. She further indicated the medication list given to patients specifically state which medications to take and which medications not to take.

In an interview on 01/10/17 at 1:00 p.m. with S6RD and S17RDRC present, both confirmed Patient #3's a list of home medications was not provided to Patient #3 at the time of discharge that included a clear indication of changes from what was taken prior to her hospitalization . S17RDRC indicated the computer system changes the medications as changes are made throughout the hospital stay. She confirmed that she could not provide an accurate list of medications that Patient #3 was taking prior to her hospitalization .