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.

WEST JEFFERSON MEDICAL CENTER 1101 MEDICAL CENTER BLVD MARRERO, LA 70072 Dec. 10, 2015
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation of Medical record Services as evidenced by:


Failing to ensure information from patients' medical records were released only to authorized individuals, that unauthorized individuals cannot gain access to or alter patient records, and that the entire medical record is not disclosed for a particular purpose unless the hospital can justify that the whole record is reasonably required for the purpose, as evidenced by:


The hospital provided individualized access (individual user name and password) to the hospital's entire electronic medical record system to 3 (S7, S15, S16) contracted individuals who are employed by Company A and 2 (S17, S18) contracted individuals who are employed by Company B. (see findings in tag A0441)
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on record reviews and interviews, the hospital failed to ensure information from patients' medical records were released only to authorized individuals, that unauthorized individuals cannot gain access to or alter patient records, and that the entire medical record is not disclosed for a particular purpose unless the hospital can justify that the whole record is reasonably required for the purpose as evidenced by:


The hospital provided individualized access (individual user name and password) to the hospital's entire electronic medical record system to 3 (S7, S15, S16) contracted individuals who are employed by Company A and 2 (S17, S18) contracted individuals who are employed by Company B.


Findings:


Review of the "Patient Rights Booklet," provided by S5DCM as the booklet presented to all patients at the time of their admission, revealed that patients had the right to be informed if the hospital has authorized other health care and/or educational institutions to participate in his/her treatment. Further review revealed the patient has the right to know the identity and function of these institutions and may refuse to allow their participation in his/her treatment. Further review revealed the patient has the right to the confidentiality of his/her clinical records, including computerized medical information. Review of the entire booklet revealed no documented evidence that the hospital included documentation that they had liaisons from Company A and Company B who had total access to the patients' electronic medical record while on-site and remotely.


Review of the "Home Health Services Agreement," presented as the agreement between the hospital and Company A by S5DCM, revealed that Company A agreed to accept and provide medically necessary home health services ordered by the patient's physician for those patients within the service area. Review of "Exhibit B Performance Expectations" revealed Company A shall ensure a seamless transfer to Company A by providing a home health liaison to process referrals and assist with the following: obtain needed information prior to the patient's acute care discharge for continuum of care; finalize arrangements for home health services within 1 hour of contact by the hospital's case management/discharge planner; coordinate visit times with the patient and/or family prior to the patient's acute care discharge; clearly and concisely document all arrangements in the patient's acute electronic medical record prior to the patient's acute care discharge.


Review of "Third Amendment To Acute Dialysis Services Agreement," presented as the agreement between the hospital and Company B by S5DCM, revealed that Company B will arrange for Company B's staff to assist the hospital to prepare and implement discharge plans for "Hospital Renal Patients." Further review revealed the hospital will provide Company B's staff a private space to work, access to a computer, phone, and printer, access to medical records of Renal Patients, in electronic format, remote access to electronic medical records of Renal Patients, and parking access.


In an interview on 12/07/15, at 2:10 p.m., S7Co.ALiaison indicated he is employed by Company A as a hospital liaison at West Jefferson Medical Center. He indicated he was based in the Case Management Department on the first floor of the hospital. S7Co.ALiaison indicated his role included the following: serves as a liaison reference for questions related to home health coverage from case managers, social workers, and discharge planners at the hospital; when a patient chooses Company A, he visits the patient after he has received the referral for home health, makes sure with the patient that they have chosen Company A, and prepares them for what will be needed at home after discharge. He further indicated he never goes into a patient's room soliciting business for Company A. He further indicated the only time he goes into a patient's West Jefferson Medical Center chart is when the patient has been referred to Company A. Observation during the interview revealed he was wearing a West Jefferson Medical Center badge that had "Contractor" printed on it. When asked why he was wearing a West Jefferson Medical Center badge if he was an employee of Company A, S7Co.ALiaison indicated he has a Company A badge downstairs. When asked how he determines whether he wears a West Jefferson Medical Center badge versus Company A badge, he indicated he usually wears both badges. He indicated the majority of his time (works Monday through Friday from 8:30 a.m. to 5:00 p.m.) is spent inputting data into the Company A system once he gets a referral. S7Co.ALiaison indicated twice (asked a second time to confirm) that he has access to "all" of West Jefferson Medical Center's electronic patient medical record data system which includes access to all West Jefferson Medical Center's patients' records.


In an interview on 12/08/15, at 1:05 p.m., S5DCM indicated the other 2 Company A home health employees who have access to the hospital entire electronic patient medical records is S15Co.ALiaison and S16Co.ALiaison.


In an interview on 12/09/15, at 12:50 p.m., S5DCM confirmed 3 Company A employees have their own log-in and password to access the hospital's electronic medical records. She indicated she checked with each employee who confirmed that they each have their own log-in and password to access the records.


In an interview on 12/09/15, at 11:15 a.m., S39System Engineer confirmed S7Co.ALiaison, S15Co.ALiaison, and S16Co.ALiaison have their own individualized access username and password to access the hospital's computerized medical record system.


In an interview on 12/09/15, at 1:20 p.m., a discussion was held with S5DCM and S6VPQ regarding liaison positions with Company A and Company B. S5DCM indicated Company A's staff does not handle any home health referrals other than those being referred to Company A. Both confirmed the Company B employee handles all renal dialysis patients, not just those referred to Company B. S6VPQ deferred to S2IHC to discuss confidentiality issues with contracted staff having access to the hospital's electronic medical record system.


In an interview on 12/09/15, at 2:40 p.m., S13HIM and S2IHC were asked about access to the electronic medical record by Company A and Company B staff: S13HIM indicated she was aware that these 5 employees of other agencies had access to to the hospital's electronic medical record system. She further indicated they were granted access under a confidentiality agreement and are supposed to only access info related to their patient seen at this facility for continuum of care. S13HIM indicated she wasn't aware of the agreement with Company B and further indicated she wasn't aware Company B staff had access to all renal patients of the hospital and not just Company B's patients. S2IHC indicated the definition of renal patient means hospital patients for which the hospital requests assistance in discharge planning. She further indicated that staff have no way of pulling specific renal patients' names, but both S13IHC and S13HIM confirmed they (contracted staff from Company A and Company B) do have access to all EMR as does every physician and nurse in the facility. S13HIM indicated she does weekly audits of access to EMR looking at different triggers that would cause further investigation (example, person with same last name, such as relative). She further indicated the audits will show what encounters a person went into and what they viewed. S2IHC indicated the hospital went into detail with the electronic medical record system to find out how they could limit access to individuals, but representatives of the electronic medical record system indicated the system is incapable of doing this, because it would impede health care.


In an interview on 12/09/15, at 3:50 p.m.,S19DCI indicated they have triggers set in place: same last name triggers, same employee name triggers, snooping triggers (same household, same close address). She further indicated the IT (Information Technology) department can run a report on a particular person for a particular day and can also set a specific report on someone that would not be a random report. S19DCI indicated she has been in her role as Director for about 10 years and has never been asked to set a specific report on the 5 contracted staff from Company A and Company B. S19DCI confirmed the 5 individuals have full access to patient documentation (physician notes, nurses' notes, referrals, consults), reviewing of lab & radiology results, and demographics. She further indicated these 5 individuals can access the system from off-site (if they know how to download the software to do so).
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Infection Control as evidenced by:


Failing to ensure the infection control officer assured the hospital's system for controlling infections and communicable diseases was implemented in accordance with hospital policy and AORN's standards of practice as evidenced by:



a) Failure to ensure IUSS was kept to a minimum and utilized in emergency situations when no replacement instruments are available as evidenced by having between 32 to 72 times per month from March 2015 through September 2015 that IUSS was performed. Review of documentation revealed 4 days in October 2015 that IUSS was utilized due to insufficient quantity of instruments in comparison to the number of surgical cases scheduled that required these particular instruments (see findings in tag A0749).


b) Failure to ensure that surgery staff, including employees, physicians, and contracted vendors, followed the hospital's policy and nationally accepted standards of practice such as the AORN's standards of practice for surgical attire in the OR as evidenced by observations of staff having exposed hair outside the surgical cap, having exposed facial hair not covered by a hood and/or mask, having a face mask hanging around the neck upon leaving the surgical suite, and having personal clothing exposed at the top of the scrub top (see findings in tag A0749).
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, record reviews, and interviews, the infection control officer failed to ensure the hospital's system for controlling infections and communicable diseases was implemented in accordance with hospital policy and AORN's standards of practice as evidenced by:


1) Failing to ensure IUSS was kept to a minimum and utilized in emergency situations when no replacement instruments are available as evidenced by having between 32 to 72 times per month from March 2015 through September 2015 that IUSS was performed. Review of documentation revealed 4 days in October of 2015 that IUSS was utilized due to insufficient quantity of instruments in comparison to the number of surgical cases scheduled that required these particular instruments.


2) Failing to ensure that surgery staff, including employees, physicians, and contracted vendors, followed the hospital's policy and nationally accpted standards of practice such as the AORN's standards of practice for surgical attire in the OR as evidenced by observations of staff having exposed hair outside the surgical cap, having exposed facial hair not covered by a hood and/or mask, having a face mask hanging around the neck upon leaving the surgical suite, and having personal clothing exposed at the top of the scrub top.


3) Failing to develop a policy that addressed how the hospital would handle a situation when there was a discrepancy between the device manufacturer's instructions and the instructions for the high-level disinfection and sterilization equipment.


4) Failing to ensure hand hygiene was performed in accordance with hospital policy as evidenced by observations of breaches in hand hygiene when cleaning Room "a" and during the prepping of Patient R1 for her surgical procedure.


5) Failing to maintain a sanitary environment as evidenced by having a soiled linen hamper located next to the scrub sink in OR, having an opened container of Hydrogen Peroxide Cleaner Disinfectant Wipes with an exposed wipe located on the Housekeeping cart outside Room "a", and having the lid to the garbage bin located outside Room "a" left in the up position.


Findings:


1) Failing to ensure IUSS was kept to a minimum and utilized in emergency situations when no replacement instruments are available:


Review of the hospital policy titled "Immediate Use Steam Sterilization," presented as a current policy by S5DCM, revealed that IUSS is to be kept at a minimum and may be utilized only in selected clinical situations and in a controlled manner. Further review revealed one instance was in emergency situations when no replacement instruments are available or when there is insufficient time to process by the preferred wrapped or container method.


Review of AORN Guidelines for Perioperative Practice, 2015 edition, revealed that IUSS should only be used when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. IUSS should not be used as a substitute for sufficient inventory.


Review of a graph of "Immediate Use steam Sterilization 2014/2015 Surgery," presented as view of the number of times IUSS was performed each month by S20DirOR, revealed the following data:

March 2015 - 72 times;

April 2015 - 32 times;

May 2015 - 46 times;

June 2015 - 69 times;

July 2015 - 59 times;

August 2015 - 53 times;

September 2015 - 58 times.


Review of the surgery schedules for 4 days in October (November data had not been compiled as of the time of review), presented and explained by S20DirOR, revealed the following days that IUSS was utilized due to insufficient quantity of instruments for the number of surgical cases scheduled in which the particular instruments were required:

10/13/15 - 4 laminectomy procedures were scheduled and performed with the hospital having only 3 sets of instruments, requiring IUSS for the 4th scheduled procedure;

10/14/15 - 2 lumbar laminectomies were scheduled and performed with the hospital having 1 instrument set that was required for these procedures, requiring IUSS for the 2nd scheduled procedure;

10/15/15 - 3 craniotomy procedures were scheduled and performed that required micro instruments with the hospital having 2 sets of instruments, requiring IUSS for the 3rd scheduled procedure;

10/28/15 - 3 procedures requiring a VP (Ventriculo-Peritoneal) Shunt set were scheduled and performed with the hospital having 1 set, requiring IUSS for the 2nd and 3rd procedures.


In an interview on 12/10/15, at 12:50 p.m., S20DirOR indicated the equipment having to be IUSS is due to the number of surgical cases scheduled without having the adequate number of instruments either owned by the hospital or able to be brought by vendors. She further indicated the cases are mostly orthopedic and neurological cases (such as spine cases).



2) Failing to ensure that surgery staff, including employees, physicians, and contracted vendors, followed the hospital's policy and nationally accepted standards of practice such as the AORN's standards for surgical attire in the OR:

Observations made on 12/10/15, in the OR revealed the following breaches in surgical attire in accordance with hospital policy and AORN's standard of practice:

9:20 a.m. - Observed 2 male staff leaving the OR suite with their face mask hanging around their neck; this observation was confirmed by S20DirOR;

9:25 a.m. - Observed S22NA wearing his face mask with his facial hair exposed; S20DirOR instructed S22NA to get a hood to cover his beard. S20DirOR confirmed that S22NA was waiting to enter Room "a" with his mask as it was with his facial hair exposed.

9:27 a.m. - Observed S22NA return wearing a different type of face mask with his facial hair exposed. Observation revealed S20DirOR instructed S22NA to get a hood, S22NA answered "what hood?" S20DirOR indicated S22NA had been an employee for about 2 months, and he "evidently had not been trained correctly."

9:33 a.m. - Observed S23ORAss't with his face mask not covering his facial hair.

9:35 a.m. - Observed S25Resident with his hair and beard not fully covered.

9:45 a.m. - Observed S24MD don a face mask to clean the anesthesia cart in Room "a" after the completion of a surgical procedure. Further observation revealed the edges of his hair and his facial hair was exposed.

10:10 a.m. - Observed S27Contractor with Company C in Room "a" with exposed facial hair. Further observation revealed S29PA had strands of hair exposed from her surgical cap.

10:15 a.m. - Observed S24MD had his sideburns and facial hair exposed while in Room "a". Further observation revealed the top of his T-shirt was exposed at the top of his scrub top. Further observation revealed S29PA and S31RN had their personal clothing exposed at the top of their scrub top. Observation revealed S31RN's sideburns were not covered by his surgical hat.

10:40 a.m. Observation in the Instrument Room revealed S32InstrTech, S33CInstrTech, and S34ST had hair exposed from their surgical cap. Further observation revealed S35InstrTech had sideburns exposed from his surgical cap.

All of the above observations were confirmed by S20DirOR who present at the time of each observation.


Review of the hospital policy titled "Attire in the Operating Room," presented as a current policy by S5DCM, revealed any and all persons entering the semi-restricted or restricted areas of the surgical suites, even for a brief period of time, shall cover all head and facial hair and don freshly laundered surgical attire or a single use jumpsuit (bunny suit) designed to completely cover outside apparel. All head and facial hair is to be covered while in restricted areas of the surgical suite. The surgical hat or hood is to be clean, free of lint, and confine the hair. Surgical staff wear disposable surgical bouffant or hoods. If they are wearing a linen head covering, they must don a disposable head covering over it. Surgical masks should cover the nose and mouth and are removed and discarded immediately after use.


Review of the AORN Guidelines for Perioperative Practice, 2015 edition, revealed that surgical masks should not be worn hanging down from the neck. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, and shirt sleeves which can be contained underneath the scrub top may be worn, but personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn. All personnel should cover head and facial hair, including the sideburns, the ears, and the nape of the neck, when in semi-restricted and restricted areas.


In an interview on 12/10/15, at 9:36 a.m., S20DirOR indicated someone from Infection Control comes monthly to observe for hair covering, but she doesn't think they address facial hair. S20DirOR indicated the hospital follows the AORN's standards of practice.


In an interview on 12/10/15, at 2:45 p.m., S37ICO indicated she makes observations in OR for hair covering, masks, surgical attire, and what's under clothing and what's over clothing of staff. She confirmed that she looks to be sure facial hair is covered. S37ICO offered no explanation for the number of breaches in surgical attire observed on 12/10/15 in the OR.



3) Failing to develop a policy that addressed how the hospital would handle a situation when there was a discrepancy between the device manufacturer's instructions and the instructions for the high-level disinfection and sterilization equipment:


In an interview on 12/10/15, at 2:20 p.m., S36EndoMgr indicated she didn't have a policy that addressed how discrepancies between the device manufacturer and the high-level disinfection equipment's instructions would be handled.


In an interview on 12/10/15, at 2:25 p.m., S20DirOR confirmed she didn't have a policy that addressed how discrepancies between the device manufacturer and the sterilization equipment's instructions would be handled.



4) Failing to ensure hand hygiene was performed in accordance with hospital policy guidelines:


Observation in Room "a" on 12/10/15 at 9:45 a.m. revealed S24MD gloved and cleaned the anesthesia equipment, removed his gloves at the completion of cleaning, and opened a drawer of the anesthesia cart to obtain a small bag of fluids without performing hand hygiene after removing his gloves. Further observation revealed S26AnesTech cleaned the surface of the anesthesia cart and the cart next to it while wearing gloves. While wearing the contaminated gloves, S26AnesTech opened an anesthesia circuit and attached it to the anesthesia machine to be used for the next patient.


Observation in Room "a" on 12/10/15, at 10:32 a.m. revealed S29PA prepped Patient R1's left knee while wearing sterile gloves. Further observation revealed she removed the sterile gloves after completing the prep and re-donned sterile gloves without performing hand hygiene.


Review of hte hospital policy titled "Hand Washing/Hand-Hygiene", presented as a current policy by S5DCM, revealed that all hospital personnel should always wash their hands before donning gloves and after removing gloves, before and after touching inanimate objects that are likely to be contaminated, and between direct contact with all patients.


In an interview on 12/10/15, at 11:03 a.m., S20DirOR confirmed the above observations were breaches in infection control and/or standards of practice.



5) Failing to maintain a sanitary environment:

Observation on 12/10/15, at 9:24 a.m. revealed a container of Hydrogen Peroxide Cleaner Disinfectant Wipes on the cleaning cart outside Room "a" with the container cap open and a wipe exposed at the top. S20DirOR indicated the container should be closed.


Observation on 12/10/15, at 9:40 a.m., revealed the soiled linen hamper was next to scrub sink. S20DirOR indicated the soiled linen hamper shouldn't be located next to the scrub sink.


Observation in Room "a" at the conclusion of a surgical procedure on 12/10/15, at 9:45 a.m., revealed S24MD applied a mask to clean the anesthesia cart. Further observation revealed he gloved and cleaned the anesthesia equipment, wiped the cords of the EKG (electrocardiogram) monitor and pulse oximeter probes with parts of the cords lying on the floor and then used same wipe to re-wipe the cords that had been lying on the floor. He then removed his gloves, took a small bag of fluids out the drawer of the anesthesia cart without performing hand hygiene after removing gloves. Continuous observation revealed S26AnesTech cleaned the surface of the anesthesia cart and the cart next to it while wearing gloves. While wearing the contaminated gloves, S26AnesTech removed and opened an anesthesia circuit and attached it to the anesthesia machine. Continuous observation revealed S22NA picked an item off the floor with gloved hands, walked to the side of the cleaned OR table, picked a second item off the floor, and touched the clean OR table with his contaminated gloved hands. Continuous observation revealed S23ORAss't, while gloved and mopping the floor, touched cleaned items (rolling carts, OR table) to move them out the way for mopping with contaminated gloves.


Observation on 12/10/15, at 10:10 a.m., revealed the garbage bin located outside Room "a" with the lid open.


In an interview on 12/10/15, at 11:03 a.m., S20DirOR confirmed the above-listed observations were breaches in infection control and/or standards of practice.
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 ensure the hospital's criteria and screening process for a discharge planning evaluation were correctly applied by responsible staff as evidenced by failure to document the type of requested DME (#3 - current inpatient) and to have a completed discharge planning evaluation (#6 - closed record) for 2 (#3, #6) of 6 patient records reviewed for discharge planning from a total sample of 6 patients.


Findings:


Review of the hospital policy titled "Post Hospital Care Services," presented as a current policy by S5DCM, revealed that arrangements for post-hospital care services are done by a Social Worker, Discharge Planner, and/or case Manager or a combination of the above. If the order is not specific as to the type of equipment or service needed, the case will be referred to the social worker or case manager for further investigation to identify the type of services needed. The Discharge Planner will then be notified of the type of services required as well as patient's vendor preferences and will proceed with arrangements.


Review of the hospital policy titled "Case Management Plan," presented as a current policy by S5DCM, revealed to provide consistent quality care across the continuum of care, patients are identified at an early stage of hospitalization who may benefit from planning for care after discharge. The Case Manager and/or Social Worker will perform an assessment of the patient, family, and support system that includes the following: collection and analysis of any relevant clinical information, functional status, situation status, social and personal history; identification of support systems available for either direct care of the patient or to provide additional support services; review an analysis of the current plan of care alternative treatment programs or delivery settings, revisions that may reduce resource usage, while promoting quality care and patient satisfaction; communication with all involved family/support/support systems in coordinating care to achieve desired outcome; case manager identifies opportunities for intervention to promote positive patient outcomes.


Review of the hospital policy titled "Triggers for Case Management Intervention," presented as a current policy by S5DCM, revealed that high risk and catastrophic cases which may trigger case management intervention include unplanned readmissions within one month.


Patient #3

Review of Patient #3's medical record revealed he was an [AGE] year old male admitted on [DATE]. Further review revealed DME was ordered, and the signed, faxed order was sent to the DME provider by S38DPC with no documented evidence of the type of DME that was ordered.


In an interview on 12/08/15, at 11:15 a.m., S5DCM indicated the social worker should have updated the discharge planning evaluation form. She further indicated S38DPC should have documented in Patient #3's progress notes what type of DME was ordered.


Patient #6

Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE]. Review of his "Discharge Planning Assessment" performed on 12/03/15 at 11:01 a.m. by S11SW revealed he was a readmit within 30 days (had a Radical Cystectomy in November 2015). Further review revealed no documented evidence of a completed discharge planning evaluation.



In an interview on 12/09/15, at 10:45 a.m., S5DCM confirmed the discharge planning evaluation was not completed appropriately by S11SW.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
Based on record reviews and interviews, the hospital failed to ensure 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 the likelihood of the patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he/she entered the hospital as evidenced by:


1) Failure to include assessments of the ability of the patient to perform ADLs, an assessment of the patient's and/or support person's ability to provide self-care/care, an assessment of whether the patient will require home and/or physical environment modifications, and whether the modifications can be made to safely discharge the patient to the previous setting for 6 (#1, #2, #3, #4, #5, #6) of 6 patient records reviewed for discharge planning from a total sample of 6 patients. Patients #2, #3, and #4 were current inpatients, and Patients #1, #5, and #6 were closed medical records.


2) Failure to ensure the evaluation included an assessment of the patient's post-discharge care needs being met in the environment from which he/she entered the hospital for 2 (#5, #6) of 6 medical records reviewed for discharge planning from a total sample of 6 patient records.


3) Failure to ensure the evaluation included an assessment of whether the patient required specialized medical equipment and if specialized medical equipment was required, it was available for 1 (#6) of 6 patient records reviewed for discharge planning from a total of 6 sampled patients.


Findings:


1) Failure to include assessments of the ability of the patient to perform ADLs, an assessment of the patient's and/or support person's ability to provide self-care/care, an assessment of whether the patient will require home and/or physical environment modifications, and whether the modifications can be made to safely discharge the patient to the previous setting:
Review of the hospital policy titled "Case Management Plan," presented as a current policy by S5DCM, revealed no documented evidence that the discharge planning evaluation included an assessment of the ability of the patient to perform ADLs, an assessment of the patient's and/or support person's ability to provide self-care/care, an assessment of whether the patient will require home and/or physical environment modifications, and whether the modifications can be made to safely discharge the patient to the previous setting.


Review of the medical records of Patients #1, #2, #3, #4, #5, and #6, who all required a discharge planning evaluation, revealed no documented evidence that their evaluation included an assessment of the ability of the patient to perform ADLs, an assessment of the patient's and/or support person's ability to provide self-care/care, an assessment of whether the patient will require home and/or physical environment modifications, and whether the modifications can be made to safely discharge the patient to the previous setting.


In an interview on 12/08/15, at 2:45 p.m., S5DCM confirmed the discharge planning evaluation did not include an assessment of the ability of the patient to perform ADLs, an assessment of the patient's and/or support person's ability to provide self-care/care, an assessment of whether the patient will require home and/or physical environment modifications, and whether the modifications can be made to safely discharge the patient to the previous setting.



2) Failure to ensure the evaluation included an assessment of the patient's post-discharge care needs being met in the environment from which he/she entered the hospital:
Review of Patient #5's and #6's discharge planning evaluations revealed no documented evidence of an assessment of whether their post-discharge needs could be met in the environment from which each of them entered the hospital.


In an interview on 12/08/15, at 2:45 p.m., S5DCM confirmed Patient #5's discharge planning evaluation didn't include an assessment of whether her post-discharge needs could be met in the environment from which she entered the hospital.


In an interview on 12/09/15, at 10:45 a.m., S5DCM confirmed Patient #6's discharge planning evaluation didn't include an assessment of whether his post-discharge needs could be met in the environment from which he entered the hospital.



3) Failure to ensure the evaluation included an assessment of whether the patient required specialized medical equipment and if specialized medical equipment was required, it was available:


Review of the hospital policy titled "Case Management Plan," presented as a current policy by S5DCM, revealed to provide consistent quality care across the continuum of care, patients are identified at an early stage of hospitalization who may benefit from planning for care after discharge. The Case Manager and/or Social Worker will perform an assessment of the patient, family, and support system that includes the following: collection and analysis of any relevant clinical information, functional status, situation status, social and personal history; identification of support systems available for either direct care of the patient or to provide additional support services; review an analysis of the current plan of care alternative treatment programs or delivery settings, revisions that may reduce resource usage, while promoting quality care and patient satisfaction; communication with all involved family/support/support systems in coordinating care to achieve desired outcome; case manager identifies opportunities for intervention to promote positive patient outcomes.


Review of Patient #6's discharge planning evaluation revealed no documented evidence of an assessment of whether Patient #6 would need specialized medical equipment and if any were needed, it would be available.


In an interview on 12/09/15, at 10:45 a.m., S5DCM indicated Patient #6's discharge planning evaluation was not completed in full by S11SW and did not include an assessment of whether he would need specialized equipment, and if so, whether it would be available at the time of discharge.
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 the patient's discharge plan at discharge and patients were counseled to prepare them for discharge as evidenced by:

1) Failing to ensure the physician's discharge orders for out-patient intravenous antibiotics post dialysis treatments were arranged as ordered by the physician for 1 (#1) of 1 patient record reviewed with physician orders for intravenous antibiotics post dialysis treatments from a total of 6 (#1, #2, #3, #4, #5, #6) patient records reviewed for discharge planning from a total sample of 6 patients.

2) Failing to ensure each patient received counseling to prepare them for discharge as evidenced by failure to provide complete discharge instructions to 1 (#6) of 6 patient records reviewed for discharge planning from a total sample of 6 patients.

Findings:

1) Failing to ensure the physician's discharge orders for out-patient intravenous antibiotics post dialysis treatments were arranged as ordered by the physician:
Review of the policy and procedure entitled, "Post Hospital Care Services, Case Management" presented as the current policy in place, revealed in part: Case Management staff members work collaboratively to arrange post hospital care services as indicated by the patient's discharge needs. (1) The referral is received in the Case Management department as noted above, after the physician's order is entered for a consult ...(ii) Once the preferred provider is known, the discharge planner will forward the referral to the provider of choice for coverage determination ...(1) The referral is made to that provider with the appropriate patient demographic and medical record information including the patient's physical and psychosocial status, a summary of care, treatment, and services provided to the patient, the patient's progress toward goals, and any other pertinent information related to the referral. (2) The Discharge Planner coordinates with that provider for the delivery and/or provision of equipment or services. (10) Case Management staff will be expected to research every discharge as they print out to ensure all Case Management consults/tasks have been addressed and any pending arrangements are finalized. (11) An assigned Case Management staff member will monitor the daily report of all Case Management consults from the day before to ensure all consults have been addressed or are in process. Weekend reports will be looked at on Mondays.

Patient #1 was a [AGE]-year-old male admitted on [DATE], and discharged on [DATE]. Patient #1's chief complaint was that he "had ingrown toenail removed in March and does not seem to be healing." diagnoses included [DIAGNOSES REDACTED]%); [DIAGNOSES REDACTED]; [DIAGNOSES REDACTED]; Coronary Artery Disease (with surgical history of Coronary Artery Bypass Graft for 3 vessels in 2004) and Cardiac Stent Placement (in 2005); AICD in situ (placement of an internal defibrillator for cardiac arrhythmia's); Severe Peripheral Vascular Disease; End Stage Renal Disease (receiving dialysis 3 times per week); Insulin Dependent Diabetes Mellitus; Hypertension; Sleep Apnea (for which he does not use his Continuous Positive Airway Pressure machine).

A review of the medical record for Patient #1 for the admission date of [DATE], revealed, in part: the discharging physician ordered "needs ceftazidime, 1 gram, after dialysis for 14 days; antibiotics can be given at dialysis center."

In an interview on 12/09/15, at 11:30 a.m., S5DCM confirmed the physician had ordered the ceftazidime to be given post dialysis on an outpatient basis for 14 days, and she also confirmed the physician's order had not been carried out by the Case Management Department, and Patient #1 did not receive the intravenous antibiotics for 14 days at the outpatient dialysis department.


2) Failing to ensure each patient received counseling to prepare them for discharge:

Review of the hospital policy titled "Discharge (Routine)," provided as a current policy by S5DCM, revealed that patient/family teaching at discharge included medications to be taken after discharge, medications not to be taken after discharge, follow-up care, signs and symptoms to report and how to report, activity, diet and any restrictions, and other post hospital activities/instructions. Further review revealed documentation should include educational materials provided including discharge instructions. The patient/caregiver's understanding of all discharge instructions should be documented, including activity and diet restrictions, diet at home, post-hospital treatments and medications, follow-up medical care, and signs and symptoms of [DIAGNOSES REDACTED]


Review of Patient #6's "Discharge Patient Summary" revealed his follow-up instructions included a follow-up medical appointment, instructions to contact Company A upon arrival home to arrange home health, and a list of medications to take and not to take. There was no documented evidence that he received educational materials that included signs and symptoms to report and how to report, activity, diet and any restrictions, and other post hospital activities/instructions.


In an interview on 12/09/15, at 10:45 a.m., S5DCM confirmed Patient #6 did not receive any educational materials at the time of his discharge that included signs and symptoms to report and how to report, activity, diet and any restrictions, and other post hospital activities/instructions.