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.

SSM HEALTH DEPAUL HOSPITAL ST LOUIS 12303 DEPAUL DRIVE BRIDGETON, MO 63044 July 11, 2012
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review and interview the facility's discharge plan failed to evaluate the patient's ability to provide self care in one (Patient #1) of four records reviewed when it failed to evaluate the patient's ability to manage care of his Diabetes (uncontrolled high blood sugar) and failed to recommend community support services. The facility census was 336.

Findings included:

1. Record review of the facility policy titled "Discharge Planning at Adult Acute Care Facilities", original date 03/95, revision date 07/11 gave the following direction:
-Discharge planning will begin upon admission with an assessment of each patient's potential continuing care needs.
-Appropriate referrals for social service support will be initiated as soon as the need is identified. This includes nursing home placements, guardianships, supportive counseling, possible abuse, assistance with activities for daily living (ADL - ability to: prepare meals, bathe, dress, provide personal hygiene) or other needs.
-Along with the collaboration of the physician and the multidisciplinary team, case management develops a plan of action to facilitate discharge. This includes alternative level of care, home health, home therapies, home medical equipment, home intravenous infusion, hospice or other needs.
-Case management ensures all discharge planning arrangements are completed prior to discharge.
-Throughout the patient's hospitalization , case management documents the discharge plan in the patient's medical record.

2. Record review of Patient #1's clinical record showed:
-A history and physical dated 05/23/12 at 8:17 PM showed the patient had complaints of nausea, vomiting and abdominal pain with an elevated blood sugar. The patient had a history of Diabetes Mellitus (a disease resulting in elevated blood sugars). The patient stated he hasn't been taking his home insulin for unclear reasons. He had abdominal pain and nausea this morning. Emergency Medical Services (EMS) brought the patient to the emergency room (ER) with a reported blood sugar of 501 mg/dL (the facility's lab report showed normal lab reference for blood sugar ranges from 74 - 106 mg/dL (milligram/deciliter, both are a unit of measure).
-The facility lab report of 05/23/12 showed a blood sugar of 342 mg/dL.
-The patient's admitting diagnosis included nausea and vomiting; diabetic gastroparesis (a condition that reduces the ability of the stomach to empty its contents, but there is no blockage); and Diabetes Mellitus Type I (Type 1 diabetes is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar to enter cells to produce energy.)

3. Review of a physician consultation report on 05/25/12 at 3:53 PM, by an endocrinologist (a physician who specializes in treating disorders of the endocrine system, such as diabetes) showed: "Type I Diabetes is uncontrolled due to the lack of usual therapy including his compliance with a prescribed regimen. Various options were discussed in an effort to find out the reason for the patient's compliance issues. It appears that he may benefit from psychiatric evaluation while in the hospital."

4. Review of case management notes for Patient #1 showed the following:
-05/24/12, 12:57 PM, the case manager attempted to interview the patient for the initial case management screening but he refused to talk to the Case Manager. The Case Manager attempted to interview the patient later that day, but he continued to refuse.
-05/25/12, 8:32 AM, the case manager reviewed the medical record and plan of care.
-05/25/12, 9:39 AM, the patient is now complaining of being too ill to be discharged . The case manager entered a note in the medical record requesting the physician to notify the patients' attending physician if ongoing inpatient stay is needed.
-05/25/12, 9:48 AM, after two days the patient agreed to meet with the Case Manager to discuss discharge planning. He was very lethargic (a state of sluggish inactivity with lack of interest in doing anything) and seemed depressed. He has remained in bed since admission with entire body and head under the blankets. The case manager discussed plan of care, level of service, discharge needs and discharge time with the patient. Prior to admission the patient lived alone in an apartment. He said he needed transport home and was agreeable to taking the bus. The case manager spoke with the physician who will see the patient later today and discharge the patient.

5. Review of physician note dated 05/25/12 at 1:45 PM, showed the patient was doing better, able to keep lunch down and ready for discharge.

6. Review of the physician discharge summary dated 06/19/12, for Patient #1 showed:
-The patient has had multiple admissions for uncontrolled blood sugar due to non-compliance;
-Discharge to home, with diet and medication instructions provided along with signs and symptoms to report to the physician; and
-discharge date of [DATE].

7. The facility failed to make appropriate discharge plans for Patient #1 when the discharge evaluation failed to assess the patient for:
-In hospital diabetic education;
-Ability to perform blood sugar checks
-Ability to correctly draw up insulin (a medication to control blood sugar);
-Ability to appropriately inject the insulin; and
-Home health care visits after the patient's discharge to home.

The facility failed to make appropriate discharge plans for Patient #1 when the discharge planning failed to:
-Show the case manager followed up with the recommendation by the physician for a psychiatric evaluation while the patient was in the hospital; and
-Evaluate the patient for a community support referral for psychological services.

8. During an interview on 07/11/12 at 10:34 AM, Case Manager, Staff N, stated that the patient may have benefited from:
-Diabetic education;
-Evaluation of ability to perform blood sugar checks;
-Ability to correctly draw up insulin in a syringe and administer the injection;
-Psychological evaluation with continued community psychological services; and a
-Referral to home health care for diabetic care and psychological support.
The case manager offered no explanation as to why the above services were not part of the discharge evaluation and discharge planning.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to reassess the patient's needs for home health care and community psychological support
for one patient (#1) of four records reviewed.

The facility census was 336.

Findings included:

1. Record review Patient #1's clinical record showed:
-The physician history and physical on 05/23/12 at 8:17 PM showed the patient had complaints of nausea, vomiting and abdominal pain with an elevated blood sugar. The patient had a history of Diabetes Mellitus (a disease resulting in elevated blood sugars). The patient stated he hasn't been taking his home insulin for unclear reasons. He had abdominal pain and nausea this AM. Emergency Medical Services (EMS) brought the patient to the emergency room (ER) with a reported blood sugar of 501 mg/dL (the facility's lab report showed normal lab reference for blood sugar ranges from 74 - 106 mg/dL (milligram/deciliter, both are a unit of measure).
-The facility lab report of 05/23/12 showed a blood sugar of 342 mg/dL.
-The patient's admitting diagnosis included nausea and vomiting; diabetic gastroparesis (a condition that reduces the ability of the stomach to empty its contents, but there is no blockage); and Diabetes Mellitus Type I (Type 1 diabetes is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar to enter cells to produce energy).

2. Review of a physician consultation report on 05/25/12 at 3:53 PM, by an endocrinologist (a physician who specializes in treating disorders of the endocrine system, such as diabetes) showed: "Type I Diabetes is uncontrolled due to the lack of usual therapy including his compliance with a prescribed regimen. Various options were discussed in an effort to find out the reason for the patient's compliance issues. It appears that he may benefit from psychiatric evaluation while in the hospital."

3. Review of the Case Manager's notes dated 05/25/12, showed that after two days the patient agreed to meet with the Case Manager to discuss discharge planning. He was very lethargic (a state of sluggish inactivity with lack of interest in doing anything) and seemed depressed. The Case Manager discussed plan of care, level of service, discharge needs and discharge time with the patient. Prior to admission the patient lived alone in an apartment. He said he needed transport home and was agreeable to taking the bus.

4. Review of the physician discharge summary dated 06/19/12 at 1:18 PM, for Patient #1 showed:
-The patient has had multiple admissions for uncontrolled blood sugar due to non-compliance;
-Discharge to home, with diet and medication instructions provided along with signs and symptoms to report to the physician; and
-discharge date of [DATE].

5. The discharge evaluation failed to reassess the patient for:
-In hospital diabetic education;
-Ability to perform blood sugar checks
-Ability to correctly draw up insulin (a medication to control blood sugar);
-Ability to appropriately inject the insulin; and
-Home health care visits after the patient's discharge to home.

6. During an interview on 07/11/12 at 10:34 AM, Staff N, Case Manager, stated that reassessment of discharge planning is required when there is a change in patient condition that may change discharge planning needs.
The Case Manager offered no explanation as to why the above services were not part of the discharge reassessment.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review and interview the facility failed to offer community referrals for one patient in (#1) of four records reviewed when Case Management failed discuss referral options with the patient for home health care and community psychological support after discharge from the hospital.

The facility census was 336.

Findings included:

1. Record review of the facility policy titled "Discharge Planning at Adult Acute Care Facilities", original date 03/95, revision date 07/11 gave the following direction:
- Appropriate referrals for social service support will be initiated as soon as the need is identified. This includes nursing home placements, guardianships, supportive counseling, possible abuse, assistance with activities for daily living (ADL - ability to: prepare meals, bathe, dress, provide personal hygiene) or other needs.
- Along with the collaboration of the physician and the multidisciplinary team, case management develops a plan of action to facilitate discharge. This includes alternative level of care, home health, home therapies, home medical equipment, home intravenous infusion, hospice or other needs.
- Case management ensures all discharge planning arrangements are completed prior to discharge.
- Throughout the patient's hospitalization , case management documents the discharge plan in the patient's medical record.

2. Record review Patient #1's clinical record showed:
-The physician history and physical dated 05/23/12 showed the patient had a history of Diabetes Mellitus (a disease resulting in elevated blood sugars). The patient stated he hasn't been taking his home insulin for unclear reasons. Emergency Medical Services (EMS) brought the patient to the emergency room (ER) with a reported blood sugar of 501 mg/dL (the facility's lab report showed normal lab reference for blood sugar ranges from 74 - 106 mg/dL (milligram/deciliter, both are a unit of measure).
-The facility lab report of 05/23/12 showed a blood sugar of 342 mg/dL.
-The patient's admitting diagnosis included nausea and vomiting; diabetic gastroparesis (a condition that reduces the ability of the stomach to empty its contents, but there is no blockage); and Diabetes Mellitus Type I (Type 1 diabetes is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar to enter cells to produce energy).

3. Review of a physician consultation report on 05/25/12 at 3:53 PM, by an endocrinologist (a doctor who specializes in treating disorders of the endocrine system, such as diabetes) showed the patient had Type I Diabetes, uncontrolled due to the lack of usual therapy including the patient's compliance with a prescribed regimen. Various options were discussed in an effort to find out the reason for the patient's compliance issues. It appears that he may benefit from psychiatric evaluation while in the hospital.

4. Review of the case manager note on 05/25/12, 8:32 AM, showed the case manager reviewed the medical record and plan of care.

5. Review of the Case Manager note dated 05/25/12, the case manager discussed plan of care, level of service, discharge needs and discharge time with the patient. Prior to admission the patient lived alone in an apartment.

The facility failed to make appropriate discharge plans for Patient #1 when the discharge planning and evaluation failed to assess/refer the patient for home health care visits after the patient's discharge to home and failed to evaluate the patient for a community support referral for psychological services.

6. Review of the physician discharge summary dated 06/19/12 at 1:18 PM, for Patient #1 showed:
-The patient has had multiple admissions for uncontrolled blood sugar due to non-compliance;
-Discharge to home, with diet and medication instructions provided along with signs and symptoms to report to the physician; and
-discharge date of [DATE].

7. During an interview on 07/11/12 at 10:34 AM, Staff N, Case Manager, stated that the patient may have benefited from a psychological evaluation with continued community psychological services and a referral to home health care for diabetic care and psychological support.

The case manager offered no explanation as to why the above services were not part of the discharge evaluation and discharge planning.