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.

NIAGARA FALLS MEMORIAL MEDICAL CENTER 621 TENTH STREET NIAGARA FALLS, NY 14302 Oct. 16, 2012
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review a registered nurse did not supervise and evaluate the nursing care for Patient #1 specifically, that the patient was discharged before a Social Work and Nutrition Screen were completed.

Review of Nursing Admission assessment dated [DATE] at 0300 revealed Social Work, Case Management/ Discharge Planning, and Nutrition referrals were triggered due to alcohol abuse, lack of transportation, no permanent housing, emaciated appearance, gastrointestinal distress of any type. The Nutritional referral section was signed off as entered in the computer, but social work and case management were blank.

Review of Physician Orders dated 02/10/12 at 0520 revealed that Patient #1 was admitted to telemetry for early/impending DTs. A nutrition consult, psychiatric consult, social work consult, case management for follow up, and discharge planning were ordered.

Review of History and Physical dated 02/10/12 at 0623 revealed that Patient #1 is concerned about his personal effects being lost or thrown out after being removed from his prior residence and will ask social work to see if there are any recommendations for help. Patient #1 does not seem to have insight to care for himself but this will need to be evaluated once sober and through DTs

Review of Nursing Activity Report dated 02/10/12 revealed the following:
-At 1200 tremors were noted in hands and has foul odor coming from patient due to poor hygiene, incontinent of urine and stool, patient will be discharged after lunch.
-At 1600 discharge papers were reviewed with patient. Not sure how much Patient #1 understood. He is going to a friend's house.

There was no medical record evidence that a Social Work Consult and Nutrition Consult were completed, or that a referral to Niagara County Adult Protection Services was completed.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and policy review, facility staff failed to provide a discharge planning evaluation in accordance with facility policies to ensure that the post hospital needs for Patient #1 were met.

Findings include:

Review of Policy "Social Work Intervention" effective on 05/02/11 revealed that Social Work staff shall be consulted when a patient meets criteria upon hospital admission, including crisis and/or supportive counseling, substance abuse, and acute mental health issues. Initial documentation of social work intervention shall include, but are not limited to: date referral received, reason, and assessment of patient/situation, discharge options, outcome and plan.

Review of Policy "Case Management/Discharge Planning Referral Process" revised on 03/2011 revealed that case management will make a referral to social work when the patient meets criteria such as alcohol/drug abuse, utility problems, acute mental health issues and crisis and/or supportive counseling, and adult protective services.

Review of Policy on "Abuse and Domestic Violence" revised 04/2007 revealed that self neglect is defined as occurring when an older person does not take care of her/himself, may be present itself when the elder is not able to manage personal finances, to provide personal care, make meals or do housework. Physical indicators of neglect include malnourishment, poor hygiene, clothing inappropriate for weather/unclean, frequent falls, decayed teeth, noncompliance with medical recommendations, signs of over medication or under medication. If a physician or health care professional suspects or confirms abuse of an elderly patient who is physically or mentally incapacitated and unable to protect her/himself, a referral should be made to the Niagara County Department of Social Services, Adult Protection Services.

Review of Emergency Department Record dated 02/09/12 to 02/10/12 revealed Patient #1 arrived via Rural Metro ambulance. Patient #1 was brought in on 941 papers for a fight with the landlord and found by police to be living in deplorable filthy conditions. The patient was covered in bed bug bites some of which are/were bleeding. The toxicology report at 1319 revealed an ethanol level of 254 mg/dL. Patient #1 was initially seen in the medical ER and sent to psych ER.The patient experienced elevated blood pressure and moderate tremors, and was transported back to the medical ER. Patient #1 was bathed while in the medical ER earlier in the day due to presence of bed bugs, and unclean clothes and body. Patient #1 was admitted to S-4 at 0300.

Review of Nursing Admission assessment dated [DATE] at 0300 revealed Social Work, Case Management/ Discharge Planning and Nutrition referrals were triggered due to alcohol abuse, lack of transportation, no permanent housing, emaciated appearance, gastrointestinal distress of any type. The Nutritional referral section was signed off as entered in the computer, but social work and case management were blank.

Review of the Psychiatric Consult dated 02/10/12 at 1138 revealed Patient #1 appears to have a history of schizophrenia and alcohol abuse with previous admissions. Patient #1 is being evicted due to living in deplorable conditions. Initially he was homeless but now states he has a place to live. He was apparently covered in bed bugs and drinking heavily, had not been taking medications for quite some time. Patient #1 is alert and oriented, is goal directed, has limited insight and judgment, is psychiatrically stable, and denied issues of lethality. Patient #1 stated he has a friend that he can reside with, but this is to be confirmed.

Review of Case Management Progress Note dated 02/10/12 revealed that Patient #1 has a place to stay with a friend as of today. The City Mission number was given, a mental health outpatient appointment was set up for 02/14/12, and he was seen by a psychiatrist for psychiatric and alcohol concerns. The case is closed, no further needs were identified.

Review of Discharge Instructions dated 02/10/12 at 1700 revealed Patient #1 was discharged home, he was ambulatory, could do partial care and was incontinent of bowel and bladder. Patient instructions included: fall precautions, given the community mission number, an outpatient mental health appointment was set for 2/14/12, and he is to follow-up with his primary medical doctor in 3-4 days. The case manager's name and phone number were given, and the patient understands the discharge instructions.

There was no medical record evidence dated 02/09/12 to 02/10/12 that a Social Work Screen and Nutrition Screen were completed, or that a referral to Niagara County Adult Protection Services was completed before Patient #1 was discharged .