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.


Based on interview and record review, the facility failed to fully evaluate the capacity of one (1) of five (5) sampled discharged patients (Patient ID # 1 ) to be cared for in the environment in which she entered the hospital.

Patient # 1 was discharged on [DATE] at 12: 15 a state licensed Type A Assisted Living facility, in which no nighttime staff was available to provide assistance. Patient # 1 was non-weight bearing due to recent trauma and orthopedic surgery; Assisted Living staff were untrained to transfer patients who were non-weight bearing.

Findings include:

Intake # TX # 796

Interview on 10-21-13 at 4:00 p.m. with Program Manager for the Department of Aging and Disability Services (DADS/ ID # 56) she stated Patient ID # 1 had been discharged from the hospital at 12:15 a.m. and arrived at the assisted living facility approximately 1:00 a.m. on 07-13-13. The staff at the assisted living facility was asleep and was awakened to allow the patient inside. The staff member stated she returned to bed after EMS (Emergency Medical Services) placed the patient in bed. Patient # 1 was transferred by ambulance alone and had no family member in attendance throughout the night on 07-13-13.

She went on to say that Patient # 1 was " non-weight bearing " due to a pelvic fracture and recent surgery and unable to care for herself. Program Manager ID #56 said when she visited Patient # 1 on 07-13-13 at 4:00 p.m. the patient told her she had not been moved in bed since she arrived by ambulance at around 1:00 a.m. In addition, the patient said had nothing available for pain and had urinated twice in her " diaper " but had not told the assisted living staff.

Program Manager ID # 56 said the assisted living facility was a licensed Type A facility, in which nighttime care by staff was not available or required. She went on to say the staff at the assisted living center told her they were not trained on how to transfer patients and not put weight on the patient ' s legs.

Program Manager ID # 56 reported that Patient # 1 was transferred to a different local hospital on the evening of 07-13-13 due to pain and inappropriate placement in a Type A assisted living facility.

Review of hospital " Discharge Summary, " dated 07-12-13 read: " Hospital Course: [AGE] year old female... with past medical history of cognitive deficiency, suicidal attempt at [AGE] ...history of drug abuse, bipolar , and depression ...admitted for right acetabular fracture and left avulsion fracture of a talus following a motor vehicle crash ...orthopedics recommend no weight bearing to bilateral lower extremities and bed to chair transfers only with hip flexion precautions ... " Patient # 1 underwent an Open Reduction Infernal Fixation (ORIF) of the right acetabulum on 07-08-13. Discharge Activity: no weight bearing as tolerating (sic) to bilateral lower extremities... "

Interview on 10-25-13 at with hospital case manager Staff ID # 53, she stated the social worker who established the discharge plan for Patient # 1 was no longer employed at the hospital.

Review of Patient # 1 ' s medical record revealed social worker progress note dated 07-10-13: " spoke with director of ( ) group home ...I informed her of pt ' s currently mobility status and she stated they can provide 24 hour care for the pt.. "

Continued interview with Case Manager ID # 53 she stated she was not aware that Patient # 1 ' s group home was a licensed assisted living facility. She went on to say, she was unaware that Type A assisted living facilities did not provide patient assistance at night or care for non-ambulatory patients. She went on to say she was surprised that Patient # 1 was discharged after midnight and this was not a usual occurrence.

Review of facility policy titled: Case Management Accountability for Discharge of High Risk Patients, " review date 1-26-12, read: " Policy Statement: Effective discharge planning for the " high risk " patient is an essential component of the Case Manager's role. It is the organization's position that every entitled to comprehensive safe discharge planning as part of his/her care ... "

Further review of this same policy revealed Patient # 1 met four (4) of the six (6) criteria for a " high risk "patient: " 1. multiple co-morbid conditions that can impact the overall decision about the most appropriate environment for safe discharge and/or : ...3. Has capacity issues that could impact his/her ability to manage his/ her own care safely. 4. Has complex needs surrounding the use of home equipment, services, or supplies ...6. Has a substance abuse or psychiatric diagnosis... "