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.

AURORA ST LUKES MEDICAL CENTER 2900 W OKLAHOMA AVE MILWAUKEE, WI 53215 March 24, 2015
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to screen for patients in need of discharge planning per facility policy for 7 of 10 patients (#1, 5, 6, 7, 8, 9, 10).

Findings:

Facility policy "Discharge Planning" #2052 dated 12/2013 states in part: "4.1) Screening 4.1.1) All inpatients will be screened to determine which patients are at risk of adverse health consequences post discharge if they lack discharge planning. 4.1.2) The screening evaluation is part of the nursing admission assessment and includes: a. current living arrangements/type of residence b. support systems/care capacity of the home environment c. type of services received prior to hospitalization d. functional status e. cognitive ability f. home devices/equipment currently in use g. confidence in filling out medical forms (health literacy screen) h. patient's anticipated discharge needs/type of post hospital care needed."

Pt. #1's MR, reviewed on 3/24/2015 at 12:40 p.m., does not contain discharge screening documentation in the admission nursing assessment. Pt. #1 was admitted to the facility on [DATE] for altered mental status and discharged on [DATE].

Pt. #5's MR, reviewed on 3/24/2015 at 11:25 a.m., does not contain discharge screening documentation in the admission nursing assessment. Pt. #5 was admitted to the facility on [DATE] for poisoning by cocaine and discharged on [DATE].

Pt. #6's MR, reviewed on 3/24/2015 at 1:25 p.m., does not contain discharge screening documentation in the admission nursing assessment. Pt. #6 was admitted to the facility on [DATE] for altered mental status related to hepatic [DIAGNOSES REDACTED] and discharged on [DATE].

Pt. #7's MR, reviewed on 3/24/2015 at 1:50 p.m., does not contain discharge screening documentation in the admission nursing assessment. Pt. #7 was admitted to the facility on [DATE] for lethargy and weakness and discharged on [DATE].

Pt. #8's MR, reviewed on 3/24/2015 at 3:10 p.m., does not contain discharge screening documentation in the admission nursing assessment. Pt. #8 was admitted to the facility on [DATE] for alcohol withdrawal and discharged on [DATE].

Pt. #9's MR, reviewed on 3/24/2015 at 3:25 p.m., does not contain discharge screening documentation in the admission nursing assessment. Pt. #9 was admitted to the facility on [DATE] for drug overdose and discharged on [DATE].

Pt. #10's MR, reviewed on 3/24/2015 at 3:45 p.m., does not contain discharge screening documentation in the nursing assessment. Pt. #10 was admitted to the facility on [DATE] for alcohol withdrawal and discharged on [DATE].

During an interview with Dir A on 3/24/2015 at 10:35 a.m., Dir A stated "nurses are responsible for screening the patients" and the SW receives "automatic triggers" for a discharge evaluation based on the screening responses. Patients are additionally identified for a discharge evaluation through MD and RN referrals, or during multi-disciplinary outcome facilitation rounds.

RN C stated on 3/24/2015 at 3:25 p.m. the discharge screening "should be done upon admission" for every patient.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to provide a discharge planning evaluation for 2 of 3 patients (#1, 9) requiring post-discharge support.

Findings:

Facility policy "Social Work and Continuing Care Documentation" #5 dated 10/7/2009 states in part: "When triggered/ordered for discharge planning needs or upon patient/family request, the social worker will document a discharge planning evaluation. The discharge planning evaluation will include factors that impact on the patient's needs for care after discharge from the acute care setting. ...The electronic health record provides a tool for completing this evaluation. The social worker should complete the elements of the tool (or provide narrative documentation) that provide information essential to evaluation of: The likelihood of a patient's capacity for self-care; Likelihood of the patient being cared for in the environment from which he/she entered the hospital; Need for post hospital services...Other considerations in the needs assessment may include: a. Basic functional review including patient orientation upon interview, cognition, ability to communicate, prior living arrangements and capacity for self care...b. Formal and informal support systems...Documentation of discussion with patient and/or representative of the results of the discharge planning evaluation must be included in the notes. ...Patient/family participation in the planning process must be documented together with agreement/disagreement with the recommended plan."

Per review on 3/24/2015 at 4:35 p.m.,the facility's "Medical Staff Rules and Regulations" state in part: "Consultations. ...Consults are generally expected to be provided within 24 hours of being requested unless otherwise indicated by patient's condition."

Facility policy "Suicide Precautions: Care of the Patient and Non-Patient" #2016 dated 2/2013 states in part: "6.1) The Suicide Screening/Focused Assessment/Evaluation Form or approved electronic health record workflow is used to perform the initial evaluation of a patient who verbalizes a history of self-harm and/or current suicidal thoughts, or if there is a reason to suspect a patient may have suicidal thoughts. ...6.3) Once the...approved electronic health record workflow is completed, the patient will be determined to be either High or Low Risk." Guidelines for low risk patients include providing the patient with "appropriate crisis resources and patient education."


1. Per Pt. #1's MR, reviewed on 3/24/2015 at 12:40 p.m., Pt #1 received inpatient services at the facility from 1/13/2015 through 1/15/2015. Pt. #1 arrived to the facility's ED via ambulance on 1/13/2015 in a confused state with a chief complaint of altered mental status. Per ED notes, Pt. #1 "reports major depression" and a partial, incomplete suicide evaluation documented on 1/13/2015 at 6:59 p.m. reports Pt. #1 responded "yes" to having thoughts about harming self. CNO B stated on 3/24/2015 at 1:50 p.m. the staff "should have used the screening tool" to assess Pt. #1's risk for suicide.

Pt. #1's admitting History and Physical reports Pt. #1 had a history of "chronic respiratory failure from pulmonary fibrosis, substance abuse, depression, anxiety and suicidal ideation..." Pt. #1's mental status is documented as "confused and inappropriate." An MD order for psychiatric consult was placed on 1/14/2014 at 1:37 p.m. Type of consult is listed as "Standard (within 24 hours)." Pt. #1 was not seen by psychiatry at the time of discharge on 1/15/2015 at 5:32 p.m., more than 24 hours after the time of consult.

Palliative Medicine consult note, dated 1/15/2015 at 12:25 p.m., documents several triggers indicating need for discharge planning evaluation. "Despite several attempts, [Pt. #1] was unable to stop talking about recent home situation and focus on answering questions about [Pt. #1's] disease, goals of care, treatment options, or options at time of discharge." "Impression: 4. Depression, Psychiatry consulted. ...7. Debility/functional status: ...(mainly sits or lies down, unable to do most activity, extensive disease. Needs considerable assistance. Normal or reduced intake. Fully conscious or confused). ...9. Other Palliative issues by domain include: ...3. Depression, additional psych history: present, with suboptimal control 4. Emotions: anxious r/t multiple social/personal issues ...6. Coping and Closure/Family: not able to ascertain if family/friends are involved." The Palliative Medicine note states discussion regarding Pt. #1's care included the MD, SW and RN. "Plan: 1. SW to attempt to discuss Advance Directives and placement challenges with patient."

Pt. #1's MR contains documentation of altered mental status and psychosocial needs througout the inpatient stay including the day of discharge on 1/15/2015:

The last documented mental status nursing assessment in Pt. #1's MR on 1/15/2015 at 9:30 a.m. reveals the following: "Level of Consciousness: 3 [Lethargic]; Attention: 2 [Reduced ability to shift attention]; Thought Process: 1 [Rambling, irrelevant or incoherent conversation]; Motor Behavior: 2 [Agitation]; Orientation: Disoriented to time; Sleep/Wake Cycle: Hypersomnolence; Affect/Behavior: Anxious/Irritable; Appearance/Dress: Disheveled appearance."

PT note dated 1/15/2015 at 2:30 p.m.: "Patient very talkative during initial approach discussing hardships in [Pt. #1's] life regarding family and home situation."

OT note dated 1/15/2015 at 3:17 p.m.: "Pt. very hyperverbal and required redirection to finish eating prior to formal evaluation. Per RN pt. was very unsteady earlier and had pulled out some lines while stumbling around. Reattempted to complete formal evaluation to address deficits however per SW pt. to D/C later today back home."

Pt. #1's Discharge Summary, dated 1/15/2015 at 2:58 p.m. documents SW involvement in discharge planning: "In regards to patient's social situation and placement, social worker was very helpful. Unfortunately, on 1/15/2015 patient's [family member] passed away and patient had to leave the hospital to attend family duties. On 1/15/2015 patient was discharged home in stable condition..."

SW note dated 1/15/2015 at 3:09 p.m.: "Patient/Family discharge goal(s): Goal #1: Home discharge arranged. Goal #2: Psychosocial needs assessed. Progress Note: Paged by RN to meet with the patient. He just found out that his father had died last night, and was loudly arguing with [significant other] on the phone about their relationship. Patient and [significant other] calmed down, [significant other] coming to the hospital in approximately an hour to pick up patient, whom the MD is discharging. The apartment is rented in both the patient and [significant other's] names, but the patient stated [Pt. #1] was going to kick [significant other] out of the house." There is no documentation of a discharge evaluation, plan or implementation in Pt. #1's MR. The discharge/transition flowsheet contains no documentation.

Pt. #1's significant other stated on 3/12/2015 at 12:55 p.m. that facility staff reported intent to discharge Pt. #1 home in a cab if significant other did not pick up Pt. #1 from hospital. Pt. #1's significant other reports verbalizing concern about Pt. #1's discharge due to mental status. Pt. #1's MR contains no documentation of significant other conversations regarding discharge planning.

Dir A stated on 3/24/2015 at 10:35 p.m. that all SW notes related to the discharge evaluation and planning are maintained in the electronic health record in the "Discharge/Transition flowsheet."

RN C stated on 3/24/2015 at 3:30 p.m. that at the time of discharge Pt. #1 "seemed a bit overwhelmed" and "preoccupied." Per RN C, assigned to Pt. #1 on the day of discharge, Pt. #1 "really wanted to leave, there was a death in the family" and Pt. #1 was "working with Social Worker."

RN discharge note, dated 1/15/2015 at 5:32 p.m.: "Patient given d/c paperwork and prescriptions and gone over with RN. Patient verbalized understanding. Patient d/c'd to home/self care via ride from significant other."

Pt. #1's significant other stated on 3/12/2015 at 12:55 p.m., Pt. #1 committed suicide within 24 hours of inpatient discharge from this facility.



2. Pt. #9's MR, reviewed on 3/24/2015 at 3:25 p.m., reveals Pt. #9 was admitted to the facility on [DATE] through 1/27/2015 due to drug overdose. The admission History and Physical documents "altered mental status, secondary to intentional overdose...past medical history significant for depression..."

Suicide evaluation in the nursing flowsheet is documented as "unable to assess at this time" on 1/24/2015 at 7:42 a.m. There is no further suicide evaluation documented for Pt. #9 throughtout the inpatient stay.

Inpatient Psychiatric consultation is ordered on [DATE] at 1:22 p.m. A neuropsychiatric consultation is performed on 1/27/2015 at 8:31 p.m., more than 24 hours after the order was placed.

An order for inpatient Neuropsychology consultation states the reason for consultation as "unintentional drug overdose needs to have psych eval for safety plan before going back to [home]."

Pt. #9's MR does not include documentation of a discharge needs evaluation or plan based on patient needs.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record review and interview, the facility failed to ensure the discharge planning process is applied to all patients receiving inpatient services.

Findings include:

The facility failed to screen for post-discharge risk in 7 of 10 patients. See tag A800.

The facility failed to provide a discharge planning evaluation despite evidence of a need for discharge planning in 2 of 3 patients. See tag A806.

The facility did not provide outpatient support for 1 of 1 discharged patients. See tag A837.

The cumulative effect of this noncompliance has the potential to adversely affect all inpatients receiving care at this facility.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on record review and interview the facility failed to provide patients with applicable outpatient support resources for 1 of 10 patients (#1).

Findings:

Facility policy "Suicide Precautions: Care of the Patient and Non-Patient" #2016 dated 2/2013 states in part: "6.1) The Suicide Screening/Focused Assessment/Evaluation Form or approved electronic health record workflow is used to perform the initial evaluation of a patient who verbalizes a history of self-harm and/or current suicidal thoughts, or if there is a reason to suspect a patient may have suicidal thoughts. ...6.3) Once the...approved electronic health record workflow is completed, the patient will be determined to be either High or Low Risk." Guidelines for low risk patients include providing the patient with "appropriate crisis resources and patient education."

Per review on 3/24/2015 at 4:35 p.m.,the facility's "Medical Staff Rules and Regulations" state in part: "Consultations. ...Consults are generally expected to be provided within 24 hours of being requested unless otherwise indicated by patient's condition."

Per Pt. #1's MR, reviewed on 3/24/2015 at 12:40 p.m., Pt #1 received inpatient services at the facility from 1/13/2015 through 1/15/2015. Pt. #1 arrived to the facility's ED via ambulance on 1/13/2015 in a confused state with a chief complaint of altered mental status. Per ED notes, Pt. #1 "reports major depression" and a partial, incomplete suicide evaluation documented on 1/13/2015 at 6:59 p.m. reports Pt. #1 responded "yes" to having thoughts about harming self. CNO B stated on 3/24/2015 at 1:50 p.m. the staff "should have used the screening tool" to assess Pt. #1's risk for suicide.

An MD order for psychiatric consult was placed on 1/14/2014 at 1:37 p.m. Type of consult is listed as "Standard (within 24 hours)." Pt. #1 was not seen by psychiatry at the time of discharge on 1/15/2015 at 5:32 p.m., more than 24 hours after the time of consult.

Per Dir A, all referrals to community services and handouts given to patients by the SW are documented in the electronic health record flowsheet.

Pt. #1's MR does not contain documentation of any type of mental health-related education, handouts or support. Pt. #1's discharge instructions due not include any mental health education or guidance for depression, anxiety, or suicidal ideation. There is no recommended outpatient follow-up with psychiatric or counseling services.

Pt. #1's significant other stated on 3/12/2015 at 12:55 p.m., Pt. #1 committed suicide within 24 hours of inpatient discharge from this facility.