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.

NORTH SUBURBAN MEDICAL CENTER 9191 GRANT ST THORNTON, CO 80229 Feb. 27, 2018
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on the nature of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.43 DISCHARGE PLANNING, was out of compliance.

A0806 - Standard: Discharge Planning Evaluation. The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) of this section, and to other patients upon the patient's request, the request of a person acting on the patient's behalf, or the request of the physician. The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services. The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. The facility failed to provide a discharge evaluation to meet the needs of the patient in 1 of 7 discharged patient medical records reviewed (Patient #2).
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
Based on interviews and document review, the facility failed to provide a discharge evaluation to meet the needs of the patient in 1 of 7 discharged patient medical records reviewed (Patient #2).

Findings include:

Policies

The policy Discharge Planning/Continued Care Process read, the nurse will utilize various sections of the nursing admission form to identify high risk discharge planning patients, e.g. skin assessment, psychosocial assessment, patient risk to fall, restraint prevention/alternative measures, specific barriers to learning, functional assessment/discharge planning. It further read, patients with an admission as a result of drug or alcohol abuse would be given an Intensive Psychosocial Assessment by social work.

The policy Suicidal Patients, Evaluation and Treatment of, read "All patients admitted to North Suburban shall have a nursing assessment completed which includes suicide risk screening."

The policy Patient Assessment and Reassessment read, all patients will have the following data collected/addressed in their initial screening (based on the patient's condition) including screening for educational needs and barriers, abuse and neglect, pain, functional status, nutritional status, psychological, social, spiritual/cultural needs, and suicide risk assessment. The policy further read, reassessment and/or data collection are to be ongoing and may be triggered by key decision points including significant change in condition or diagnosis.

1. The facility failed to provide a discharge evaluation to meet the needs of Patient #2, including suicide risk screening and social work evaluation for a high risk admission.

a. Review of the Emergency Provider Report, dated 11/16/17, showed Patient #2 presented to the emergency department (ED) on 11/16/17 at 3:06 p.m. On arrival to the ED, Patient #2 was deeply sedated due to an elevated blood alcohol level (BAL). Patient #2 was intubated for respiratory failure to protect his airway on 11/16/17 at 3:20 p.m. and subsequently admitted to the intensive care unit.

Registered Nurse (RN) #1 documented Patient #2's ED admission assessment on 11/16/17 at 4:37 p.m. She documented she was unable to complete the suicide ideation assessment due to the patient's condition.

An interview was conducted with RN #1 on 2/27/18 at 10:19 a.m., in which she stated while a patient was intubated, their suicide risk could not be assessed.

According to ED nursing notes, Patient #2 transferred to the intensive care unit (ICU) on 11/16/17 at 5:27 p.m. At 7:00 p.m., RN #3 documented Patient #2's ICU admission assessment. She documented she assessed Patient #2 for suicide risk, and he had no current suicidal thoughts. However, the RN noted she was "Unable to assess" if the patient was "at risk for suicide." Additionally, the nursing assessment noted Patient #2 was not alert and oriented. She also documented she was unable to assess recent attempts at self harm, and recent stressful events. RN #3 noted Patient #2 was still intubated on 11/16/17 at 7:00 p.m.

A review of nursing notes revealed Patient #2 was extubated on 11/17/17 at 8:05 a.m. On 11/17/17 at 10:19, Physician #5 documented, in his discharge summary, Patient #2 was awake and alert, and walking around the unit independently. Despite Patient #2 being awake and alert, no further attempts were made to assess Patient #2's suicide risk.

Review of Case Manager (CM) #11's discharge summary revealed that she met with Patient #2 prior to discharge. CM #11 stated Patient #2 had no discharge needs and would walk home.

An interview with CM #11 was conducted on 2/26/18 at 3:37 p.m. CM #11 stated she had a questionnaire for patients with alcohol related admissions. She stated if the patient scored high, she would utilize a social worker with the patient. Review of Patient #2's medical record revealed the assessment was not done for Patient #2, and a social worker did not see this patient. This was in contrast to the facility's policy regarding discharge planning for high risk admissions.

During an interview with RN #1 on 2/17/18 at 10:19 a.m., RN #1 reviewed Patient #2's medical record. She stated a complete suicide risk assessment was not completed by nursing staff in the ED. RN #1 stated suicide risk should be assessed prior to discharge. RN #1 stated screening all patients for suicide risk was important because it allowed the facility to "weed out those who need more support. Those who are saying they have stomach pain, but are really coming in because they need more help." RN #1 stated she was unaware of any triggers to reassess a patient once the patient's condition changed. She stated the only way she was aware of to communicate the need to reassess suicide risk after extubation was direct communication during shift report. There was no documentation this communication occurred in Patient #2's record.

An interview with ICU RN #2 was conducted on 2/17/18 at 1:59 p.m. RN #2 reviewed her documentation and confirmed she had not documented a suicide risk assessment for Patient #2 after he was extubated. RN #2 confirmed that there was not a complete suicide risk assessment charted by nursing throughout his entire stay.

b. Three weeks prior, on 10/21/17, Patient #2 was brought to the facility's ED for trauma. According to the discharge summary, dated 10/22/17 at 10:25 a.m., Patient #2 had been seen lunging at cars by the police earlier that evening. When the police returned later, Patient #2 was found unconscious with a laceration on his scalp. Patient #2 was released by the ED pending a ride home; however, he became tachycardic (fast heart rate) and began to display symptoms of alcohol withdrawal. Patient #2 was then admitted for withdrawal symptoms management.

There was no documentation Patient #2 received an intensive psychosocial assessment by social work prior to discharge pursuant to the facility's policy.

c. An interview with Physician #5 was conducted on 2/17/18 at 3:05 p.m. Physician #5 stated during Patient #2's November 2017 admission, he assumed he screened Patient #2 for suicide risk. However, he stated he could not find the assessment in his documentation. A review of Physician #5's discharge note revealed no documentation of suicide risk screening. Physician #5 stated Patient #2 should have been assessed for suicide risk prior to discharge.

d. An interview was conducted with Social Worker (SW) #4 on 2/27/18 at 11:18 a.m. She stated the initial suicide risk assessment should be done by nursing staff. She also stated the case manager would review this nursing assessment during the process of discharge planning. She stated the case manager would also review the physician's history and physical for indications of suicide risk.

SW #4 stated high risk case management screens were for more complex patients and included patients with frequent admissions for substance abuse and mental health. SW #4 stated Patient #2 met this criteria and it would have been appropriate for social work to have been consulted and evaluate Patient #2 during his November 2017 admission due to his multiple ED visits and inpatient stays related to alcohol.