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.

ADVOCATE TRINITY HOSPITAL 2320 E 93RD ST CHICAGO, IL 60617 Dec. 5, 2018
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 2 of 10 patient records (Pt. #7 and Pt. # 8) reviewed for discharge planning, the Hospital failed to ensure that discharge evaluations/assessments were completed to assess the patient's post discharge needs.

Findings include:

1. On 12/4/18 at approximately 9:24 AM, the Hospital's Department Scope of Service document titled, "Care Management" (revised 6/17/14) was reviewed and included, "...The Care Management Department provides an avenue for patient, family, physician, insurer, and caregiver interaction which encompasses level of care assessment for appropriateness of...discharge planning...The Care Management staff collaborates, communicates and coordinate with...members of the health care team to ensure that the plan of care and discharge plan are aligned with individual patient's needs. The Care Management Department assists in ensuring that physician documentation accurately reflects the severity of the patient's illness and the intensity of the treatment plan..."

2. On 12/3/18 at approximately 1:30 PM, Pt. #7's medical record was reviewed. Pt. #7 was a [AGE] year old male who was admitted on [DATE] with the diagnosis of new onset severe renal failure. Pt. #7 was discharged home on 10/13/18. Pt. #7's physician order dated 10/13/18 included, "discharge planning eval (evaluation) adult...specify in special instructions, days till discharge: EST [estimated] disch [discharge] today, home RN (Registered Nurse) CBC/BMP (complete blood count/basic metabolic panel) in 1 week." Pt. #7's medical record lacked documentation of a discharge evaluation/assessment.

3. On 12/3/18 at approximately 1:50 PM, Pt. #8's medical record was reviewed. Pt. #8 was an [AGE] year old female who was admitted on [DATE] with the diagnoses of end stage renal disease, anemia, and suspected nosocomial [hospital acquired] pneumonia. Pt. #8 was discharged home on 10/21/18. Pt. #8's physician order dated 10/19/18 included "discharge planning eval [evaluation] adult...specify in special instructions...home nurse for chronic disease and medication management." Pt. #8's medical record lacked a discharge planning evaluation/assessment.

4. On 12/3/18 at approximately 2:10 PM, an interview was conducted
with the Vice President of Clinical Excellence (E #5). E #5 stated that when ordered, a discharge evaluation should be completed.

5. On 12/4/18 at approximately 11:15 AM, an interview was conducted with the Manager of Care Management (E #1). E #1 stated that discharge evaluation is an order set (physician orders that include standard and specialized orders for a specific category) and the discharge staff follow the special instruction orders. E #1 stated that the staff should complete an evaluation/assessment for discharge planning.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 1 clinical record (Pt. #1) for a patient who tested positive for the Hepatitis B Antigen (person is infected with hepatitis B - an infection caused by a virus that attacks the liver and leads to inflammation), the Hospital failed to ensure the patient's Dialysis Facility was informed of a positive Hepatitis B test result.

Findings include:

1. On 12/4/18 at 2:40 PM, the Hospital's policy titled, "Continuum of Care," (reviewed 7/23/18) was reviewed. The policy required, "IV. Procedure: E. Discharge Planning Process: 8. Upon discharge, provides a Patient Discharge Record with pertinent information on special instructions i.e., medication... restrictions and summary of discharge status to the patient or healthcare provider assuming responsibility for the care of the patient... F. 'Post Exit' Need Identification: 3. Information exchange between caregivers for all transfers include: b) Patient's physical and psychosocial status: (1) Includes assessment related to diagnosis and key problems..."

2. On 12/3/18 at 10:40 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with a diagnosis of dyspnea [shortness of breath]. Pt. #1's history and physical (H&P) dated 10/6/18, included diagnoses of arthritis (inflammation of 1 or more joints), chronic pain, depression, end stage renal disease (ESRD), and human immunodeficiency virus (HIV). The H&P did not indicate if Pt. #1 was Hepatitis B positive.

- A physician's order dated 10/6/18 at 3:15 PM, included an "Acute Hepatitis Panel." Pt. #1's Chemistry Laboratory Test Results for the Hepatitis B Surface Antigen dated 10/6/18, collected at 3:15 PM, was positive. The report did not include the date and time the test was reported.

- A Discharge Planning note dated 10/8/18 at 2:25 PM, indicated that the Hospital sent Pt. #1's dialysis treatment sheet to his in-center Dialysis Clinic/Facility. However, the note lacked documentation that the positive Hepatitis B antigen test results were reported to the Facility.

3. On 12/3/18 at 1:15 PM, Pt. #1's prior admission in September 2018 was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of dehydration (a significant loss of body fluid that impairs normal body functions), hypovolemia (a condition in which the liquid portion of the blood plasma is too low), hypotension (low blood pressure), syncope (dizziness), ESRD, and HIV.

- Pt. #1's H&P dated 9/17/18, included that Pt. #1 "was brought to the ED (Emergency Department) by EMS (Emergency Medical Services) from his Dialysis Clinic following his syncopal episode at his Dialysis Clinic". The H&P did not indicate that Pt. #1 was Hepatitis B positive.

- A physician's order dated 9/18/18 at 2:00 PM, included a "HB S AG [Hepatitis B Surface Antigen]." Pt. #1's Chemistry Laboratory Test Results for the Hepatitis B Surface Antigen dated 9/20/18 at 6:34 AM, was positive.

- Pt. #1's Social Service Note dated 9/18/18 at 3:21 PM, (39 hours before the positive Hepatitis B Surface Antigen was reported), indicated that Pt. #1's Dialysis Facility was contacted and was "willing to accept patient" back. The Note did not include that the Dialysis Facility was informed of Pt. #1's positive Hepatitis B Antigen.

- Pt. #1's Discharge Summary dated 9/19/18 at 2:14 PM, (more than 18 hours before the positive Hepatitis B Antigen was reported), included, that Pt. #1 collapsed in the Emergency Department, was admitted , was treated with IV (intravenous) fluids, and "is stable for discharge." The Discharge Summary lacked documentation that Pt. #1's Dialysis Facility was informed of the positive Hepatitis B Antigen.

4. On 12/4/18 at 10:50 AM, 12:40 PM, and 1:55 PM, interviews were conducted with the Vice President of Clinical Excellence and Care Management (E #5). E #5 stated that the Social Worker sent all of Pt. #1's information to the Dialysis Facility for the September admission, except for the positive Hepatitis B Antigen report, because the results had not returned. When the positive Hepatitis B Antigen results were available, they were not sent to the Dialysis Facility. E #5 stated that there is no procedure to send positive Hepatitis B Antigen results to the Dialysis Facility because they are not a critical value (test result that may require rapid clinical attention) and Pt. #1 had HIV, so there would be no difference in dialysis treatment.

- E #5 stated that the Social Worker sent all of October's clinical documents to the Dialysis Facility, except for the positive Hepatitis B antigen report. The positive Hepatitis B result was never sent to the Dialysis Facility in September or October. E #5 stated that the Physician who orders the laboratory test should be responsible to report the results to the Dialysis Facility.