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.

JEWISH HOSPITAL & ST MARY'S HEALTHCARE 200 ABRAHAM FLEXNER WAY LOUISVILLE, KY 40202 Nov. 7, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on interview, record review, and facility policy review, it was determined the facility failed to inform the patient representative in advance of discontinuing patient care for one (1) of ten (10) sampled patients, Patient #1. The facility discharged and sent home Patient #1, a ward of the state, without notifying the patient caregiver or the State Liaison.

The findings include:

Review of the facility's policy, Discharge Planning, revised August 2016, revealed members of the Care Coordination team educated the patient and caregivers about the discharge plan.

Review of the facility's policy, Discharge (Transition of Care) Planning, revised June 2016, revealed the nurse or discharge planning team would confer with the patient, family/significant other, and physician in developing and implementing the discharge plan.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 09/11/17, with the chief complaint of Seizures and listed problems of Dementia and Seizure. Documentation by the Emergency Department Physician revealed the patient had significant Dementia, Mild Intellectual Disability, and was a Ward of the State.

Interview with Registered Nurse (RN) #2, via telephone, on 11/07/17 at 9:07 AM, revealed she worked in the Emergency Department when Patient #1 was admitted . She stated Patient #1's niece was with the patient and stated she was the caretaker and that the patient was a ward of the state. RN #2 stated she relayed that information to the nurse on the floor when she gave report.

Interview with the State Guardianship Assistant Manager, on 11/06/17 at 3:12 PM, revealed the facility should treat wards of the state like a minor child; the facility should inform the state guardian at admission, during the stay for updates, and for discharge. She stated the state assumed guardianship of Patient #1 in 2013 and the facility should have had a record of guardianship on file from previous hospitalization s.

Continued review of Patient #1's medical record revealed the facility listed the patient as the Guarantor of the account and the patient was able to follow all commands with language intact. Further review revealed a physician order, dated 09/14/17 at 2:37 PM, to discharge the patient home with home care.

Review of Patient #1's Discharge Instructions revealed the patient signed he/she received the patient education material/instructions on 09/14/17 at 3:50 PM.

Interview with RN #1, on 11/07/17 at 12:32 PM, revealed she was unaware Patient #1 was a ward of the state or that the caregiver should have been contacted prior to discharge. RN #1 stated she noted the physician discharge order, discussed with the facility Transitional Care Center (TCC) about patient appropriateness to utilize the TCC, and then discharged the patient and arranged for facility transport to take the patient to TCC, where staff arranged transportation home for the patient. RN #1 stated she assessed the patient to be alert and oriented, able to understand simple questions, and responded using full sentences. RN #1 reviewed the discharge instructions with Patient #1 and then RN #1 obtained the signature of the patient on the discharge paperwork.

Continued interview with RN #1 revealed information related to guardianship or wards of the state may be passed from staff to staff in shift report, or may be obtained through the patient's medical record. RN #1 stated she was unaware of family involvement or would have called them. Additionally, RN #1 stated she was unaware of how her responsibilities would be different for a patient who was a ward of the state, and added she thought wards of the state had no family. RN #1 stated responsible parties should be notified of patient discharge for patient safety reasons.

Interview with the Director of Nursing (DON) for Medical/Surgical, on 11/06/17 at 2:48 PM, revealed the state representative for a ward of the state or a caregiver should be notified of a patient's pending discharge prior to leaving the facility to ensure a safe discharge home. Continued interview, on 11/07/17 at 11:45 PM, revealed information related to wards of state, powers of attorney, or significant others should be relayed in shift change report, as they should be involved in the care decisions of the patient. The DON stated contact should continue for the duration of the patient stay unless the facility learned otherwise. Additionally, the DON stated decisions regarding the care of wards of the state were made in collaboration with the state representative. The DON was unable to verbalize why communication did not occur in Patient #1's incident, but stated perhaps resulted from a lack of communication and staff being unaware.

Interview with the Case Manager (CM), on 11/06/17 at 10:07 AM, revealed she was alerted to Patient #1's discharge order and called the patient's caregiver to alert her of the discharge. The CM stated the caregiver explained the patient had already arrived at home without prior notification from the facility. The CM stated she was aware of the comment in the medical record regarding Patient #1 being a ward of the state and asked the caregiver who was the responsible party for the patient. The CM stated the caregiver replied that she (caregiver) was the responsible party. The CM added Patient #1 was higher functioning, but could tell she needed to talk with the family.

Interview with the Care Management Manager (CMM), on 11/06/17 at 10:07 AM, revealed the TCC was utilized for patients who were waiting for a ride home after discharge, and who were assessed as competent and able. The CMM added Patient #1 was confused at baseline as documented in the patient's chart, and was not appropriate to put in a cab.

Interview with the Chief Nursing Officer (CNO), on 11/07/17 at 1:10 PM, revealed she believed information should be documented in the patient medical record regarding patients not able to make their own decisions, even for discharge. The CNO stated her role was to ensure patients were cared for safely and she was unable to verbalize what occurred in Patient #1's instance.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview, record review, and facility policy review, it was determined the facility failed to resolve a patient grievance for one (1) of ten (10) sampled patients, Patient #1. The facility discharged and sent home Patient #1, a ward of the state, without notifying the patient caregiver or the State Liaison. Facility staff reported the patient caregiver called to complain the patient was sent home prior to notifying the caregiver.

The findings include:

Review of the facility's policy, Patient Rights and Patient Responsibilities, revised December 2016, revealed patients had the right to present complaints and expect corrective action would be taken, when indicated. Additionally, patients had the right to expect prompt response to and resolution of a grievance, including a written notice of the organization's decision, the name of a contact person, steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 09/11/17, with the chief complaint of Seizures and listed problems of Dementia and Seizure. Documentation by the Emergency Department Physician stated the patient had significant Dementia, Mild Intellectual Disability, and was a Ward of the State.

Interview with Registered Nurse (RN) #2, via telephone, on 11/07/17 at 9:07 AM, revealed she worked in the Emergency Department when Patient #1 was admitted . She stated Patient #1's niece was with the patient and stated she was the caretaker and that the patient was a ward of the state. RN #2 stated she relayed that information to the nurse on the floor when she gave report.

Continued review of the medical record revealed the facility listed the patient as the Guarantor of the account and that the patient was able to follow all commands with language intact. Further review revealed a physician order to discharge the patient home with home care on 09/14/17.

Interview with RN #1, on 11/07/17 at 12:32 PM, revealed she was unaware Patient #1 was a ward of the state or that the caregiver should have been contacted prior to discharge. RN #1 stated she assessed the patient to be alert and oriented, able to understand simple questions, and responded using full sentences. RN #1 reviewed the discharge instructions with Patient #1 and then RN #1 obtained the signature of the patient on the discharge paperwork. RN #1 stated responsible parties should be notified of patient discharge for patient safety reasons.

Interview with the 5 East Assistant Manager, on 11/06/17 at 10:38 AM, revealed she received a phone call from the caregiver who complained the patient was discharged and sent home without notifying the caregiver. The Assistant Manager stated she apologized to the caregiver and informed him/her she would relay the concern to the Unit Manager.

Interview with the Unit Manager (UM), on 11/06/17 at 10:23 AM, revealed she was no longer employed by the facility and could not recall any specifics about the event.

Interview with the Director of Nursing (DON) for Medical/Surgical, interim 5 East Unit Manager, on 11/07/17 at 11:45 AM, revealed staff members who received patient complaints should attempt to resolve the issue immediately. If unable, the staff member should relay the issue to the Unit Manager. If the Unit Manager was unable to resolve the issue, the matter should then be escalated to Administrative staff. The DON stated she was unaware of any issues surrounding Patient #1. She stated a possible lack of communication might be responsible for the complaint not being resolved.

Interview with the Chief Nursing Officer (CNO), on 11/07/17 at 1:10 PM, revealed staff addressed patient complaints and then escalated when appropriate. She stated she was unsure of what occurred with Patient #1, but the matter may have been lost to follow up related to the resignation of the Unit Manager and lack of communication of the event.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
Based on interview, record review, and facility policy review, it was determined the facility failed to make appropriate arrangements prior to discharge for one (1) of ten (10) sampled patients, Patient #1. The facility discharged Patient #1 home prior to arranging home health, per the physician order.

The findings include:

Review of the facility's policy, Discharge (Transition of Care) Planning, revised June 2016, revealed the goal of discharge planning was to ensure appropriate preparations were in place by the time the patient was medically ready to be discharged .

Review of the medical record for Patient #1 revealed the facility admitted the patient on 09/11/17, with a chief complaint of Seizures and listed problems of Dementia and Seizure. Review of a physician order, dated 09/14/17 at 2:37 PM, revealed an order to discharged the patient home with home care.

Review of Patient #1's Discharge Instructions revealed the patient signed he/she received the patient education material/instructions on 09/14/17 at 3:50 PM. The instructions stated to follow up with the primary care provider within two (2) to four (4) days. There were no instructions for home care.

Interview with Registered Nurse (RN) #1, on 11/07/17 at 12:32 PM, revealed she noted the physician discharge order, discussed with the facility Transitional Care Center (TCC) about patient appropriateness to utilize the TCC, and then discharged the patient and made arrangements for facility transport to take the patient to TCC, where staff arranged transportation home for the patient. RN #1 reviewed the discharge instructions with Patient #1 and then RN #1 obtained the signature of the patient on the discharge paperwork.

Interview with RN #3, on 11/06/17 at 11:20 AM, revealed after a physician wrote a discharge order, the nurse reviewed the order to see if additional services were required and arranged by Care Management. RN #3 stated discharge paperwork was then prepared.

Interview with the Case Manager (CM), on 11/06/17 at 10:07 AM, revealed she was alerted to the discharge order and called the patient's caregiver to alert her of the discharge. The CM stated the caregiver explained the patient had already arrived at home without prior notification from the facility. The CM stated she was unaware the patient had already been sent home prior to home health services arranged. The CM stated she explained the physician's order for home health to the caregiver and made the necessary arrangements.

Interview with the Director of Nursing (DON) for Medical/Surgical, on 11/06/17 at 2:48 PM, revealed after the physician wrote orders for discharge, the CMs worked with patients to arrange any necessary services, and discharge paperwork was then prepared only after all arrangements had been made. Patients should not transport out until all paperwork and the process have been completed.

Interview with the Chief Nursing Officer (CNO), on 11/07/17 at 1:10 PM, revealed the facility had not previously identified any issues with the discharge process.
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
Based on interview, record review, and facility policy review, it was determined the facility failed to discuss the results of discharge planning prior to discharge for one (1) of ten (10) sampled patients, Patient #1. The facility discharged Patient #1, a ward of the state, home prior to notifying the caregiver or State Liaison.

The findings include:

Review of the facility's policy, Discharge Planning, revised August 2016, revealed members of the Care Coordination team educated patients and caregivers about the discharge plan.

Review of the facility's policy, Discharge (Transition of Care) Planning, revised June 2016, revealed the nurse or discharge planning team would confer with the patient, family/significant other, and physician in developing and implementing the discharge plan.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 09/11/17, with a chief complaint of Seizures and listed problems of Dementia and Seizures. Documentation by the Emergency Department Physician stated the patient had significant Dementia, Mild Intellectual Disability, and was a Ward of the State.

Interview with Registered Nurse (RN) #2, via telephone, on 11/07/17 at 9:07 AM, revealed she worked in the Emergency Department when Patient #1 was admitted . She stated Patient #1's niece was with the patient and stated she was the caretaker and that the patient was a ward of the state. RN #2 stated she relayed that information to the nurse on the floor when she gave report.

Interview with the State Guardianship Assistant Manager, on 11/06/17 at 3:12 PM, revealed the facility should treat wards of the state like a minor child; the facility should inform the state guardian at admission, during the stay for updates, and for discharge. She stated the state assumed guardianship of Patient #1 in 2013 and the facility should have had a record of guardianship on file from previous hospitalization s.

Continued review of the medical record revealed the facility listed the patient as the Guarantor of the account and the patient was able to follow all commands with language intact. Further review revealed a physician order, dated 09/14/17 at 2:37 PM, to discharge the patient home with home care.

Review of Patient #1's Discharge Instructions revealed the patient signed he/she received the patient education material/instructions on 09/14/17 at 3:50 PM.

Interview with RN #1, on 11/07/17 at 12:32 PM, revealed she was unaware Patient #1 was a ward of the state or that the caregiver should have been contacted prior to discharge. RN #1 stated she noted the physician discharge order, discussed with the facility Transitional Care Center (TCC) about patient appropriateness to utilize the TCC, and then discharged the patient and arranged for facility transport to take the patient to TCC, where staff arranged transportation home for the patient. RN #1 reviewed the discharge instructions with Patient #1 and then RN #1 obtained the signature of the patient on the discharge paperwork. RN #1 stated she was unaware of family involvement, as she would have called them. Additionally, RN #1 stated she was unaware of how her responsibilities were different for a patient who was a ward of the state and added she thought wards of the state had no family. RN #1 stated responsible parties should be notified of patient discharge for patient safety reasons.

Interview with the Director of Nursing (DON) for Medical/Surgical, on 11/06/17 at 2:48 PM, revealed the state representative for a ward of the state or a caregiver should be notified of a patient's pending discharge prior to leaving the facility to ensure a safe discharge home. The DON stated contact should continue for the duration of the patient stay unless the facility learned otherwise. Additionally, the DON stated decisions regarding the care of wards of the state were made in collaboration with the state representative. The DON was unable to verbalize why communication did not occur in Patient #1's incident, but stated perhaps it resulted from a lack of communication and staff being unaware.

Interview with the Case Manager (CM), on 11/06/17 at 10:07 AM, revealed she was alerted to the discharge order and called the patient's caregiver to alert her of the discharge. The CM stated the caregiver explained the patient had already arrived home without prior notification from the facility. The CM stated the caregiver informed her that she (caregiver) was the responsible party. The CM stated she discussed the physician order for home health, which was agreeable to the caregiver, and then made the necessary arrangements.

Interview with the Chief Nursing Officer (CNO), on 11/07/17 at 1:10 PM, revealed she believed information should be documented in the patient's medical record regarding patients who were not able to make their own decisions, even for discharge. The CNO stated her role was to ensure patients were cared for safely and she was unable to verbalize what occurred in Patient #1's instance.