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BAYFRONT HEALTH - ST PETERSBURG 701 6TH ST S SAINT PETERSBURG, FL 33701 April 19, 2019
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
Based on policy review, medical record review, and staff interview, it was determined the facility failed to ensure patient discharge planning evaluations were performed, which included an evaluation of post discharge needs, services, and ability to return to prior care setting, for 2 (#3, #5) of 7 medical records sampled.

Findings included:

A review of the facility Emergency Department (ED) policy entitled, "Case Management High Risk Screening for Discharge Planning," no #, reviewed 05/07/18, showed the reference for making the policy was the regulatory standard, 482.43 Conditions of Participation for Discharge Planning. There were no further references cited. The policy failed to show a discharge planning process applied to all patients, including ED patients. The policy showed the purpose was to identify inpatients that may have high-risk discharge planning needs necessitating case management intervention. The policy showed the guiding principles where Case Manager's (CM's) are able to recognize patient characteristics that typically indicate the need for CM intervention in order to facilitate a safe and efficient discharge (DC).

A review of the facility ED policy entitled, "Emergency Department Discharge," no #, reviewed 04/17/18, showed the following:
Provide the patient with written information regarding their care in the ED, as well as at home.
Provide the patient with community resource available to them and to provide a standardized method of providing discharge information for all ED patients.
All patient DC's from the ED will receive condition-appropriate DC instruction and follow-up care including information about their condition, medication and appropriate referral including community resources.
Include the family in DC instructions when indicated.
Patient will sign DC instructions Sheet. The responsible driver may sign the DC instruction when the patient has received medication that renders them unable to drive; two nurses may sign if the patient refuses to do so.
Community Resources Guides will be provided as needed.
If the patient is being DC'd to a facility where nursing care is to be provided, the ED RN will provide a handoff to the receiving facility.

A review of Patient #3's physician history and physical (H&P) documentation dated 02/25/19, showed the patient presented to the ED via Emergency Medical Services (EMS) after being found intoxicated in the streets. The note showed the patient's alcohol blood level was 0.31.
Blood alcohol levels - 0.01 - 0.05 g/dL - Mild euphoria, decreased inhibitions, diminished attention & judgement.
Blood alcohol levels - 0.25 - 0.40 g/dL Sleep or stupor, marked muscular incoordination, markedly decreased response to stimuli, incontinence.

A review of Patient #3's physician discharge summary documentation dated 02/25/19, showed a diagnosis of acute alcohol intoxication. The physician note showed the patient was DC'd with instructions to follow up with his primary care physician. The note failed to reveal documentation of a safe DC evaluation or plan.

A complete review of Patient #3's medical record failed to reveal the presence of CM documentation of an assessment for a safe and appropriate condition based DC that included identification of family members, community resources, and the patient's prior care setting.

A review of the RN DC instructions dated 02/25/19, showed two RN's signed Patient #3's DC instructions and not the patient. The DC instructions failed to reveal the patient was provided a list of available shelters, alcohol treatment resources, or community resources. Patient #3 was DC'd with a bus pass.

A review of Patient #5's physician H&P dated 02/25/19 at 3:41 PM, showed documentation the patient arrived via EMS from a skilled nursing facility (SNF) with complaints of facial swelling. The note showed the physician performed an incision and drainage (I&D) of a facial abscess.

A review of Patient #5's RN triage notes dated 02/25/19 at 3:41 PM showed the patient arrived via EMS from a SNF.

On 04/19/19 at 9:50 AM, an interview with the Risk Manager (RM) revealed Patient #5's medical record contained a Certificate of Incapacity indicating the patient could not make decisions for himself or provide accurate and informed decisions. The RM stated EMS had brought the certificate, along with the patients' medical record, at the time of the transfer. The RM stated the nurses and physician failed to review the SNF paperwork brought to the facility by EMS. The staff also failed to reveal the ED RN triage documentation, which also showed where the patient was transferred from.

A review of Patient #5's physician discharge summary documentation dated 02/25/19, showed a diagnosis of facial cellulitis, abscess, and pain. The patient was provided antibiotic prescriptions and referred to an outpatient community health center for medical follow up. Continued review of the physician notes showed the patient was DC'd to home on 02/25/19 at 6:36 PM and not back to the facility he resided. The note failed to reveal the physician assessed the patient's DC needs to ensure a safe DC was performed.

A review of Patient #5's medical record failed to reveal the presence of CM documentation indicating the patient had been assessed for potential DC needs and services.

On 04/19/19 at 1:15 PM, an interview was conducted with the ED CM regarding patient DC planning evaluations. The CM stated he only sees the patients referred to him by the ED physicians and nurses. The CM stated that homeless patients receive appropriate resource lists and a bus pass to get to a shelter.

A review of Patient #5's RN DC instructions dated 02/25/19 at 6:37 PM, showed the patient was provided instructions related to his diagnosis, prescriptions, community health center referral. The instructions showed the patient was to return to the ED for a wound check in two days. The DC instructions failed to reveal where or with whom the patient was DC'd. The DC instructions failed to show the patient was offered or provided transportation services at the time of DC.

On 04/19/19 at 9:50 AM, an interview was conducted with the RM regarding Patient #5's DC. The RM stated she received a call from the ED Nurse Manager on 02/26/19 at 8:20 AM informing her she had received a phone call from the SNF where Patient #5 resided. The SNF informed the manager the patient had not returned to the facility. The RM stated the St. Petersburg Police Department was notified at 9:30 AM. At 10:30 AM, the RM reviewed the ED security footage and sent a picture of Patient #5 to the SNF. The SNF confirmed Patient #5 was their patient. At 12:20 PM, the RM contacted the court appointed guardian to make them aware of the situation. The following day, 02/27/19 at 8:59 AM, Adult Protective Services (APS) arrived to investigate the incident. The RM was informed by APS at 9:29 AM, Patient #5 had been found. The RM stated she contacted the SNF at 9:35 AM inquiring about Patient #5. The RM was informed by the nursing director (DON) the patient had been found on 02/26/19 at 6:30 PM at a pizza parlor. The DON told the RM the pizza parlor had called the SNF and coordinated the patients return.

On 04/19/19 at 10:10 AM, an interview was conducted with the ED nurse manager regarding Patient #3's and #5's DC. The manager indicated the staff sometimes make assumptions patients are homeless based on their appearance. The manager indicated the ED staff have been reminded frequently to not make assumptions based on how patients are dressed. The manager confirmed there was no documentation in Patient #3 and Patient #5's medical record indicating the staff had asked the patients if they had family that could be contacted. The manager also confirmed there was no documentation Patient #5 was offered or provided transportation at the time of DC.

An interview on 04/19/19 at 4:00 PM with the Clinical Informatics Manager confirmed the above medical record findings.