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FORT WALTON BEACH MEDICAL CENTER 1000 MAR-WALT DR FORT WALTON BEACH, FL 32547 March 19, 2019
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the facility failed to reassess the discharge plans for 2 of 3 patients (#1 & #2).

The Findings Included:

Patient #1
On 9/10/18 the patient presented to the Emergency Department (ED) by ambulance as a level 1 trauma after slipping and falling on hydraulic oil resulting in paralysis of his right arm with pain in his neck, back and right hip. Patient #1 had history of spinal issues and computerized tomography scan (CT) of the patient's cervival spine showed a plate that had been previously placed and used two screws to hold it in position. The CT scan showed displacement of the left screw from the C7 vertebral body anteriorly along the esophagus and the right screw was partially out of the plate and vertebral body. Review of the CT scan report showed the radiologist contacted the ED physician at 1:49PM to notify him of the abnormal results related to the displaced screws seen on the patient's imaging.

Interview with Registered Nurse (RN), Staff member C on 03/18/2019 at 1:41 PM confirmed the radiologist calls only if there are abnormal findings the physician needs to be aware of, which she stated was probably the findings with the loose screws in the C-spine report, as there were no acute injuries seen on any of his images according to the radiologist.

Review of the Disposition Decision, electronically signed by the ED physician, stated she had spoken to the patient and caregivers and explained the patient's condition, diagnosis and treatment plan based on the information available to her at that time. It stated she had answered the patient's questions and addressed any concerns and noted the patient had a good understanding of the condition and treatment plan as could be expected at that point. It further stated the patient had been stabilized within the capability of the ED and would be transported for further care and management or would be moved to observation or inpatient status. Planned to admit to trauma 4S for observation based on documentation and consulted Neurology.

Further review of the medial record for Patient #1 showed that he had not been admitted as the physician stated in her Disposition Decision, nor had the patient been seen by the neurologist, but rather had been discharged home. Review of the discharge instructions provided to Patient #1 revealed the physician recommendation to follow-up with his primary care physician in 7-10 days and alerted the patient to return to the ED with increased pain, but did not instruct the patient to follow-up with a neurologist or othropedic specilaist to address the displaced screws in his cervical spinal area.


Patient #2
On 10/20/18 patient #2 was transfered to the Emergency Department (ED) by ambulance from a hospital in Panama City as a level 2 trauma with left humerous (arm) pain. According to an interview with the ED Director, Patient #2 was a [AGE] year old resident of Panama City that had lost his home during Hurricane Michael, and had been staying at a neighbor's home when he suffered a fall that sent him to the ED at a hospital in Panama City. He was diagnosed with a fractured left humerus and was transferred to this facility's ED for further treatment, as the hospital in Panama City had also been significantly damaged by the hurricane and was not able to deal with trauma patients at that time.

Review of the assessment of Patient #2, conducted in the ED, confirmed the left humerus fracture and showed the patient to have a diagnosis of dementia, noting the patient had slight confusion. The assessment also revealed that the patient was stable and there was no intervention needed for the fracture, other than to keep in a sling for 4-6 weeks while healing and the hospital made plans to discharge the patient back home.

Review of nursing documentation for Patient #2 showed the patient lived with his son but their home had been rendered uninhabitable due to the storm and the hospital had not been able to reach the son via telephone, as cellular service was not available in Panama City at that time due to storm damage to cellular towers. The notes did indicate that hospital staff had spoken to the daughter of Patient #2, who lived some 5 hours away, and had alerted the daughter to their plans to discharge the patient back home. The patient's daugher expressed that her father had nowhere to go as his home had been destroyed and the hospital told her they could send her father to a shelter, but the daughter refused as the patient would have had to have a family member with him at all times to be allowed in the shelter and there was no family close by that could be contacted to meet the [AGE] year old patient at the shelter. The notes also indicated the hospital called Adult Protective Services after the family refused to come pick the patient up from the ED. The physician did note that family was refusing to pick up due to no place to take him and the physician even noted that he would check blood work to see if he could find a reason to admit the patient, but was unable to identify a reason for admission. Nursing notes showed Patient #2 was sent via ambulance to a shelter in Panama City on discharge that was mixed medical and general, but did not indicate whether there would be family available to meet the patient at the shelter. Review of discharge information showed Patient #2 received information about his fracture and use of the sling until his fracture healed in 4-6 weeks and instructed the patient to follow-up with a physician in one week to determine when range of motion could be started.

In an interview with the ED Director on 3/18/19 at approximately 11AM, she stated that due to the condition of patient #2, he probably shouldn't have even been transferred from the original hospital, but "they needed help." She stated that the patient did not meet medical necessity for skilled nursing facility (SNF) placement but probably could have been placed in an assisted living facility; however, they could not hold him in the ED nor did they have any reason to admit the patient and there were no facilities in the area with available beds at that time due to sheltering others affected by the storm. She was asked to look and see if there was evidence that case management had been contacted concerning this case, and she stated there were no notes entered by case management.

Review of the facility policy on Discharge Planning (ID 27), last reviewed 6/18/18, contained a section specific to the Emergency Department that stated (A) Patients identified as needing additional assistance for SNF placement or home health to meet Activities of daily living (ADL), nursing, and/or Durable Medical Equipment (DME) needs shall have the home health agency or SNF contacted from the ER. The ER physician is responsible for initiating the order for placement, home health, and/or DME needs. (B) Patients requiring further assistance specific to the identified patient needs shall be directed to the agency, or the staff shall contact the agency, prior to the patient leaving the ER. This information is documented in the nursing record. (C) A case manager is assigned to the ER to assist with discharge planning needs.