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.


Based on review of policy, review of medical records, interviews with staff, the facility failed to supervise nursing care by failing to complete a physician order for case management evaluation in 1 of 1 patients discharged from the emergency room (#2).

The findings include:

Review of policy titled "Assessment/Reassessment Dimensions" with revision date of November 2017, revealed "...Case Management: Outpatient/Observation: Upon receipt of a referral from a provider, interdisciplinary team or patient/support person request....High Risk Criteria: ...Assistance needed with discharge planning to home, extended care facility, rehabilitation center, or other facility....Reasssment is ongoing...."

Review of closed medical record of Patient #2 revealed a [AGE] year old female that presented to the emergency room (ER) on 08/28/2019 at 1238 with complaints of being assaulted by another resident of the assisted facility where she lived. Review of the Domestic Violence Abuse assessment performed by RN #1 revealed patient #2 answered "No" to "Do you feel safe in your living environment?" Review revealed Patient #2 answered "Yes" to "In the last year, have you been hit/slapped/kicked/harmed by your partner/caregiver?" Review of an ER physician's (MD #1) order written at 1334 revealed "Inpatient consult to Case Management, RN/SW." Review of ED notes written by RN #2, who discharged the patient, revealed "Spoke with family member who came to pick up patient-she states that patient needs to be reevaluated for her psych medications. Psych care was offered to patient and family member whom declined as they did not want to want to wait. Information given to family about following with PCP (Primary Care Provider) and referrals given for psych care--no other needs expressed." Review of a Case management consult note dated 08/30/2019 at 1043, (2 days after discharge) revealed "SW received consult but pt was already discharged . Per RN, SW was consulted because family was interested in a new placement but later decide (sic) to take patient home and work on placement from there with PCP."

Interview on 10/29/2019 at 1515 with MD #1 revealed a phone call was made to patient's son without success. Interview revealed the consult was ordered for assistance with evaluation of placement or discharge options. Interview confirmed MD #1 was not aware that the patient left before the consult was completed.

Interview on 10/29/2019 at 1522 with RN #2, discharging RN, revealed RN #2 discharged the patient for another nurse. Interview revealed RN #2 was also the Charge Nurse on that shift and was assisting with discharges. Interview revealed RN #1 was not aware of an order for the patient to see Case Management before discharge. Interview revealed Patient #2's family wanted a psychiatrist evaluation before discharge. Interview revealed no phone call was made to the physician to notify of the family failing to wait for the Case Management evaluation.

Interview on 10/30/2019 at 1350 with Director of CM revealed Case Managers should see patients within 2 hours after the consult is written. Interview confirmed Patient #2 was not seen before discharge. Interview revealed no phone call was made to the ordering physician to notify that patient was not seen before discharge.

Interview on 10/29/2019 at 1545 with CM #1 revealed there was no documentation of a case management consult completed with the patient. Interview revealed there was no documentation of notification of physician of a lack of case management evaluation. Interview confirmed the patient was not seen prior to discharge.

NC 661