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.
| SAINT ALPHONSUS REGIONAL MEDICAL CENTER | 1055 NORTH CURTIS ROAD BOISE, ID 83706 | May 27, 2021 |
| VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION | Tag No: A0123 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined an informal grievance was not documented, investigated, and responded to in writing, for 1 of 1 patient (Patient #2) whose medical record documented a complaint and whose record was reviewed. This resulted in an uninvestigated grievance, and missed opportunity to address concerns. Findings include: A hospital policy, "Patient Complaint and Grievance Program -- SAHS," dated 6/06/19, defined a grievance as a formal or informal written or verbal complaint by a patient or patient representative regarding the patient's care, abuse or neglect, patient harm, quality of care, issues related to the RHM's compliance with the the CMS Conditions of Participation or a Medicare Beneficiary billing complaint related to rights and limitations. The following informal verbal complaint was not captured as a grievance. Patient #2 was a [AGE] year old female who resided in an ALF. She was admitted on [DATE] for back surgery, discharged on [DATE], and returned to the ED on 5/14/21 after the ALF refused to accept her when she arrived by taxi after her initial discharge. A "CM Narrative Note," dated 5/14/21 at 9:33 AM, stated the hospital's CM discussed Patient #2's discharge with an RN at the ALF (where Patient #2 had resided prior to her admission). It stated the ALF's RN wanted Patient #2 to go to an inpatient rehabilitation unit. The hospital's CM explained to the ALF's RN that therapy staff recommended Patient #2 return to the ALF with home health services. The ALF's RN stated she wanted to review the hospital notes prior to approving Patient #2's return to the ALF and she provided the ALF's fax number. A "CM Narrative Note," dated 5/14/21 at 1:17 PM, stated Patient #2 left prior to orders being available to the hospital's CM. It stated that nursing staff reported Patient #2 called a cab to take her back to her ALF, and the hospital's CM did not meet with her prior to her discharge. A "CM Narrative Note," dated 5/14/21 at 5:05 PM, stated the CM received a call from Patient #2's NP provider, stating Patient #2 "has been denied return to her ALF. NP stated patient was advised to return to the hospital." The note further documented the ALF representative complained that Patient #2 "should not have returned to the facility by cab...that cab transportation was inappropriate for a post surgical patient." She also complained Patient #2 was in terrible pain upon arrival at the ALF and that she was instructed to return to the ED. Patient relations later notified the hospital's CM that Patient #2 was in the ED. There was no documentation the informal verbal complaints, received from an ALF representative, alleging Patient #2's inappropriate transfer to the ALF or inadequate pain management was documented as a grievance and investigated. The Regional Director for Patient Safety/Regulatory Compliance was interviewed on 5/26/21 at 2:30 PM. She confirmed there were no grievance reports filed related to Patient #2's hospitalization [DATE] to 5/14/21, or return visit to the ED on 5/14/21. An informal verbal complaint on behalf of Patient #2 was not documented as a grievance, subsequently investigated, and responded to as a grievance. |
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| VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING | Tag No: A0130 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of patient rights information, record review, and staff interview, it was determined the hospital failed to ensure a patient was included in her discharge plan for 1 of 6 patients (Patient #2) who were discharged and whose records were reviewed. This resulted in a lack of clarity as to a patient's approval of her discharge disposition. Findings include: An undated patient brochure, "Patient Rights & Responsibilities," stated: "You have the right to make informed decisions regarding your care, including the rights to:...Participate in your plan of care, discussing and working together with your provider to make decisions regarding your treatment...Be informed of the need for a transfer and the alternatives to transfer, prior to your transfer to another health care facility." Patient #2 was a [AGE] year old female, admitted on [DATE] for a surgical procedure and discharged to her prior residence, an ALF, on 5/14/21. After Patient #2 arrived at the ALF in a taxi, ALF staff would not accept her, and sent her back to the hospital. After her return to the hospital's ED on 5/14/21, she was discharged to a SNF. There was no documentation Patient #2 was included in decision making regarding her discharge disposition to the SNF after returning to the hospital's ED. The Director of Acute Care assisted with navigating Patient #2's electronic health record on 5/27/21 at approximately 11:30 AM, along side a CM who made arrangements for Patient #2's discharge from the ED to a SNF. The CM stated "I let her know and she was fine with it." They were unable to point out any documentation of discussion with Patient #2 regarding the option of being discharged to a SNF. There was no documentation Patient #2 was informed of or participated in decision making regarding her discharge to a SNF. |
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| VIOLATION: PATIENT SAFETY | Tag No: A0286 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of hospital policies, patient records, and staff interview, it was determined the hospital failed to ensure the hospital tracked adverse patient events, analyzed their causes, and implemented preventive actions for 1 of 1 patient (Patient #2) whose record documented incidents and whose record was reviewed. This resulted in a failure to analyze incidents and potentially improve discharge planning processes that led to an adverse event. A hospital policy, "Event Reporting and Investigation Process -- SAHS," dated 2/27/20, included: - "This policy sets forth guidelines for the identification, reporting and investigation process for Events as defined in this policy." - "An event is an occurrence that is inconsistent with the normal or expected operation of the organization that either did, or could, adversely affect a visitor or patient, or a patient's planned care." - "The employee or medical staff member involved in, observing, or discovering an Event is responsible for initiating an event report." - "File Manager Checklist" included: "...Document ... How you investigated the event...What you found...What you did to resolve this event...What you did to prevent a similar event from reoccurring in the future..." A hospital policy, "DISCHARGE OR TRANSFER OF A PATIENT," dated 5/2012, stated "The patient will be assessed prior to discharge or interfacility/interagency transfer. Patient will have a Licensed Independent Practitioner (LIP) order and a discharge plan prior to discharge...Interdisciplinary collaboration, with appropriate disciplines, will occur to meet the needs of patient and family prior to discharge...Patients, significant others, and/or identified caregivers will be included in discharge planning and instruction." The following events were not tracked or investigated to analyze and prevent recurrence: Patient #2 was a [AGE] year old female who resided in an ALF. She was admitted on [DATE] for back surgery, discharged on [DATE], and returned to the ED on 5/14/21 after the ALF refused to accept her when she arrived by taxi after her initial discharge. A "CM Narrative Note," dated 5/14/21 at 9:33 AM, stated the hospital's CM discussed Patient #2's discharge with an RN at the ALF (where Patient #2 had resided prior to her admission). It stated the ALF's RN wanted Patient #2 to go to an inpatient rehabilitation unit. The hospital's CM explained to the ALF's RN that therapy staff recommended Patient #2 return to the ALF with home health services. The ALF's RN stated she wanted to review the hospital notes prior to approving Patient #2's return to the ALF and she provided the ALF's fax number. There was no documentation the ALF reviewed and agreed to accept Patient #2 back to their facility, prior to her hospital discharge. A "CM Narrative Note," dated 5/14/21 at 1:17 PM, stated Patient #2 left prior to orders being available to the hospital's CM, and that nursing reported Patient #2 called a cab to take her back to her ALF, and the hospital's CM did not meet with her prior to her discharge. A "CM Narrative Note," dated 5/14/21, stated the CM received a call from Patient #2's NP provider, stating Patient #2 "has been denied return to her ALF. NP stated patient was advised to return to the hospital." Patient #2 returned to the hospital's ED, and was later discharged to a SNF. This event was not investigated to determine why Patient #2 was discharged prior to completion of discharge planning, necessitating her return to the ED the same day she was discharged . The Director of Case Management was interviewed on 5/26/21 at 1:00 PM. She stated it was their discharge planning process to send referral information to the ALF or SNF prior to discharge and for the CM to verify and validate the facility's acceptance prior to discharge. This did not occur. The Regional Director for Patient Safety/Regulatory Compliance was interviewed on 5/26/21 at 2:30 PM. She confirmed no incident reports were filed related to Patient #2's hospitalization [DATE] to 5/14/21 or return visit to ED on 5/14/21. Patient #2's premature discharge was not tracked, investigated, and analyzed to prevent similar occurrences. |
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| VIOLATION: DISCHARGE PLANNING - PT RE-EVALUATION | Tag No: A0802 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of hospital policies, record review, and staff interview, it was determined the hospital failed to ensure discharge plans were re-evaluated to identify changes that required modification of the discharge plan to include relevant patient education. This lack of re-evaluation directly affected 1 of 3 patients (Patient #1) whose records were reviewed for discharge planning and who were discharged to their homes. Findings include: The hospital's policy, "Discharge Planning -- SAHS," approved 6/17/20, included the following: - "The discharge plan identifies needs that the patient may have for psychosocial or physical, treatment or services after discharge, or transfer from the hospital." - "Clinical indicators which may identify a potential need for transition/discharge planning include: ...New assistive or medical equipment after discharge..." - "Reassessment of discharge needs occur based on changes in patient's condition, anticipated post discharge needs..." - "The RN will provide discharge instructions..." The hospital's policy, "DISCHARGE OR TRANSFER OF A PATIENT," approved May 2012, stated, "Patients being discharged will be given written and verbal discharge instructions..." Patient #1 was a [AGE] year old male, admitted on [DATE] for a lumbar laminectomy. He was discharged to his home on 5/13/21. Patient #1's record included a "Progress Note," signed by an NP on 5/13/21. The section of the note titled "Plan" stated, "DC JP drain [a drain that uses suction to collect fluid from a surgical site and is periodically emptied.] Patient will shower and then please Place Pravena [sic] wound VAC ... Discharge home with family follow-up with Dr. [name] in 7-10 days." The Prevena wound VAC system is a product of KCI. The website, "mykci.com" was accessed on 6/01/21. It included patient information and education on the Prevena wound VAC system, including: "Keep your therapy unit in a safe place where: Tubing will not become kinked or pinched It cannot be pulled off a table or dropped onto the floor Showering: If cleared by your doctor, a quick, light shower is OK. Keep the therapy unit away from direct water spray. Do not submerge dressing in water. When towel drying, be careful not to disrupt the dressing. See PREVENA PLUS (Trademark) Therapy Patient Guide for additional details. Batteries: This therapy unit comes with three AA size batteries and cannot be recharged. It is recommended that you keep extra batteries on hand. If the batteries run out, consult your PREVENA (Trademark) Therapy Patient Guide on how to replace the batteries." Patient #1's record included a Case Management note entered on 5/12/21 at 11:10 AM, signed by an RN. The note stated, "Plan: transition to po [oral] pain meds, JP drain-monitor output ... Anticipate dc home tomorrow w/spouse support. CRM will [continue] to follow for dc needs." Patient #1's record included a Case Management note entered on 5/13/21 at 10:53 AM, signed by an RN. The note stated "Anticipate pt will DC home later today after medically cleared, no known DC needs." The note did not include an update regarding the discontinuation of the JP drain and application of the Prevena wound VAC. Patient #1's record included a "Discharge/Depart Form," undated, that stated, "pravena [sic] wound vac in place. Discharge instruction given." The form did not specify what instructions were provided to Patient #1. Patient #1's record included "PATIENT DISCHARGE INSTRUCTIONS" The instructions included a section titled, "WOUND/DRESSING CARE." The section did not include information or instructions related to the Prevena wound VAC. Patient #1's record did not include documentation that he was educated on the care of his Prevena wound VAC. The Director of Acute Care was interviewed on 5/27/21 at 11:25 AM. She reviewed Patient #1's record and confirmed it did not include documentation of patient education regarding his Prevena wound VAC. She stated it was important to educate patients with a Prevena wound VAC on how to reinforce the wound dressing if necessary and to watch the level of drainage in the canister to ensure it was not too full. Patient #1's discharge plan was not updated to include the Prevena wound VAC applied on the day of his discharge. The hospital failed to ensure he received necessary information and was educated on the care of his wound VAC at home. |
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| VIOLATION: POST-HOSPITAL SERVICES | Tag No: A0808 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure an acceptable discharge plan was established in coordination with the patient and the patient's ALF representative for 1 of 2 patients (Patient #2) who resided in an ALF prior to admission and whose records were reviewed. This resulted in a patient being discharged prior to acceptance by an ALF, and a subsequent refusal by the ALF to receive the patient, resulting in a return to the hospital. Findings include: A hospital policy, "Discharge Planning --SAHS," dated 6/17/20, stated: - "Patients will receive discharge/transition planning to facilitate continuity of care." - "Effective discharge/transition planning requires the coordinated efforts of many departments and staff in the hospital." A hospital policy, "DISCHARGE OR TRANSFER OF A PATIENT," dated 5/2012, stated: - "Interdisciplinary collaboration, with appropriate disciplines, will occur to meet the needs of patient and family prior to discharge" - "Patients, significant others, and/or identified caregivers will be included in discharge planning and instruction." These policies were not followed. Patient #2 was a [AGE] year old female who resided in an ALF. She was admitted on [DATE] for back surgery, discharged on [DATE], and returned to the ED on 5/14/21 after the ALF refused to accept her when she arrived by taxi after her initial discharge. A "CM Narrative Note," dated 5/14/21 at 9:33 AM, stated the hospital's CM discussed Patient #2's discharge with an RN at the ALF (where Patient #2 had resided prior to her admission). It stated the ALF's RN wanted Patient #2 to go to an inpatient rehabilitation unit. The hospital's CM explained to the ALF's RN that therapy staff recommended Patient #2 return to the ALF with home health services. The ALF's RN stated she wanted to review the hospital notes prior to approving Patient #2's return to the ALF and she provided the ALF's fax number. There was no documentation the ALF had reviewed Patient #2's notes and agreed to accept her, upon hospital discharge, into their facility. A "CM Narrative Note," dated 5/14/21 at 1:17 PM, stated Patient #2 left prior to orders being available to the hospital's CM, and that nursing reported Patient #2 called a cab to take her back to her ALF, and the hospital's CM did not meet with her prior to her discharge. Patient #2 was discharged from the hospital with discharge instructions by an RN based on provider discharge orders, prior to any confirmation of acceptance by the ALF, any orders being sent to the ALF, or the opportunity for the CM to meet with Patient #2. Interdisciplinary collaboration was missing. The RN who discharged Patient #2 on 5/14/21 was interviewed on 5/27/21 at 11:00 AM. He stated he saw Patient #2 by the elevator getting ready to leave, and he invited her back to her room to review discharge instructions and prescriptions. He stated a provider order had been signed to discharge Patient #2 to home (ALF) with home health services. He printed her discharge instructions and gave her prescriptions and had a CNA escort her out of the hospital. When asked, he stated he was not aware of any reason to delay her discharge. He stated Patient #2 was anxious to leave as she was fearful the ALF would get rid of her cat if she did not return right away. Interdisciplinary collaboration and communication between the discharging RN, provider, and Case Management was missing. A "CM Narrative Note," dated 5/14/21, stated the CM received a call from Patient #2's NP provider, stating Patient #2 "has been denied return to her ALF. NP stated patient was advised to return to the hospital." The Director of Case Management was interviewed on 5/26/21 at 1:00 PM. She stated it was their discharge planning process to send referral information to the ALF or SNF prior to discharge and for the CM to verify and validate the facility's acceptance prior to hospital discharge. This did not occur. The Manager of Care Coordination was interviewed on 5/27/21 at approximately 11:30 AM. She stated "we thought we had a soft yes" of acceptance at the ALF, but there was not a firm yes as the ALF had not reviewed the paperwork. Patient #2 returned to the hospital's ED, and was later discharged to a SNF. There was no documentation Patient #2 was included in decision making related to her second discharge from the ED to a SNF. Patient #2's ED CM was interviewed on 5/27/21 at approximately 12:00 PM. She stated she let Patient #2 know about the discharge to a SNF and "she was fine with it." She was not able to point to any documentation stating Patient #2 was included in her discharge plan. The hospital failed to establish an appropriate discharge plan for Patient #2 and failed to ensure she was included in her discharge planning decisions. |
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