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 record review, staff interviews and facility discharge planning policies and procedures, 1 of the 8 dismissed sampled patients (Patient 2) from a total of 10 sampled patients (Pt) failed to have a reassessment prior to discharge. The evening prior to discharge the patient had increased agitation requiring 3 prn (as needed) doses of Zyprexa (an antipsychotic medication given for behaviors) to control the patients behaviors.

Findings are:

Review of Patient 2's medical record revealed, Pt 2 was brought to the hospital on [DATE] at 1951 (7:51 PM) by the police due to harmful behaviors and agitation towards those around the patient at their home. Pt 2 was found to have vascular dementia (brain damage caused by multiple strokes making the person have memory loss) with behavioral disturbances. The psychiatrist evaluated the patient, and found that the patient would not benefit from psychothearapy due to the major neurocognitive disorder (vascular dementia) which is not a mental illness. The patient had been followed under a neurologist (a doctor that treats the brain and nervous system) at home, and the psychiatrist recommended consulting the pts neurologist for medication adjustments. The neurologist (Dr T) followed Pt 2 while hospitalized and ordered Seroquel (a medication used to treat mental/mood conditions) 50 mg (milligrams) at bedtime. While Pt 2 was hospitalized the patient required a 1:1 sitter (someone within arms reach at all times) initially then close observation (someone that can see the patient at all times). The patient had intermittent behaviors and agitation during the hospitalization . The patient was referred to several long term nursing home facilities while at the hospital which refused admission. A nursing home (NH W) agreed to come to the hospital on [DATE] to assess Pt 2 to verify that the facility could meet the patients needs. NH W agreed to admit the patient on 10/14/20.

The nurses notes revealed:
-On 10/13/20 at 3:33 PM, Pt 2 was "ambulating with staff in the hallways and became increasingly agitated and focused on leaving to "get to (a business the pt used to work for) to get to work." Pt was redirected into the pt room and pt continued to be agitated with wanting to leave. Continual redirection failed. Pt was given 5 mg of Zyprexa (antipsychotic mood altering medication) to calm pt."
-On 10/13/20 at 11:40 PM the RN (registered nurse) wrote, "RN starts shift at 1800 (6:00 PM) and pt is close obs (observation). From the beginning of my shift pt has been continuously getting up out of (gender) chair with refusal of a gait belt (a belt that helps steady the pt when walking). Pt became increasingly agitated and focused on 'getting to the 1st floor to work'. Pt was redirected into pt room but refused multiple times to stay in room. Pt walked the halls and then decided to go back into the room. Pt then become more agitated and started to yell at staff for not letting (gender) leave the floor. Security was called to calm down the pt. Pt was given 5 mg IM (intramuscular-in muscle) Zyprexa to calm pt and another 5 mg IM Zyprexa. Pt is now resting in bed."

Review of the Medication Administration Record (MAR) revealed:
Dr D gave an order dated 9/26/20 for Zyprexa 5 mg IM every 6 hours PRN (as needed):
-the medication was documented as given on 10/13/20 2159 (9:59 PM); 10/13/20 1530 (3:30 PM); 10/8/20 1944 (7:44 PM); 10/8/20 1745 (5:45 PM) and 10/3/20 2353 (11:53 PM)
An additional order was received from Nurse Practitioner E on 10/13/20 at 2217 (10:17 PM) for Zyprexa 5 mg IM one time:
-the medication was documented as given on 10/13/20 2224 (10:24 PM)

Review of the Social Worker B (SW B) note dated 10/13/20 at 3:12 PM revealed, spoke with NH W in regards to discharge plan for Wednesday at 12:00. NH W confirmed that they will pick up the pt at noon.

Review of the Physician Discharge Summary by Dr C dated 10/14/20 at 8:58 AM revealed, "Pt has had intermittent agitation for several days no significant agitation. Suspect this is due to being in a hospital environment but ultimately may need increasing antipsychotics if behaviors do return."

Review of the information sent with Pt 2 to NH W revealed that the "After Visit Summary" and the "Transition Orders and Information for the Continuation of Pt Care" documents lacked documentation of the 10/13/20 evening behaviors requiring the 3 injections of the antipsychotic medication. The record also lacked a note from SW B dated 10/14/20 prior to discharge to update the receiving facility.

The patient was discharged on [DATE] at 1310 (1:10 PM) to NH W via their van.

An interview on 12/1/20 at 1:50 PM with the SW B revealed that NH W called back 20-35 minutes after Pt 2 arrived and said they were sending the patient back due to the patients combative behaviors. When asked if SW B was aware that the patient had a 3 doses of the Zyprexa due to behaviors the evening (10/13/20) before discharge (10/14/20); SW B stated, "No, I wasn't aware, that morning the pt was not having any issues so just went ahead with with discharge." SW B verified, that (gender) did not let the NH W know about the behaviors 10/13/20 due to (gender) was unaware.

Review of the emergency room medical record dated 10/14/20 at 1523 (3:23 PM) revealed, "(Pt 2) presented to the emergency department for dementia with agitation." "The pt was discharged today around noon. Pt was placed at (NH W), where staff reports (Pt 2) was very combative with them. Consequently, pt was brought back to the emergency department." "Will admit the patient observation status to facilitate placement to a geriatric psychiatric bed better equipped to manage (gender) chronic issues."

The patient was discharged on [DATE].

A review of the policy and procedure titled "Medical-Surgical Case Management" dated 9/2019, revealed:
-The Purpose: To define Medical-Surgical Case Management and the discharge planning process for pts receiving care at (the hospital).
-This policy applies to all pts with assessed discharge planning needs on admission and/or anytime during the hospital stay via reassessment of needs to in the hospital and as they transition to home or placement on discharge.
-"Nursing staff will notify case management if discharge needs are identified or condition changes."