HospitalInspections.org

Based on observation, interview, record review and document review, the facility failed to follow the process for prompt resolution of patient grievances.

Findings include:

Patient #4 was admitted to the facility on 9/17/11 with diagnoses including pericardial tamponade and effusion and hand infection.

On 10/4/11 at 3:15 PM, Patient #4 explained she let Physician #1 know she no longer wanted him as her physician on 10/4/11 in the morning. The patient stated the physician told her "Well that's fine with me. I was getting tired of you anyway" and he walked out of the room. The patient stated the physician had not talked to her, did not check her lungs or listen to her heart if he came in to see her.

Patient #4 expressed concern regarding future care while in the facility since the physician was mad. The patient stated the Chief Executive Officer (CEO) had notified Physician #1 prior to his arrival in the facility regarding the patient wanting to discharge his services. The patient was not sure why the CEO contacted the physician and was concerned he was also angry with her.

On 10/4/11 at 1:15 PM, the CEO acknowledged there had been a couple of occasions where Physician #1's demeanor had been brought up to him. The CEO explained the physician was in good standing with the medical committee. The CEO stated Physician #1 had a fairly large patient load at the facility.

On 10/4/11 at 3:55 PM, the Certified Occupational Therapy Assistant (COTA) and the Physical Therapy Assistant (PTA) were interviewed in the therapy department office.

The PTA explained Patient #4 was walking with a walker in the patient's room. The patient explained she was planning on firing Physician #1. The PTA explained during therapy in the patient's room, Physician #1 entered the room. The PTA stated the patient told the physician she was relinquishing the physician from her care. The PTA heard the physician tell the patient she would be leaving in a few days. The patient then repeated her request to have another physician. The PTA stated the physician told the patient "Well, I was tired of you any way." The PTA informed the house supervisor and the charge nurse.

The COTA explained she was setting up supplies in Patient #4's bathroom during the time Physician #1 entered the patient's room. The COTA acknowledged the interaction with the patient and physician. The COTA stated she had heard Physician #1 talk over patients or tell them he did not have time to answer their questions. The COTA relayed a time when Physician #1 was at the nursing station and stated "I don't give a [swear word] about what these patients want." The COTA reported the incident to her supervisor.

On 10/7/11 at 10:20 AM, the Registered Nurse (RN) Supervisor explained the complaint process. When a complaint was received, she would refer the issue to the shift supervisor. The supervisor acknowledged the complaint log documentation was not forwarded to the upper management team. The supervisor explained issues were tried to be resolved immediately. The supervisor acknowledged she was not familiar with the facility's grievance and complaint policies.

Patient Complaint/Grievance Log for June, July, August, September and October were reviewed.

There were 18 complaint/grievances in June 2011. On 6/3/11, a complaint regarding Physician #1 verbally abused a patient's daughter. Patient complaint regarding night nurses and certified nursing assistants mean to a patient on the 300 hall. Employees were to be talked to by the supervisor. There was no documented evidence a Complaint form was completed.

There were 11 complaint/grievances in July 2011. There were allegations of staff not providing care, being rude and disrespectful, not receiving pain medications and not answering the call light. There was no documented evidence a Complaint form was completed.

There were five patient complaints in August 2011. There was no documented date received or comments regarding an allegation of a nurse rough with a Foley catheter insertion. There were two complaints regarding patient call bells. Documentation of communication with the nurse and certified nursing assistants and the patient was satisfied. Two complaints regarding night shift very noisy. There was no documented evidence a Complaint form was completed.

September 2011 documented two certified nursing assistants at night would "mock" the patient residing in room 207. The issue was resolved by transferring the patient to a different area of the building. There was no documented evidence regarding investigation into the allegations regarding the staff treatment of the patient. There was no documented evidence a Complaint form was completed.

October 2011 documented concern with the care given at night by the certified nursing assistants on the 200 hall. The log documented the complaint would be given to the night supervisor to have a meeting with the night staff. There was no documented evidence a Complaint form was completed.

Patient Rights and Responsibilities policy 001-48-017.5, revised January 2011 was reviewed.

"C. Patients have the right to participate in the development and implementation of their plan of care, including their discharge plan. The plan of care must meet both their medical and psychological needs."

"P. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation. Patients have a right to access protective and advocacy services."

Complaint, Patient/Family policy 001-05-001.3, revised June 2011 was reviewed.

"B. The individual receiving a complaint will immediately take steps to resolve the issue and complete a Complaint form. The Complaint form is given to the appropriate Department manager or designee. The Department Head or designee will review the concern and verify that the complaint has been resolved. A copy of all complaints are sent to the Quality Management Department for review."

Grievance, Patient/Family policy 001-05-002.6, revised September 2011 was reviewed.

Procedure

"5. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements are considered a grievance."

Grievance Process

"7. Grievances will be evaluated bi-weekly to ensure follow-up actions have been implemented and to identify trends by a complaint/grievance panel. Members of the complaint grievance panel reviewing the grievances may be the DQM (Director of Quality Management), DON (Director of Nursing), DCM (Director of Case Management), and Department Manager involved. The Quality Management analysis of grievances will be reported to the Medical Executive Committee and the Governing Board on a regular basis."

Abuse, Neglect, Assault Alleged or Suspected policy 001-01-035.4, revised August 2010 was reviewed.

The definition of Verbal Abuse was documented as "the use of any oral, written or gestured language that includes disparaging and derogatory terms to or within hearing distance of the person regardless of age, ability to comprehend or disability."

Review of the Quality Council Meeting minutes from 4/27/11 was completed. The meeting minutes discussed a new Patient Satisfaction Survey vendor. The notes documented there was only March data and the sample size would be larger the next quarter.

The 2011 Performance Indicator Dashboard documented there were no trends identified with customer complaints.

A Quality Council Meeting was held on 8/4/11. There was no documented evidence of patient satisfaction noted on the previous council meeting minutes.

The 2011 Performance Indicator Dashboard documented there were no trends identified with customer complaints.

Based on observation, interview, record review and document review, the facility failed to assure the patient's were free from all forms of abuse and harassment.

Findings include:

Patient #4 was admitted to the facility on 9/17/11 with diagnoses including pericardial tamponade and effusion and hand infection.

On 10/4/11 at 3:15 PM, Patient #4 explained she let Physician #1 know she no longer wanted him as her physician on 10/4/11 in the morning. The patient stated the physician told her "Well that's fine with me. I was getting tired of you anyway" and he walked out of the room. The patient stated the physician had not talked to her, did not check her lungs or listen to her heart if he came in to see her.

Patient #4 expressed concern regarding future care while in the facility since the physician was mad. The patient stated the Chief Executive Officer (CEO) had notified Physician #1 prior to his arrival in the facility regarding the patient wanting to discharge his services. The patient was not sure why the CEO contacted the physician and was concerned he was also angry with her.

On 10/4/11 at 3:55 PM, the Certified Occupational Therapy Assistant (COTA) and the Physical Therapy Assistant (PTA) were interviewed in the therapy department office.

The PTA explained Patient #4 was walking with a walker in the patient's room. The patient explained she was planning on firing Physician #1. The PTA explained during therapy in the patient's room, Physician #1 entered the room. The PTA stated the patient told the physician she was relinquishing the physician from her care. The PTA heard the physician tell the patient she would be leaving in a few days. The patient then repeated her request to have another physician. The PTA stated the physician told the patient "Well, I was tired of you any way." The PTA informed the house supervisor and the charge nurse.

The COTA explained she was setting up supplies in Patient #4's bathroom during the time Physician #1 entered the patient's room. The COTA acknowledged the interaction with the patient and physician. The COTA stated she had heard Physician #1 talk over patients or tell them he did not have time to answer their questions. The COTA relayed a time when Physician #1 was at the nursing station and stated "I don't give a [swear word] about what these patients want." The COTA reported the incident to her supervisor.

Patient Rights and Responsibilities policy 001-48-017.5, revised January 2011 was reviewed.

"P. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation. Patients have a right to access protective and advocacy services."

Abuse, Neglect, Assault Alleged or Suspected policy 001-01-035.4, revised August 2010 was reviewed.

The definition of Verbal Abuse was documented as "the use of any oral, written or gestured language that includes disparaging and derogatory terms to or within hearing distance of the person regardless of age, ability to comprehend or disability."

Based on observation, interview, record review and document review, the nursing staff failed to turn 6 patients every two hours as identified on the critical care flow sheet (Patients #1, #8, #9, #10, #11 and #12); the nursing staff failed to follow physician order for wound care (Patients #1); and the facility staff applied Prafo boots without a physician order (Patient #8).

Findings include:

Patient #1

Patient #1 was readmitted to the facility on 5/12/11 with diagnoses including anoxic brain injury, respiratory failure, sepsis, end stage renal disease, diabetes mellitus, bacteremia and decubitus ulcers.

The wound care assessment dated 5/13/11 documented an occipital wound occurring prior to admission. There was no documented evidence of the size of the wound. On 5/27/11, the wound measured 3 centimeter (cm) long by 5 cm wide.

On 7/8/11, the wound care assessment documented the wound was 5 cm by 6.8 cm by 1 cm deep. The wound was open to the bone. On 7/14/11, a wound vacuum was placed on the wound. On 9/22/11, the wound measured 5 cm by 5 cm. The wound was 100% filled with tissue overgrowth.

1. A random review of the patient care flowsheet/nursing interventions revealed inconsistent documentation of the patient being repositioned every two hours. The patient had not been turned:
- On 6/25/11 from 7:00 pm - midnight
- On 6/27/11 from 7:00 am - 7:00 pm
- On 6/14/11 from 7:00 am -5:00 pm
- On 8/21/11 from 11:00 am - 5:00 pm
- On 8/21/11 from 5:00 pm - 6:00 am
- On 8/3/11 was turned every four hours from 6:00 pm - 6:00 am.

2. Xenaderm to be applied after each episode of incontinence was ordered on 5/13/11. Review of the Medication Administration Record (MAR) revealed the wound care team was to apply. There was no documented evidence the nursing staff applied the xenaderm after each episode of incontinence.

Patient #8

Patient #8 was admitted to the facility on 9/12/11 with diagnoses including ruptured infrarenal anterior aorta aneurysm, acute renal insufficiency, chronic subdural hematoma, acute respiratory failure, hepatic failure and anemia.

The initial nursing assessment, dated 9/12/11, documented a healing incision in the right and left groin and a swollen scrotum.

The wound care orders on 9/13/11 documented the heels were to be off loaded at all times. The patient was placed on a Size Wise Alternating Pressure (SWAP) mattress due to severe debilitation.

On 9/20/11, the wound assessment form documented the patient had on Prafo boots. There was no documented evidence of a physician order for Prafo boots found in the patient's medical record.

A wound was noted on the right fifth metatarsal head measuring 3 cm by 3.5 cm. Ultrasound treatments were ordered and provided.

On 10/7/11 at 8:35 am, Patient #8 was observed in room 408 with pillows under his left hip and left shoulder. The nursing documentation indicated the patient was placed on his left side. The wound care nurse #1 acknowledged the coccyx remained on the bed and the patient was not positioned on his left side. The nurse explained she had discussed with her supervisor the concern of patients not being turned enough. The wound care nurse demonstrated placing a pillow under the patient's ankles to off load the heels from the bed.

The wound care nurse explained Prafo boots were used to off load heels from the mattress. The nurse explained a pillow would also be used to off load the patients' heels. The nurse stated the Prafo boots would be on the patient for two hours then removed for two hours throughout the day. The nurse believed the boots were removed at night.

A random review of the nursing interventions revealed the patient had not been repositioned every two hours. The following dates were reviewed: 9/13-9/22/11 and 10/1-10/4/11. The patient was not turned from:
- 7 pm - 7 am on 9/15/11.
- The patient was left on his left side from 7 am - 1 pm and on his right side from 7 pm - 7 am on 9/17/11.
- The patient remained on his right side for 24 hours on 9/18/11.
- On 9/15, 9/16 and 9/19/11, the notes documented the patient had on Podus Boots.
- On 9/17, and 9/18/11, the notes documented the patient had on Prafo boots. There was no documented evidence the boots were removed or the skin was checked.
- On 9/19/11, the night shift noted redness on the right plantar area and left the wound open to air.

Patient #9

Patient #9 was admitted to the facility on 8/12/11 with diagnoses including ventilator dependent respiratory failure, gastrointestinal bleed, kidney failure requiring hemodialysis and anemia.

The wound care assessment documented on 8/13/11 a pressure sore on the coccyx present on admission to the facility.

On 8/17/11, the wound care assessment documented a left lateral heel wound acquired post admission.

Review of the nursing interventions/routine patient care sheet revealed inconsistent documentation of the patient being turned every two hours.
- On 8/14, the documentation revealed the patient had not been turned in 24 hours.
- On 8/16, the patient had not been turned from midnight to 6:00 am.
- On 8/21, the patient remained on his right side from 7:00 am through 7:00 pm. There was no documentation the patient was turned from 7:00 pm through 7:00 am.

On 10/5/11, at 7:30 am, Patient #9 was observed in the supine position. At 9:10 am, the patient was observed in the same position. There was no documentation on the nursing daily flow record the patient was repositioned.

On 10/5/11 at 9:15 am, Patient #9 stated he had not been turned. A pillow was noted to be placed under the patient's left hip.

The patient was turned to his left side by the Chief Nursing Officer (CNO). The CNO acknowledged the patient could have been considered turned to his right side, but there was no off loading on the patient's coccyx area.

Patient #10

Patient #10 was admitted to the facility on 8/29/11 with diagnoses including cerebrovascular accident, persistent vegetative state, renal failure and hemodialysis. The wound assessment documented the patient arrived with a coccyx pressure ulcer, Stage IV.

Review of the nursing interventions/routine patient care sheet revealed inconsistent documentation of the patient being turned every two hours. There was no documented evidence the patient was turned from 7:00 am -7:00 pm on 10/2/11 or from 5:00 pm - 6:00 am on 10/2/11.

The Protocols for the Braden Risk Assessment documented on 8/30/11 the patient was to have the head of the bed less than or equal to 30 degrees at all times. The nursing documentation revealed the patient was placed in Fowlers/Hi Fowlers on 10/3/11.

Patient #10 was observed on 10/5/11 at 7:30 am to be supine. At 9:10 am, the patient was observed in the same position. There was no documentation on the nursing daily flow record the patient had been repositioned.

Patient #11

Patient #11 was admitted to the facility on 9/28/11 with diagnoses including methicillin resistant staphylococcus aureus, anemia, gastroesophageal reflux disease and an ulcer on the right biceps.

The Protocols for the Braden Risk Assessment documented on 9/29/11 the patient was to have the head of the bed less than or equal to 30 degrees at all times. The nursing documentation revealed the patient was placed in Fowlers/Hi Fowlers on 9/29 and 9/30/11.

Review of the nursing interventions/routine patient care sheet revealed inconsistent documentation of the patient being turned every two hours. The documentation revealed the patient remained on his right side from 7:00 am - midnight on 9/29/11.

Patient #11 was observed on 10/4/11 at 7:45 am to be in the supine position. At 9:00 am, the patient was noted to be in the supine position. The nursing documentation revealed the patient was placed in the supine position at 5:00 am. There was no documentation of a change of position at 7:00 am or 9:00 am.

Patient #12

Patient #12 was admitted to the facility on 9/21/11 with diagnoses including Klebsiella bacteremia; right leg wound infection, cellulitis of the right lower extremity, coronary artery disease, hypertension, chronic kidney disease Stage III and decubitus ulcer on the buttocks.

The Protocols for the Braden Risk Assessment documented on 9/22/11 the patient was to have the head of the bed less than or equal to 30 degrees at all times. The nursing documentation revealed the patient was placed in Fowlers/Hi Fowlers on 10/3/11.

Review of the nursing interventions/routine patient care sheet revealed inconsistent documentation of the patient being turned every two hours. The documentation revealed the patient was not turned on 10/2/11 and 10/3/11 from 6:00 pm - 6:00 am.

On 10/4/11 at 7:45 am, three patients were observed in the Intensive Care Unit. All three patients were noted to be in the supine position. At 9:00 am, the patients appeared to be in the same position. The patient in 406 was on a ventilator and was noted to have pillows placed on both sides of her hips. The patients in room 413 and 414 nursing notes documented the patient was placed in the supine position at 5:00 am. There was no documentation of a change of position at 7:00 am or 9:00 am.

On 10/7/11 at 8:15 am, the Wound Care Nurse #1 explained the wound care staff completed all ordered treatments, including applying Santyl. The nursing staff would apply xenaderm as ordered by the physician.

On 10/7/11 at 8:45 am, Registered Nurse (RN) #1 explained xenaderm and nystatin powder treatments were documented on the Medication Administration Record (MAR) by the nurse. The nurse explained Prafo boots were removed every two hours. The boots would remain off for a few minutes or up to 30 minutes. The removal of the boots would be documented in the nursing notes. The nurse explained when a patient was turned to their side; the patient's back should be exposed.

On 10/7/11 at 9:05 am, Wound Care Nurse #2 explained when a patient was wearing a Prafo boot; the staff nurse would assess the skin daily and the wound care nurse weekly. The boot should remain on for two hours then be removed for two hours.

The wound care nurse acknowledged he had noted patients were not always turned every two hours.

On 10/7/11 at 9:30 am, the patient in room 316 stated he was only turned when he messed the bed and then was turned onto his back. The patient complained of pain in his lower back. The patient stated he told his nurse he had a bowel movement and said "the nurses don't care". There was no documented evidence the patient was turned on 10/7/11. There was one pillow observed on the chair beside the patients' bed. The wound care nurse found a pillow in a drawer. The patient required three pillows for positioning due to his size.

On 10/7/11 at 11:00 am, RN #2 explained staff nurses applied xenaderm if ordered. The patients were to be turned every two hours.

RN #2 explained the physical therapy department provided the treatment plan for Prafo boots. The boots were to be on for two hours and off for two hours. If the staff nurse observed a new wound, an incident report was to be completed and the wound care team notified.

On 10/7/11 at 1:05 pm, the Director of Physical Medicine and Rehabilitation explained physical therapy would order treatment for a specialty boot only. The Prafo boot was found in central supply. The Director could not describe a Podus boot.

On 10/7/11 at 1:20 pm, RN #3 explained patients were to be turned every two hours. The nurse explained a patient often would return to the supine position after the nurse had turned the patient.

The RN explained the staff nurses would check the patients' skin daily and apply xenaderm as ordered. The nurse would document on the MAR. The nurse explained the Prafo boot would be kept on for four hours and removed for one hour. The nurse stated the physician must order the Prafo boots. The nurse acknowledged there was no physician order for Prafo boots for Patient #8. The nurse could not describe a Podus boot.

On 10/7/11 at 1:30 pm, the CNO stated Prafo boots would require a physician order. The CNO acknowledged there was no facility protocol regarding the care of the patient with Prafo boots. The CNO stated the facility policy would to use the protocol found in the Lippincott manual. The CNO explained she could not find any information regarding a Prafo boot in the Lippincott manual. The CNO acknowledged there was no record of a completed incident report for Patient #8. The CNO could not describe a Podus boot.

Wound Care policy 201-21-045.5, revised June 2011 was reviewed.

Procedure

"J. Routine assessment and wound care may be provided by the patient's assigned nurse each shift and recorded on the Daily Nursing Assessment."

Complaint #NV00029404

Based on interview, record review and document review, the facility failed to ensure a list of home health agencies were available to 2 of 12 patients sampled (Patient's #2 and #3).

Findings include:

Discharge Planning, Discharge Documentation policy #021-29-001.5, revised June 2011.

"F. The social worker should be familiar with community resources and provides written/oral information to patients and significant others in order for them to make informed decisions regarding services."

"J. In all cases, the Case Manager/Social Worker must inform the patient, legal representative and family as to their freedom to choose among providers of post-hospital care. Patient preferences should be considered regarding their choice of services.

1. When the discharge planning evaluation indicates the need for home health care, the Case Manager/Social Worker includes in the discharge plan a list of participating Medicare home health agencies that are available and serve the patient's geographic area or have a contract with the patient's managed care organization...
3. Case Manager/Social Worker will document in the medical record that the list of home health agencies or skilled nursing facilities was presented to the patient or the individual acting on the patient's behalf including an identification of any financial interests."

Upon arrival to the facility on 10/4/11, a request was made for the facility's list of home health agencies used to provide to the patients. There was no specific list for home health agencies.

Patient #2

Patient #2 was admitted to the facility on 5/27/11 and discharged on 6/27/11. The case management addendum, dated 5/30/11, documented prior community services used was with Home Health Agency (HHA) #1.

The case management concurrent review, dated 6/14/11, documented the patient and patient's wife want to go home with HHA #1.

On 6/27/11, the physician's orders documented a discharge to home order. The discharge instructions documented on 6/27/11, Home Health Agency (HHA) #2 was arranged for the patient. There was no documented evidence of an order for home health evaluation found in the medical record.

Patient #3

Patient #3 was admitted to the facility on 1/6/10 with diagnoses including diabetes mellitus, metastatic prostate cancer, vertebral metastasis, hypertension, deep vein thrombosis, bilateral nephrostomy tubes and transient atrial fibrillation.

On 1/20/11, the phycian's orders documented Physician #1 wrote an order "H/H (home health) is HHA #2. No exceptions." A second order was written on 1/20/11 by Physician #1 "D/C (discharge) home. HHA #2 not HHA #1."

The interdisciplinary progress note documented, by the social worker, the patient was discharged home on 1/21/11 with HHA #2 providing home health care.

Complaint #NV00029404 and #NV00029569

Based on interview, record review and document review, the facility staff failed to apply xenaderm as ordered by the physician for Patient #1.

Findings include:

Patient #1 was readmitted to the facility on 5/12/11 with diagnoses including anoxic brain injury, respiratory failure, sepsis, end stage renal disease, diabetes mellitus, bacteremia and decubitus ulcers.

Xenaderm to be applied after each episode of incontinence was ordered on 5/13/11. Review of the Medication Administration Record (MAR) revealed the wound care team was to apply. There was no documented evidence the nursing staff applied the xenaderm after each episode of incontinence.

On 10/7/11 at 8:15 am, the Wound Care Nurse #1 explained the wound care staff completed all ordered treatments, including applying Santyl. The nursing staff would apply xenaderm as ordered by the physician.

On 10/7/11 at 8:45 am, Registered Nurse (RN) #1 explained xenaderm and nystatin powder treatments were documented on the Medication Administration Record (MAR) by the nurse.

On 10/7/11 at 11:00 am, RN #2 explained staff nurses applied xenaderm if ordered.

On 10/7/11 at 1:20 pm, RN #3 explained the staff nurses would check the patients' skin daily and apply xenaderm as ordered. The nurse would document on the MAR.

Wound Care policy 201-21-045.5, revised June 2011 was reviewed.

Procedure

"J. Routine assessment and wound care may be provided by the patient's assigned nurse each shift and recorded on the Daily Nursing Assessment."

Complaint #NV00029404

Based on interview, record review and document review, the facility failed to ensure a list of skilled nursing facilities were available to 4 of 12 patients sampled (Patient's #4, #5, #6 and #7).

Findings include:

Discharge Planning, Discharge Documentation policy #021-29-001.5, revised June 2011.

"F. The social worker should be familiar with community resources and provides written/oral information to patients and significant others in order for them to make informed decisions regarding services."

"J. In all cases, the Case Manager/Social Worker must inform the patient, legal representative and family as to their freedom to choose among providers of post-hospital care. Patient preferences should be considered regarding their choice of services. If a patient's funding is Medicaid or state funded and DME is denied, the Case Manager/Social Worker may seek additional community funding sources for the equipment...

2. When the discharge planning evaluation indicates the need for post hospital extended care services, the Case Manager/Social Worker includes in the discharge plan a list of participating Medicare skilled nursing facilities that are available and serve the patient's geographic area or have a contract with the patient's managed care organization.
3. Case Manager/Social Worker will document in the medical record that the list of home health agencies or skilled nursing facilities was presented to the patient or the individual acting on the patient's behalf including an identification of any financial interests."

Upon arrival to the facility on 10/4/11, a request was made for the facility's list of skilled nursing facilities used to provide to the patients. There was no specific list for skilled nursing facilities.

Patient #4

Patient #4 was admitted to the facility on 9/17/11 with diagnoses including pericardial tamponade and effusion and hand infection.

The case management (CM) progress notes documented on 9/20/11, the CM met with the patient's legal guardian. A discharge plan was discussed. The notes documented the patient preferred assisted living, which would be the Assisted Living #1. The note documented if the patient required a skilled nursing placement, the facility would be the Skilled Nursing Facility (SNF) #1.

On 10/4/11 at 3:15 PM, Patient #4 stated the CM told her about two places she could go to upon discharge. The patient was not sure what the places were and did not have any written names or phone numbers regarding agencies upon discharge.

Patient #5

Patient #5 was admitted to the facility on 9/13/11 with diagnoses including osteomyelitis of the lower extremities, peripheral vascular disease, chronic anemia, history of hypertension and chronic renal failure.

The physician's orders, dated 10/1/11, documented a skilled nursing facility evaluation. The case management progress notes documented on 10/3/11, a referral was made to the SNF #1. The facility declined due to the patient smoked and the facility was non-smoking.

On 10/4/11, the case management notes revealed a referral to SNF #2. The progress notes documented the patient was accepted and the patient was notified on 10/5/11 of a projected discharge date of 10/6/11.

On 10/5/11 at 7:55 AM, Patient #5 stated he was suppose to go somewhere for three days, but no one tells him what is going on. The patient did not have a list of agencies or phone numbers at his bedside.

Patient #6

Patient #6 was admitted to the facility on 9/21/11 with diagnoses including colon cancer, deep vein thrombosis, colostomy and history of anemia.

The case management progress notes, dated 9/22/11, documented the patient had been at Rehabilitation Hospital #1 prior to admission to the facility. The CM discussed acute rehabilitation versus skilled nursing facility as the discharge plan.

On 10/4/11, the progress notes documented the CM discussed with the patient he would most probably transfer to a skilled nursing facility and then to acute rehabilitation facility. The note documented the CM would provide the patient with a list of skilled nursing facilities.

On 10/5/11 at 8:00 AM, Patient #6 stated the staff was talking about his need to go to another facility to have enhanced physical therapy. The patient did not have a list of facilities or phone numbers. The patient was not sure who discussed the need for a transfer to another facility.

Patient #7

Patient #7 was admitted to the facility on 9/2/11 with diagnoses including squamous cell cancer, aspiration pneumonia, collapsed left lower lobe, chronic obstructive pulmonary disease, hypotension and hypothyroid.

On 9/29/11, the case management progress notes documented the patient told the CM she was not ready to go home because her husband would not be able to care for her yet. The CM called SNF #3 to evaluate the patient for transfer.

On 10/5/11, the progress notes documented the patient required a skilled nursing facility with respiratory services. The CM discussed with the patient, her husband and son regarding the change in transfer facility. The family requested evaluation from SNF #1 and SNF #4.

On 10/6/11, the progress notes documented the patient requested SNF #4. The notes documented the patient and her husband was very happy with the transfer. The patient was transferred on 10/6/11.

On 10/5/11 at 11:15 AM, Patient #7 stated the CM mentioned two or three places the patient could be transferred. The patient stated she never saw any representative from any facility. The patient stated she told the physician and CM she wanted to go to a facility close to her home so her husband could come and visit. The patient stated she thought she was to be transferred to the SNF #3. The patient denied having a list of facilities to choose from and requested information on the SNF #3.

At 12:15 PM, a pamphlet for SNF #3 was provided to the patient. The patient explained she now may be going to another facility which would provide more pulmonary care. The patient did not know the name of the facility, but knew the name of the CM recommending the new facility.

On 10/4/11, at 10:35 AM, a CM was interviewed. The CM requested to remain anonymous. The CM explained when an order was received for referral to another agency; the patient would be notified of the order. The CM would provide the patient with a list of agencies. The CM explained the names of the agencies were provided verbally. The CM stated several agencies would be called to evaluate the patient. The patient provided consent for the evaluation. If the physician ordered a specific agency, the CM explained they had to call the agency to evaluate the patient. The CM stated when Physician #1 orders a specific agency, the CM's were told not to call another agency.

On 10/4/11, at 10:55 AM, CM #2 explained when a physician wrote an order for an evaluation to a community agency, the CM explained to the patient what would occur. The CM explained the CM would choose agencies depending on the needs of the patients. The preferred agency of a physician would be included for evaluation of the patient.

On 10/4/11 at 11:50 AM, the Director of Case Management explained she would check with the patient and family to see if they had a preferred provider. If the family did not have a preferred provider, the Director would recommend several different agencies. The Director explained she would write down the name and phone numbers of the agencies and provide to the patient and/or family. If the physician wrote for a specific agency, the Director would explain to the family the physician recommended the agency but the patient had a choice of what agency they would choose.

Complaint #NV00029569

Based on interview, record review and document review, the facility failed to ensure a list of home health agencies or skilled nursing facilities were available to 2 of 12 patients sampled (Patient's #4 and #5).

Findings include:

Discharge Planning, Discharge Documentation policy #021-29-001.5, revised June 2011.

"3. Case Manager/Social Worker will document in the medical record that the list of home health agencies or skilled nursing facilities was presented to the patient or the individual acting on the patient's behalf including an identification of any financial interests."

Patient #4

Patient #4 was admitted to the facility on 9/17/11 with diagnoses including pericardial tamponade and effusion and hand infection.

The case management progress notes documented on 9/20/11, the Case Manager (CM) met with the patient's legal guardian. A discharge plan was discussed. The notes documented the patient preferred assisted living, which would be the Assisted Living #1. The note documented if the patient required a skilled nursing placement, the facility would be the Skilled Nursing Facility (SNF) #1.

There was no documented evidence found in the patient's medical record a list of SNF's was provided to the patient.

Patient #5

Patient #5 was admitted to the facility on 9/13/11 with diagnoses including osteomyelitis of the lower extremities, peripheral vascular disease, chronic anemia, history of hypertension and chronic renal failure.

The physician's orders, dated 10/1/11, documented a skilled nursing facility evaluation. The case management progress notes documented on 10/3/11, a referral was made to the SNF #1. The facility declined due to the patient smoked and the facility was non-smoking.

On 10/4/11, the case management notes revealed a referral to SNF #2.

Complaint #NV00029404 and #NV00029569

Based on interview, record review and document review, the facility failed to ensure a list of home health agencies or skilled nursing facilities were available for 3 of 12 patients sampled
(Patient's #1, #2 and #3).

Findings include:

Discharge Planning, Discharge Documentation policy #021-29-001.5, revised June 2011.

"F. The social worker should be familiar with community resources and provides written/oral information to patients and significant others in order for them to make informed decisions regarding services."

"J. In all cases, the Case Manager/Social Worker must inform the patient, legal representative and family as to their freedom to choose among providers of post-hospital care. Patient preferences should be considered regarding their choice of services. If a patient's funding is Medicaid or state funded and DME is denied, the Case Manager/Social Worker may seek additional community funding sources for the equipment.

1. When the discharge planning evaluation indicates the need for home health care, the Case Manager/Social Worker includes in the discharge plan a list of participating Medicare home health agencies that are available and serve the patient's geographic area or have a contract with the patient's managed care organization.
2. When the discharge planning evaluation indicates the need for post hospital extended care services, the Case Manager/Social Worker includes in the discharge plan a list of participating Medicare skilled nursing facilities that are available and serve the patient's geographic area or have a contract with the patient's managed care organization.
3. Case Manager/Social Worker will document in the medical record that the list of home health agencies or skilled nursing facilities was presented to the patient or the individual acting on the patient's behalf including an identification of any financial interests."

Patient Rights and Responsibilities policy 001-48-017.5, revised January 2011 was reviewed.

"C. Patients have the right to participate in the development and implementation of their plan of care, including their discharge plan. The plan of care must meet both their medical and psychological needs."

Patient #1

Patient #1 was readmitted to the facility on 5/12/11 with diagnoses including anoxic brain injury, respiratory failure, sepsis, end stage renal disease, diabetes mellitus, bacteremia and decubitus ulcers.

On 9/6/11, the physician's orders documented the pulmonologist wrote an order for palliative care consult with Hospice Agency #1.

On 9/7/11, the medical record documented Hospice Agency #1evaluated the patient and documented the agency would follow up with the patient's husband.

On 9/13/11, Physician #1 wrote an order to cancel Hospice Agency #1and wrote a referral for Hospice Agency #2 to see the patient on 9/13/11.

Case Manager #2's (CM) progress notes documented on 9/12/11 the patient's husband wanted to talk with the hospice representative from Hospice Agency #1. There was no further documentation of the patient's husband speaking with the hospice representative or the outcome of the discharge.

Transdisciplinary Team Conference Report, dated 9/13/11, documented palliative care consult with hospice was pending.

On 9/26/11, a Category III resuscitation physician order form was signed by the patient's husband requesting comfort care.

On 10/4/11, at 10:55 AM, CM #2 explained the pulmonologist requested palliative care for Patient #1. The patient's husband, daughter (who lived locally) and a daughter who lived out of state were involved in the decision for hospice care. The CM explained the daughter who lived out of state did not want the patient placed on hospice. The CM stated the patient's husband had a friend who used the agency recommended by the pulmonologist. The patient's husband requested this hospice agency assess the patient for admission. The CM explained Physician #1 cancelled the agency the patient's husband requested and wrote an order for another hospice agency to be notified. The CM notified the family of Physician #1's order for another hospice agency. The family declined and Physician #1 was notified.

Patient #2

Patient #2 was admitted to the facility on 5/27/11 and discharged on 6/27/11. The case management addendum, dated 5/30/11, documented prior community services used was with Home Health Agency (HHA) #1.

The case management concurrent review, dated 6/14/11, documented the patient and patient's wife want to go home with HHA #1.

On 6/14/11, the physician's orders documented a skilled nursing facility evaluation was ordered.

On 6/27/11, the physician's orders documented a discharge to home order. The discharge instructions documented on 6/27/11, HHA #2 was arranged for the patient. There was no documented evidence of an order for home health evaluation found in the medical record.

Patient #3

Patient #3 was admitted to the facility on 1/6/10 with diagnoses including diabetes mellitus, metastatic prostate cancer, vertebral metastasis, hypertension, deep vein thrombosis, bilateral nephrostomy tubes and transient atrial fibrillation.

On 1/20/11, the phycian's orders documented Physician #1 wrote an order "H/H (home health) is Home Health Agency #2 (HHA). No exceptions." A second order was written on 1/20/11 by Physician #1 "D/C (discharge) home. HHA #2 not HHA #1."

The interdisciplinary progress note documented, by the social worker, the patient was discharged home on 1/21/11 with HHA #2 providing home health care.

On 10/4/11, at 10:35 AM, a CM was interviewed. The CM requested to remain anonymous. The CM explained when an order was received for referral to another agency; the patient would be notified of the order. The CM would provide the patient with a list of agencies. The CM explained the names of the agencies were provided verbally. The CM stated several agencies would be called to evaluate the patient. The patient provides consent for the evaluation. If the physician orders a specific agency, the CM explained they have to call the agency to evaluate the patient. The CM stated when Physician #1 orders a specific agency, the CM's were told not to call another agency.

The CM recalled Physician #1 had ordered a specific agency, even though some patients had used other agencies or requested other agencies. The CM explained the patients were told when at home, to tell the ordered agency they do not want their services then call their family physician to refer to the agency they requested.

On 10/4/11, at 10:55 AM, CM #2 explained when a physician wrote an order for an evaluation to a community agency, the CM explained to the patient what would occur. The CM explained the CM would choose agencies depending on the needs of the patients. The preferred agency of a physician would be included for evaluation of the patient.

CM #2 explained Physician #1 used specific agencies. The CM explained the patient would be told the physician recommended the agency, but the patient had other choices. The CM would write in the CM notes what agency was called.

CM #2 explained on occasion, Physician #1 had held up a discharge order due to the patient not requesting the agency Physician #1 ordered. The CM explained Physician #1 would tell her to write down her concerns and he would deal with it later. The CM stated concerns regarding Physician #1 had been relayed to the Director of Case Management.

On 10/4/11 at 11:50 AM, the Director of Case Management explained she would check with the patient and family to see if they had a preferred provider. If the family did not have a preferred provider, the Director would recommend several different agencies. The Director explained she would write down the name and phone numbers of the agencies and provide to the patient and/or family. If the physician wrote for a specific agency, the Director would explain to the family the physician recommended the agency but the patient had a choice of what agency they would choose.

The Director expressed concern regarding developing a concrete discharge plan for Physician #1's patients. The Director explained the family would request a certain agency. Physician #1 would be asked if he concurred with the patient's request. The Director explained often Physician #1 would not provide an answer. The Director explained the Transdisciplinary team would make written recommendations and present to Physician #1. If the physician wrote the order, the team knew he agreed with the discharge plan.

The Director explained Physician #1 would not communicate with the CM's. The Director stated she had brought concerns regarding Physician #1 to the Chief Executive Officer (CEO).

On 10/4/11 at 12:15 PM, CM #3 explained during the admission assessment, the CM would identify if the patient had used any agency prior to admission. If the patient requested to continue with the previous agency, the CM would call for evaluation prior to discharge. CM #3 explained if Physician #1 wrote for a specific agency, she would call the ordered agency. The CM explained she had heard Physician #1 yell at staff when a patient did not receive the agency he ordered. The CM explained she would tell the patients if they did not like the ordered agency, they could choose another agency after discharge.

On 10/4/11, at 1:15 PM, the CEO acknowledged he had received an occasional report from nursing and case management staff regarding Physician #1 may take longer than anticipated to concur with the discharge plan of patients. The CEO explained the physician was waiting for the result of laboratory test or checking to see if one home health agency could do better than another, based on the needs of the patient.

On 10/5/11 at 2:00 PM, Physician #1 explained he ordered specific agencies for families who had no prior experience with home health agencies, hospices or skilled nursing facilities. The physician explained he preferred certain agencies as they provide good care and he would receive patient updates while the nurse was in the patient's home. The physician explained he had patients tell him other agencies did not come out to see the patients and did not get good care. The physician explained he would not receive timely updates with some of the other agencies. The physician stated he did not want to take away patients who had used another agency prior to recent admission to the facility.

Complaint #NV00029569