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Based on review of documentation and interviews, the Hospital failed to ensure that Patient #11 had the right to participate in the development and implementation of his or her plan of care.

Findings included:


Background information:

Review of Patient #11's medical record indicated that the Patient presented to the Hospital Emergency Department on 2/7/11 after falling at home. Review of the Admission History and Physical dated 2/7/11 indicated Patient #11 was 81 years of age and fell outside the home on the ice. Patient #11 broke the right patella [knee cap] in the fall. Documentation indicated the Patient was hard of hearing, but in excellent general health. Review of the Operative Report indicated Patient #11 underwent surgery to repair the fractured knee cap on 1/8/11. Documentation indicated the surgery was completed with no complications. Review of the Postoperative plan indicated that Patient #11 will be full weight bearing with Physical Therapy. Skilled Nursing Facility [SNF] discharge hopefully tomorrow. Review of the Discharge Summary dated 2/10/11, section on Disposition indicated Patient #11 was discharged to a Skilled Rehabilitation Facility on 2/10/11 .

1) The Complainant was interviewed by telephone on 5/26/11 at 7:20 am. The Complainant said Patient #11's Spouse was not present for the discharge planning process and it was a problem because Patient #11 was hard of hearing and could not process verbal information well. The Complainant said Patient #11 and the Spouse selected the Rehabilitation Hospital as their first choice. The Complainant said Patient #1 only had the choice of a SNF. The Complainant said Patient #11 was not happy with the services provided at the SNF, so the Spouse went to the first choice Rehabilitation Hospital and were informed that in fact, there was a bed available at the hospital during the time Patient #11 was discharged. The Complainant said Patient #1's Surgeon was a "poor communicator," was "abrupt" with the Spouse and Patient #11.

Based on review of documentation and interviews, the Hospital failed to ensure that Patient #11 and his or her representative (as allowed under State Law) has the right to make informed decisions regarding his or her care.

Findings include:

1) Please see Tag A 130.

2) Case Manager #2 was interviewed in person on 5/25/11 at 10:40 am. CM #2 said she was aware the Acute Rehabilitation Hospital refuses to accept patients from this particular Surgeon who performed orthopedic surgery on Patient #11. CM #2 said this issue was discussed with the Hospital Chief Executive Operating Officer [CEO]. CM #2 said this problem put the case managers in a very difficult situation.

3) CM #2 said the Acute Rehabilitation Hospital Nurse Liaison will not even conduct a screen of the patient once they learn the patient is one of the Surgeon's cases.

4) CM #2 said she did not inform Patient #11 and the Spouse of the true reason why the Acute Rehabilitation Hospital did not screen or offer a bed to Patient #1.

Based on review of documentation and interviews, the Hospital failed to ensure that the medical staff were well organized and accountable to the governing body for the quality of the medical care provided to the patients.

Findings included:

1) The Orthopedic Surgeon was interviewed by telephone on 5/25/11 at 11:10 am. The Orthopedic Surgeon said he was aware there was an issue between him and the nearest Rehabilitation Hospital. The Orthopedic Surgeon said it was because of his personal medical philosophy regarding anti-coagulation therapy - they boycott his patients because he does not agree with routinely prescribing anti-coagulant medications for those without risk factors. The Orthopedic Surgeon said he made several calls to the Rehabilitation Hospital Medical Director and never received a return phone call. The Orthopedic Surgeon said the ball was dropped there. The Orthopedic Surgeon said that if there was an issue regarding accepting his patients for post-hospital care, it should be discussed, but the Rehabilitation Hospital Medical Director never returned his phone calls.

This Surveyor asked the Orthopedic Surgeon for the name of the person he called and the dates. The Orthopedic Surgeon had no recall of the details. The Orthopedic Surgeon mentioned two names for the person he called that were not the Rehabilitation Hospital Medical Director.

2) The Medical Director of the Acute Rehabilitation Hospital was interviewed by telephone on 5/25/11 at 12:20 pm. The Medical Director was asked about the restriction of limitations for admissions of patients from this particular Surgeon. The Medical Director replied matter of factly that this was true: they do not accept the Surgeon's patients at all, for any reason. The Medical Director said this decision was based on several "horrid experiences in trying to obtain aftercare help" from the Surgeon. The Medical Director said many physicians at the Acute Rehabilitation Hospital were left in "untenable situations" in trying to co-manage the Surgeon's patients. The Medical Director said he tried to mitigate problems, but was not successful. The Medical Director said that in desperation - the only solution was to not accept any of the Surgeon's patients. The Medical Director confirmed that the Nurse Screeners will not even screen a patient once they learn the Surgeon did the case.

3) The Medical Director said they have had "so many bad experiences." This Surveyor asked the Medical Director to be more specific in regards to the problems - they included: 1) Post-operative infections that required follow-up. The Medical Director said the Surgeon would direct them to send patients to Boston for care. 2) Medical complications requiring acute hospitalization care. The Surgeon will refuse to acknowledge that a problem exists. 3) The Surgeon has blamed the above problems on the Acute Rehabilitation Hospital Physicians and staff - when the problems stemmed from the Surgeon.

4) The Medical Director said the Acute Rehabilitation Hospital does not refuse referrals from any other provider - only this particular Surgeon. The Medical Director said the Surgeon ignores the patients and levels blame on them.

5) The Medical Director was asked by this Surveyor if the Surgeon had left messages regarding wanting to speak about this issue to resolve the problems. The Medical Director said: "Non-sense," "I have never received a call from [the Surgeon]." The Medical Director said there has been so much history, this is such an ingrained behavioral pattern that even if I try to force them [Physicians at the Acute Rehabilitation Hospital] to take the Surgeon's patients, I can't do it. The physicians refuse to work with him, there are so many quality of care issues with the Surgeon. The Medical Director said there would have to be a behavioral contract for them to even consider it.

6) The Chief Executive Officer [CEO] of the Hospital was interviewed in person on 5/25/11 at 2:20 pm. The CEO said he was made aware of the personality problems with the Surgeon by the Case Management Department staff sometime in January. The CEO said he phoned the CEO of the Acute Rehabilitation Hospital about 2 times and he never received a return phone call. The CEO said the Surgeon did not statistically stand out for quality indicator data.

7) The CEO of the Hospital again tried to make telephone contact with the CEO of the Acute Rehabilitation Hospital on 5/26/11 and was successful. The CEOs acknowledged the problem and they are working on resolving the issues. The CEO of the Hospital spoke with the Surgeon about the issue and indicated that a solution would be reached. The CEO of the Hospital also tried to contact the Rehabilitation Hospital Medical Director, but was not successful.

Based on review of documentation and interviews, the Hospital failed to ensure the Hospital included a discharge planning evaluation in Patient #11's medical record for use in establishing an appropriate discharge plan and must discuss the results of the evalution with the patient or individual acting on his or her behalf.

Findings included:


1) Case Manager #2 was interviewed in person on 5/25/11 at 10:40 am. CM #2 said she was aware the Acute Rehabilitation Hospital refuses to accept patients from this particular Surgeon who performed orthopedic surgery on Patient #11. CM #2 said the Acute Rehabilitation Hospital Nurse Liaison will not even conduct a screen of the patient once they learn the patient is one of the Surgeon's cases.

2) Review of Patient #11's medical record indicated there was no screening conducted by the Acute Rehabilitation Hospital Nurse Liaison.

3) CM #2 said she did not inform Patient #11 and the Spouse of the true reason why the Acute Rehabilitation Hospital did not screen or offer a bed to Patient #1.

4) Patient #11 and the Spouse were only informed of the bed offer from the SNF as the option for post-hospital rehabilitation care.

Based on review of documentation and interviews, Patient #11 and the Spouse were not adequately counseled to prepare them for post-hospital care. Specifically, Patient #11 and the Spouse were not informed that their first choice for post-hospitalization rehabilitation was denied based on personality conflicts between the Orthopedic Surgeon and the Rehabilitation Hospital.

Findings included:

1) Please see Tag A 811,828 and 829.

Based on review of documentation, interviews and review of statistical data regarding discharge disposition from the Surgeon's professional practice, the Hospital failed to ensure Patient #1 and the Spouse regarding their freedom to choose among participating Medicare Providers of post-hospital care services.


Findings included:


1) To provide factual data to the information obtained during interviews regarding the Acute Rehabilitation Hospital not screening or accepting patients from this Surgeon, a data inquiry from 12/10 through 5/11 for the Surgeon and his Professional Practice Partner was obtained. The Surgeon sample size consisted of 52 patients whom he operated on. Of the 52 patients, none of them were referred to the Acute Rehabilitation Hospital. For the Surgeon's Partner, the sample size was 26 and 5 patients were referred for rehabilitation services. From the sample size of 5 patients, 4 were accepted at the Acute Rehabilitation Hospital and one was referred for SNF care.

2) The analysis of the above data: that the Surgeon had no discharges to the Rehabilitation Hospital in the past six months, confirmed the lack of ensuring Medicare participants the freedom to choice among participating Medicare Providers of post-hospital care services.

Based on review of documentation and interviews, the Hospital failed to ensure that Patient #11 and the Spouse had the freedom to choose among participating Medicare providers of post-hospital care services and must, when possible, respect patient and family preferences when expressed.


Findings included:


1) Please see Tags, 130, 131, 811, 822, 828 for additional information.

2) Interviews with the Orthopedic Surgeon, CM #1 and #2, Director of Case Management Services and the CEO confirmed that Patient #11 and the Spouse were not allowed the freedom to choose among Medicare Providers and have their preference/first choice for a post-hospitalization provider respected. Furthermore, Patient #11 and the Spouse were not informed of the true reason for non-acceptance to the Rehabilitation Hospital - a personality conflict with the Orthopedic Surgeon - they were informed they were no beds available.