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Based on review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that all patient rights are protected and promoted.

Findings include:

1. The facility failed to ensure the notice of rights requirements are met (Cross refer to Tag A-116).

2. The facility failed to ensure a language interpreter is provided to all non-English speaking patients (Cross refer to Tag A-117).

3. The facility failed to ensure patient rights requirements are met (Cross refer to Tag A-129).

4. The facility failed to ensure all patients are included in the development and implementation of the discharge plan (Cross refer to Tag A-130).

5. The facility failed to ensure that all patients are educated on advance directives (Cross refer to Tag A-132).

Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that all patients sign consent forms prior to treatment.

Findings include:

1. Review of Medical Record #1 on 8/9/18 revealed the following:

a. Patient #1 was admitted to the Emergency Department (ED), on 2/27/18 at 10:39 AM. He/ She was incapacitated at the time of admission and unable to sign the "General Consent" form. Patient #1 was admitted to the Critical Care Unit (CCU) with alcohol toxicity at 11:15 AM.

b. On 3/4/18, Patient #1 was admitted to a Medical Surgical Unit.

c. On 3/9/18, Patient #1 was admitted to the CCU.

d. On 3/10/18, Patient #1 was admitted to a Medical Surgical Unit.

e. On 3/20/18, Patient #1 was discharged from the hospital.

2. Patient #1 was at the hospital for a total of twenty-one (21) days. The "General Consent" form lacked the patient's or patient representative's signature.

3. Upon interview, Staff #19 stated that if a patient is incapacitated and unable to sign the General Consent form upon admission, it is the responsibility of the registrar to follow the course of the patient and obtain a signature.

4. Staff #1 and Staff #17 confirmed the above findings.

Based on medical record review, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that notices of patient rights are provided and explained in a language or manner that the patient (or the patient's representative) can understand.

Findings include:

Reference: Facility policy, Patient Rights states, "... Communication and Information... To receive as soon as possible, the services of a translator or interpreter or assisted listening devices... ."

1. Review of Medical Record #1 on 8/9/18 revealed that Patient #1 was a non-English speaking patient.

2. There was no documented evidence that the services of a translator or interpreter, or any listening/translator devices were used to inform Patient #1 of his/her patient rights.

3. Staff #1 and Staff #2 confirmed the above findings.

Based on medical record review, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that all patients are treated with courtesy, consideration, and respect.

Findings include:

Reference: Facility policy, Patient Rights states, "... Patient's Rights are as follows... To considerate, respectful care at all times with recognition of your personal dignity. ... ."

1. Review of Medical Record #1 on 8/9/18 revealed the following:

a. The patient arrived to the ED (Emergency Department) on 2/27/18 via ambulance with a diagnosis of alcohol poisoning and subsequently admitted.

b. Upon interview, Staff #1 confirmed that the patient was homeless and Spanish-speaking with a history of alcohol abuse.

c. The patient was discharged on 3/20/18 at 5 PM. Staff #1 confirmed that the patient was discharged via taxi to a county agency "to receive assistance with finding a homeless shelter."

2. Upon interview, Staff #1 confirmed that the patient was discharged wearing "two hospital gowns, hospital pajama bottoms, yellow hospital socks, and two blankets."

3. Upon interview, Staff #1 and Staff #2 confirmed that the patient was found at the county agency the day after his/her discharge, sleeping under a fire escape. The patient spent the night outdoors during a snowstorm, wearing two hospital gowns, hospital pajama bottoms, yellow hospital socks and covered with two blankets.

Based on review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure all patients are included in the development and implementation of the discharge plan.

Findings include:

Reference: Facility policy, Patient Rights states, "... Medical Care...To participate in the development and implementation of your plan of care. ... ."

1. Review of Medical Record #1 on 8/9/18 lacked evidence that Patient #1, a non-English speaking patient, participated in the development and implementation of his/her discharge plan of care.

2. Review of Medical Record #8 on 8/9/18 lacked evidence that Patient #8, a non-English speaking patient, participated in the development and implementation of his/her discharge plan of care.

3. Staff #1 and Staff #2 confirmed the above findings.

Based on review of medical records, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that education regarding the patient's right to formulate an advance directive, is provided in a language that the patient understands.

Findings include:

Reference: Facility policy, Patient Rights states, "... Purpose: To protect and promote each patient's rights. To establish a mechanism by which patients will be informed of their rights in a language they understand. ...To make informed decisions regarding the course of care and treatment, including resolving dilemmas about care decisions formulating advance directives... ."

1. Review of six (6) of six (6) medical records (#1, #8, #9, #10, #11 and #12) on 8/10/18, revealed that all patients were identified as non-English speaking patients requiring the assistance of the language line for translation services.

a. Medical Records #1, #8, #9, #10, #11, and #12 contained information regarding formulating an advance directive in English. There was no documented evidence that the patients received information regarding advance directives in a language that they understood.

2. Staff #1 and Staff #2 confirmed the above findings.

Based on review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that its discharge planning process applies to all patients.

Findings include:

1. The facility failed to reassess the patient's discharge plan on an on-going basis (Cross refer to Tag A-0843).

2. The facility failed to ensure that the patient was included in the discharge plan (Cross refer to Tag A-0811).

3. The facility failed to ensure that qualified personnel developed and/or supervised the discharge plan (Cross refer to Tag A-0818).

Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that all patients are included in the discharge planning process.

Findings include:

Reference: Facility policy, Discharge Planning states, "... 3. The case manager will complete a timely evaluation of discharge needs as identified by... direct communication with... patient/patient representative. ... Any changes to the discharge plan will be discussed with the patient/patient representative... ."

1. Review of Medical Record #1 on 8/10/18 revealed the following:

a. The patient arrived to the ED (Emergency Department) on 2/27/18 via ambulance with a diagnosis of acute alcohol poisoning. Documentation on the Patient History form dated 2/27/18 states, "... Preferred Language: Spanish; Fluent in English: No; Special Needs Devices: Language Line... ."

i. Upon interview, Staff #1 confirmed that the patient was homeless. The patient was discharged via taxi to a County social services agency on 3/20/18 at 5 PM.

b. A Social Services Progress note entered on 2/28/18 states, "Patient on a 1:1, lethargic and unable to answer questions appropriate [sic]."

c. A Social Services Progress note entered on 3/6/18 states, "[Name of County] Department of Health Alcohol and Drug Resources and Homeless Shelter Assistance was provided. Supportive services were rendered. Will follow as appropriate."

i. There was no description of the type of supportive services rendered.

d. A Social Services Progress note entered on 3/22/18 [entered as a late entry] states, "SW (social worker) received a telephone call from [Name of Registered Nurse] informing 'Patient is cleared for discharge today... .' [Name of County] Homeless Assistance/Special Response information was provided to patient at bedside. Patient denied any further need for assistance at this time."

i. There was no evidence of additional Social Services Progress notes.

ii. There was no evidence that the language line was used to communicate with the patient when community resources were discussed.

iii. There was no evidence that the information provided to the patient was in a language that he/she could understand.

e. Staff #6 was identified as the writer of the Social Services Progress notes entered on 3/6/18 and 3/22/18.

i. Upon interview, Staff #6 confirmed that he/she did not use the language line to communicate with the patient. He/she stated, "I spoke with the patient and he/she verbalized understanding."

ii. Staff #6 confirmed that he/she is not fluent in Spanish. He/she stated, "I speak a little Spanish, but I was able to say some things that he/she could understand."

iii. When asked how Staff #6 determined the patient understood him/her, Staff #6 stated, "He/she nodded his/her head."

2. Staff #1 and Staff #2 confirmed the above findings.

3. Review of Medical Record #8 on 8/10/18 revealed the following:

a. The patient arrived to the ED on 7/31/18 with a diagnosis of Altered Mental Status, and was subsequently admitted.

b. The Case Manager Progress note entered on 8/1/18 stated, "Patient lives with his/her daughter @ this time."

c. The Case Manager Progress note entered on 8/6/18 at 11:14 AM stated, "spoke with patient's daughter [name of daughter] via language line... . Per daughter, she went back to maryland as she could not find a place to stay. Informed her the nurse practitioner informed me pt. (patient) being discharged today. ... educated her via interpretor [sic] that [the patient] would need follow up care in maryland and that she should look into a clinic in maryland for him/her. ... [name of daughter] questioned with me [sic] that she knew pt had "blood on the Brain" but that no doctor explained to her. ... Hung up with [name of daughter] and spoke directly to patient with interpretor [sic] patient knows he/she in hospital but does not know year or month when asked. He/she does know his/her date of birth. Explained to patient that he/she is planned to be discharged today and that we spoke with [name of daughter] and that she is coming to get him/her to take back to Maryland. ... ."

d. The Case Manager Progress note entered on 8/6/18 at 11:30 AM stated, "Spoke with [name of staff] in Physical therapy about patient and need for dme (durable medical equipment)... Spoke with nurse [name of nurse] explained to her to please go over with daughter walking pt with contact guard... ."

e. There was no evidence in the medical record that the Case Manager discussed a discharge evaluation or the discharge plan with the patient or his/her family member prior to the patient's date of discharge.

Based on review of personnel files, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that discharge plans are developed and/or supervised by appropriately qualified personnel.

Findings include:

Reference: Facility policy, Discharge Planning states, "... Definitions... Case Manager: Licensed registered nurse or licensed/certified social worker with training in discharge planning. ... 5. The case manager will develop a discharge plan and document that plan in the electronic health record... ."

1. Review of three (3) of five (5) personnel files of Case Managers on 8/10/18 revealed the following:

a. The personnel file of Staff #7 identified him/her as an RN Case Manager. There was no evidence of training in discharge planning in his/her personnel file.

b. The personnel file of Staff #18 identified him/her as an RN Case Manager. There was no evidence of training in discharge planning in his/her personnel file.

c. The personnel file of Staff #6 identified him/her as a Social Worker in Case Management. There was no evidence of training in discharge planning in his/her personnel file.

2. Staff #1 and Staff #2 confirmed the above findings.

Based on review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that the discharge planning process is reassessed on an on-going basis.

Findings include:

Reference #1: Facility policy, Discharge Planning states, "... 3. The case manager will complete a timely evaluation of discharge needs as identified by record review, interdisciplinary team rounds, direct communication with the interdisciplinary health care team... The case manager will complete ongoing assessment throughout the patient's hospitalization to determine post hospital needs and document any changes in the electronic health record. ... ."

Reference #2: Facility policy, Assessment/Reassessment states, "... Department: Case Management (Social Work)... Initial Admission Assessment: On identified patients, initiate discharge planning, utilization review, and quality review within 48 hours of admission. 24 hours for admission referral... Reassessment: Every 3 days, review of case for continued follow-up."

1. During a facility tour on 8/9/18, Staff #4 stated that interdisciplinary rounds occurred daily on every unit.

a. He/she stated that discharge planning was discussed during interdisciplinary rounds and all members of the patient's interdisciplinary health team are present during rounds.

2. Review of Medical Record #4 on 8/10/18 revealed the following:

a. The patient arrived to the ED on 5/3/18 with a diagnosis of shortness of breath, and subsequently admitted. He/she was discharged on 5/8/18.

b. A Case Manager Progress Note entered on 5/4/18 at 12:21 PM states, "...82 Y/O (year old)... alert and oriented lives at home alone. ... Patient has been seen by cardiology; troponins are positive, patient may need cardiac catherization. Case management to follow."

c. A Social Services Progress Note entered on 5/4/18 at 3:34 PM states, "Patient is an 82 year old male who per ED note came to the hospital for shortness of breath. Patient is currently in the CCU. Per cardiology consult, patient may need cardiac catherization. SW to follow as appropriate."

d. There was no evidence that a reassessment occurred within 3 days, as referenced in the facility policy.

e. There was no evidence in the medical record indicating interdisciplinary rounds occurred.

3. Review of Medical Record #5 on 8/10/18 revealed the following:

a. The patient arrived to the ED on 8/5/18 with a diagnosis of new onset atrial fibrillation and chronic renal failure. The patient was admitted to an inpatient telemetry unit.

b. There was no evidence that interdisciplinary rounds were conducted on 8/6/18 or 8/7/18.

4. Review of Medical Record #8 on 8/10/18 revealed the following:

a. The patient arrived to the ED on 7/31/18 with a diagnosis of altered mental status/CVA (stroke), and subsequently admitted. The patient was discharged on 8/6/18.

b. Case Manager Progress Notes, which detailed follow-up with the patient's case, were entered on 8/1/18 and 8/6/18.

c. There was no evidence that reassessment of the patient's case occurred within 3 days.

d. There was no evidence that interdisciplinary rounds were conducted on 8/3/18, 8/4/18, and 8/5/18.

5. Staff #1, Staff #2, and Staff #4 confirmed the above findings.