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Based on record review and interview, the facility did meet the condition of participation for discharge planning by failing to:

1. Provide a discharge planning evaluation that included community based services that are available to meet the patients' post hospital care for 4 of 20 sample patients. (Refer to A 806)

2. Ensure the discharge planning evaluations of 20 sample patients were developed by qualified personnel as per facility Position Description. (Refer to A 807)
3. Evaluate patients so that appropriate arrangements for post-hospital care are made before discharge for one of 20 sampled patients (Patient 11). (Refer to A 810)
4. Inform the result of the discharge planning for 1 of 20 sample patients. For Patient 2, there was no documentation that the patient was informed of the discharge plan to go to a long term acute care hospital. (Refer to A 811)
5. Implement the patient's discharge plan for 1 of 20 sample patients (Patient 2). (Refer to A 820)
6. Reassess the discharge plan to address the post discharge care needs of 1 of 20 sample patients (Patient 1). (Refer to A 821)

The cumulative effect of these systemic problems resulted in the surgery center's inability to ensure the provision of quality health care in a safe environment.

Based on record review, observation, and interview, the facility failed to ensure the advance directive acknowledgements for three of 20 sample (Patient 5, 10 and 11) were completed to determine whether or not the patients had executed an advance directive concerning health care decisions, as indicated in the facility's policy and procedure. The facility also failed to ensure a copy of the advance directive was in the patient's medical record for two of 20 sample patients (Patient 3 and 20) that contain the patient's health care decisions.

This deficient practice had the potential to result in the patients not having the right to formulate advance directives and not having the hospital staff comply with the patient's advance directives.

Findings:

1. A review of the Patient Demographic Profile indicated Patient 3 was admitted to the facility from the skilled nursing facility (SNF) on September 18, 2014 at 3:02 p.m. with diagnoses that included seizure disorder (sudden disruption of brain electrical activity) and acute urinary tract infection (infection in the urinary system). The Discharge Summary dictated September 27, 2014, indicated Patient 3 was discharged on September 21, 2014, to the skilled nursing facility.

The Initial Admission collected on September 18, 2014 at 4:46 p.m., indicated the Advance Direction section of the admission form was left blank. However, on the screening section of the admission form, Patient 3 had executed an advance directive.

A review of Patient 3's Advance Directive Acknowledgement dated September 18, 2014, indicated the patient had executed an advance directive, do not have a copy but one can be obtained by contacting ... There was no contact information documented to obtain a copy of the patient advance directive. On March 11, 2015 at 6:05 p.m., during an interview, Admin 2 stated there was no copy of Patient 3's advance directive in the patient's record.

2. A review of the Patient Demographic Profile indicated Patient 5 was admitted to the facility from the skilled nursing facility on December 5, 2014, with diagnoses that included closed fracture of the distal end of radius (fracture of the left wrist). The Discharge Summary dictated December 29, 2014, indicated Patient 5 was discharged to the skilled facility on December 15, 2014. For the fracture of the left wrist, Patient 5 underwent a surgical procedure, closed reduction, application of long arm cast under intravenous anesthesia.

The Initial Admission collected on December 5, 2014 at 2:44 p.m., indicated Patient 5 had an advance directive. The Advance Directive Acknowledgement dated December 5, 2014, indicated the form was blank to indicate whether or not Patient 5 had advance directive. On March 11, 2015 at 6:05 p.m., Admin 2 stated the Advance Directive Acknowledgement for Patient 3 was not completed.

3. During an initial tour of the medical-psyche unit with the registered nurse (RN) on March 10, 2015 at 10:25 a.m., Patient 10 was observed sitting up on her bed, awake and smiling. The RN stated Patient 10 would be discharge today to the SNF.

A review of the Patient Demographic Profile indicated Patient 10 was admitted to the facility from the skilled nursing facility on March 5, 2015, with diagnoses that included poor appetite, congestive heart failure ( a condition that the heart not able to pump blood throughout the body) and confusion. The Discharge Assessment collected on March 10, 2015 at 3:26 p.m., indicated Patient 10 was discharged to the skilled nursing facility on March 10, 2015 at 5:30 p.m.

The Advance Directive Acknowledgement dated March 5, 2015, indicated Patient 10 was unable to sign due to medical condition. There was no documentation whether or not Patient 10 had an advance directive.



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4. A review of Patient 11's medical record indicated the patient presented to the facility's emergency room by ambulance on January 16, 2015 at 9:26 p.m., from a skilled nursing facility (SNF) with asthenia (lack or loss of strength and energy), for evaluation regarding generalized weakness. The patient was transferred to the medical/surgical unit on January 17, 2015.

The Initial Admission, Screening section for Advance Directive indicated "No."

The Advance Directive Acknowledgement form for Patient 11 dated January 17, 2015 was left blank.

During an interview on March 11, 2015 at 6 p.m., Admin 2 stated the Advance Directive Acknowledgement for Patient 11 was not completed.

5. A review of the Patient Demographic Profile for Patient 20 indicated the patient was admitted to the facility on March 3, 2015 with diagnosis of chronic obstructive pulmonary disease.

The Advance Directive Acknowledgement form for Patient 20 dated March 3, 2015 indicated, the patient was unable to sign. However, the Initial Admission, Screening section on Advance Directive for Patient 20 indicated "Yes." The documentation indicated has executed an advance directive.

On March 11, 2015 at 6 p.m., Admin 2 was not able to provide a copy of the advance directive. Admin 2 stated there was no copy of the patient's advance directive in the medical record.

A review of the facility policy titled, Advance Health Care Directive dated approved January 2013, indicated, as part of the admission process, the admission office staff will inform the patient or surrogate of the patient rights and responsibilities and state law regarding Advance Directives. If a patient has executed a Directive, the admitting representative will request a copy of the Directive. If Directive is not provided, the surrogate will be asked to bring in copy and present to nursing unit.

Based on observation and interview, the facility failed to ensure patient right to personal information privacy. This deficient practice had the potential to result in the public's ability to view patient information without patient authorization.

Findings:

On March 10, 2015 at 10:30 a.m., in Nurses Station 2, telemetry monitors displaying patients' heart rhythm were observed on the counter by the wall. The monitors were facing the hallway. The screen has the patient's name, date of birth (DOB) or date of arrival (DOA), diagnosis, room and bed numbers.

During an interview on March 11, 2015 at 1:25 p.m., Admin 1 stated monitors in the Nursing Station 2 are the dummy monitors. Admin 1 stated the information were small and added the monitors could be placed on the counter where the computers were.

Based on record review and interview, the facility failed to collect data regarding identified problems with discharge planning and to use the data collected to monitor effectiveness of the change. This deficient practice resulted in the facility's failure to conduct discharge planning evaluations that included community-based services that are available to meet the patient's post hospital care needs for 4 of 20 sample patients (Patient 1, 3, 11 and 12).

1. For Patient 1, who required total assistance in activities of daily living, was discharged to a board and care facility. There was no documentation of discharge planning that included community based services such home health service that is available to meet the care needs of the patient after discharged from the hospital

2. For Patient 3, there was no discharge planning evaluation completed for the patient.


3. For Patient 11, there who needed complete assistance with activities of daily living, and with a gastrostomy tube (GT is a tube surgically inserted into the stomach through the abdominal wall for purposes of feeding and medication administration), there was no documentation of discharge planning to include evaluation of the services to meet the patient's needs.

4. For Patient 12, there was no documentation that the case management discharge planning was completed.


Findings:

Review of medical records for Patients 1, 3, 11 and 12 indicated concern with facility discharge planning.

On March 11, 2015 at 1:25 p.m., Admin 1 stated they have identified problems with case management last year. Admin 1 stated between July 2014 to November 2014, the case management were registry staff and they got rid of them. Admin 1 stated from December 2014, they are just following up on case management. Admin 1 stated the facility does not have a social worker for medical/surgical unit. They have a licensed clinical social worker that works with patients with psychiatric problems.

Review of the quality assurance performance improvement plan (QAPI) documents indicated no data collected on discharge planning since the change.

During an interview on March 12, 2015 at 5:20 p.m., Admin 1 stated each department collects data monthly and reports data collected. Admin 1 stated the committee meets quarterly. Admin 1 was not able to provide data collected on discharge planning.

A review of the facility's policy titled, Performance Improvement Plan, with effective date October 2010, indicated performance improvement plan included to improve quality of care, improve patient safety, and to continuous use of data collection and evaluation that identifies or triggers further opportunities for improvement.

3. A review of the Unit Assignment Sheet dated March 10, 2015, during the 7 a.m. to 7 p.m., indicated there were 19 patients in the medical-psyche unit, Nursing Station III, and there were 5 registered nurses (RN) assigned to take care of the patients with 2 RNs on orientation. During an interview on March 10, 2015 at 10:30 a.m., the staffing ratio for the unit is 1 RN to 5 patients.

The Unit Assignment Sheet dated March 10, 2015, indicated there was no documentation who will cover or assign to the patients when the RNs take their meal breaks. During an interview on March 10, 2015 at 10:30 a.m., RN 5 stated there was no documentation when the staff are taking their breaks and who will cover their patients when the staff goes on their meal breaks.

A review of the facility's policy and procedure titled, "Patient Classification System Committee," effective date September 2012, indicated the system is a method of establishing staff requirement by unit, patient and shift which includes a method to predict a nursing care requiremeents of individual patients. The staffing ratio for the medical-surgical unit is 1 licensed nurse to 5 patients.




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Based on observation, interview and record review, the facility failed to ensure there were adequate numbers of staff to provide nursing care to all patients as needed including during meal and/or break time. This deficient practice had the potential to cause the facility's inability to provide the nursing assessment and care to meet the patient needs.

Findings:

1. On March 10, 2015 at 9:25 a.m., during tour of Unit 2 (medical surgical unit), the assignment sheet was not available upon request. RN 2 stated there were 33 patients in the unit, 8 of 33 patients were on telemetry with 8 registered nurses (RN) on duty.

During an interview at 10 a.m., RN 2 stated the nurse to patient ratio for the unit is 1:4 to 1:5. The staff cover each other during break time.

A review of the Unit Assignment Sheet for Unit 2 dated March 10, 2015, received at 10:10 a.m., indicated no documentation which patient was on telemetry.

Random review of the the Unit Assignment Sheets for Unit 2, indicated the column for acuity for each patient was not consistently completed. The assignment did not indicate which patient was on telemetry. The staff meal and break time were not identified on the sheet. There was no documentation to indicate who would cover during meal and break times.

2. On March 10, 2015 at 8:38 a.m., during initial tour with Admin 1, there were seven patients in the Intensive Care Unit (ICU). When requested, the assignment sheet was not available. Admin 1 informed the charge nurse (RN 1) the assignment sheet should have been done.

During an interview at the same time, RN 1 stated the unit secretary had not done the assignment sheet, but the assignment was written on the board. RN 6 stated there were seven patients, one charge nurse and 3 registered nurses. RN 6 stated the nurse to patient ratio was 1:2.

A review of the Unit Assignment Sheets for March 10, 2015 at 9 a.m., indicated there was no documentation of meal time or break time coverage.

During an interview at 9:05 a.m., RN 1 stated they cover each other for breaks. A staff would have more than 2 patients during meal and/or break time. RN 1 also stated when someone answers to a rapid response, the other staff would cover the assigned patients for another RN.

Based on recorded review and interview, the facility failed to evaluate the nursing care for 1 of 20 sample patients (Patient 2) by failing to ensure a reassessment was conducted for effectiveness of pain relief 30 minutes after Dilaudid 2 milligrams intravenously was given at 1:58 p.m. on December 25, 2014, and to notify the surgeon when Dilaudid 2 mg IV was given to the patient on December 25, 2014 at 1:58 p.m. and 7:58 p.m., as indicated in the Orders Report. Without notifying the surgeon after the administration of the initial dose of Dilaudid 2 mg IV at 1:58 p.m. on December 25, 2014, , the patient received another dose of Dilaudid 2 mg IV at 7:58 p.m. on December 25, 2014, 7 hours later, at 4 a.m. on December 26, 2014, Patient 2's respirations were labored, he was hyperventilating, with foaming in his oral cavity, and his oxygen saturation (a measure of how much oxygen thru blood is carrying as a percentage of the maximum it could carry) was 68 %. Patient 2 was transferred to the intensive care unit for further care.


Findings:

The Patient Demographic Profile indicated Patient 2 was admitted to the facility from the skilled nursing facility on December 23, 2014, 5:30 p.m., with diagnoses that included sepsis (infection in the bloodstream), acute lower urinary tract infection (infection in the urinary system), and altered mental status. The ED Nursing Disposition Note collected on December 23, 2014 at 6 p.m., indicated the patient was admitted to the telemetry unit.

The Initial Admission collected on December 23, 2014 at 8:30 p.m., indicated Patient 2 was paraplegic (impairment in motor or sensory function of the lower extremities), had colostomy (surgical procedure that creates an opening for feces to be removed from the body), had a foley catheter (urinary catheter that is inserted through the urethra and into the bladder to drain urine), had stage III pressure ulcers (skin breakdown caused by pressure on the skin and usually over the bony prominence) in the right and left buttocks and right later leg, and was at risk for falls and skin breakdown.

A review of Patient 2's electronic medical record was conducted with RN 4 on March 12, 2015 at 2:40 p.m. A review of the Orders Report indicated on December 25, 2014 at 10:30 a.m., an order for Dilaudid (Hydromorphone) 2 milligrams (mg), 2 milliliters (ml) intravenously (IV every 2 hours as needed for severe pain and call for the surgeon.


A review of the electronic medication record indicated Patient 2 received Dilaudid 2 mg IV at 1:58 p.m. for pain level of 8 out of 10. The "MAK Findings" in the electronic record dated December 25, 2015 at 1:53 p.m. indicated Patient 2's blood pressure was 152/50 and at 1:59 p.m., Patient 2 had a back pain with pain level of 8 out of 10. The "Assessment" section of the electronic record indicated there was no documentation of a reassessment for effectiveness of pain relief 30 minutes after Dilaudid 2mg IV was given at 1:58 p.m. on December 25, 2014. There was no documentation in Patient 2's electronic record regarding notifying the surgeon when Dilaudid 2 mg IV was given to the patient as indicated in the Orders Report.


The Nursing Notes collected on December 25, 2014 at 7:50 p.m., indicated Patient 2 was screaming, yelling and confused. Respiration was even and unlabored, wound dressings were intact, encouraged to verbalized concern and redirected to reality. At 8 p.m., Patient 2 was in bed, awake, screaming of pain to his back area, pain level 10 out of 10,
blood pressure was 150/86, pulse 118, respiration 20 and oxygen saturation was 96%. Dilaudid 2mg IV was given for pain.


The "Medication" section of the electronic record indicated Patient 2 received Dilaudid 2 mg IV at 7:58 p.m. December 25, 2014 and the pain scale was 10 out 10.


The Nursing Notes collected on December 25, 2014 at 8:30 p.m., indicated Patient 2 was sleeping, easily arousal, and denied any pain. At 9 p.m., Patient 2 was lethargic, responsive to stimuli, vital signs were 136/62, pulse 108, respiration 17 and oxygen saturation 93%. Medications that were due at this time were held. At 11 p.m., the patient was in deep sleep, arousable, respiration 17, oxygen saturation 92%, blood pressure 113/62, and pulse 78. Continue to hold the medications. At 12:30 a.m., December 26, 2014, Patient 2 was asleep, arousable, and offered 9 p.m. medications and the patient refused. At 2 a.m., the patient was asleep, easily arousable. At 4 a.m., the patient was asleep, easily arousable, respirations were labored and hyperventilation, with foaming in his oral cavity, vital signs were stable (readings not documented), but oxygen saturation was 68 %. Oxygen at 100% was given to the patient, elevated the head of the bed, Rapid Response was called, the physician ordered arterial blood gas blood test, and chest Xray immediately. At 4:30 a.m., Patient 2 was alert and responsive, Bipap (machine that helps to get more air into the lungs) support was administered and vital signs were stable. At 5:45 a.m., December 26, 2014, Patient 2 was transferred to the intensive care unit for further care.


There was no documentation the surgeon was contacted as indicated in the Orders Report when the patient received Dilaudid 2mg IV on December 25, 2014 at 1:58 p.m. and 7:58 p.m. for severe pain. During the review of Patient 2's electronic record on March 12, 2014 from 2:40 p.m. to 3:40 p.m., RN 4 confirmed there was no documentation the licensed nurses had contacted the surgeon when the licensed nurses had administered Dilaudid 2 mg IV to Patient 2.


The facility's policy and procedure titled, "Pain Management," approval date November 2012 indicated the patients shall be assessed for effectiveness of pain relief after receiving pain medication 30 minutes after an IV pain or IM medication. The facility's policy indicated all patients would receive a comprehensive pain assessment, the best level of pain control, and reduce post procedure complications.

Based on record review and interview, the facility failed to ensure the nursing staff developed and kept current the nursing care plan for discharge planning for 20 of 20 sample patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20). This deficient practice had the potential for not meeting the patients's needs in continuing care after the patients are discharged from the hospital.

Findings:

1. A review of the facility's policy and procedure titled, "Care Plan," approval date November 2012, indicated the care plan is completed by the multidisciplinary team, develop for each patient admitted at the facility, updated every shift or whenever a new problem occur. The care plan will be initiated by a registered nurse within 8 hours of the patient admission. The care plan will be based on problems identified during the initial admission assessment. The actual or potential problem included psychosocial concern or other additional problems.

According to the facility's policy and procedure titled, "Assessment, Initial Admission (Nursing Data Base)" approval date November 2012, the Initial Nursing Data Base is the Initial Admission Assessment of a newly admitted patient. It is use as a nursing tool in order to communicate or document patient care related needs. In the area of Discharge Planning, it includes where the patient will go after discharge and knowledge of or use of available community resources. The Initial Nursing Data Base is used to document a baseline of the patient's discharge planning needs.

A review of the Patient Demographic Profile indicated Patient 1 was admitted to the facility from home on January 7, 2015, at 2:08 p.m., with diagnoses that included acute urinary tract infection (infection in the urinary system), spastic paraparesis (disorder where parts of the body develop spasticity and weakness), dementia (gradual decline in thinking, reasoning and memory) and ataxia (lack of voluntary coordination of muscle movements.

The ED Physician Note collected on January 7, 2015 at 2:03 p.m., indicated Patient 1 had pain in the lower extremity for years, the patient cannot walk, disoriented to time, had garbled speech, and impaired judgement. Patient 1 was not safe to go home and needed long term care. Patient 1 was admitted to the medical-surgical unit.

The Initial Admission collected on January 7, 2015 at 2:35 p.m., indicated that under the screenings section, Patient 1 lived with family, had no current resource utilization and anticipated discharge plan was the skilled nursing facility.

A review of the electronic plan of care for Patient 1 last reviewed January 23, 2015 indicated the problems included pain in the lower extremity, dementia, acute urinary tract infection, ataxia, spastic paraparesis, mobility impairment and acute pain. There was no documentation of a care plan developed for the patient's discharge planning.

During the electronic record review and interview with RN 3 on March 10, 2015 at 3 p.m., RN 3 stated there was no care plan in discharge planning for Patient 1.

The CM/SS Supplementing Note collected on January 14, 2015 at 10:46 a.m., collected by CM 2 indicated as per insurance, Patient 1 did not meet the criteria for SNF. The physician was contacted and stated the patient can be discharge home and to inform the family member.

The CM/SS/DC Planning Assessment collected January 23, 2015 at 5:23 p.m., by CM 1, Patient 1 was discharged to Board and Care #1, located at the city of Riverside. There was no documentation the patient was assessed for community based services such as home health services to meet the post hospital care needs of the patient. There was no documentation of a physician order to discharge Patient 1 to Board and Care #1.

The Continuity of Care collected January 23, 2015 at 5:50 p.m., indicated Patient 1 was discharged to Board and Care #1. Patient 1 is confused, was unable to do dressing, personal hygiene, toileting, eating, bathing, walking, was incontinent of urine at risk for fall. There was no documentation the patient was assessed for community based services such as home health services to meet the post hospital care needs of the patient. There was no documentation of any communication with staff from Board and Care #1 regarding Patient 1's continuity of care.

During an interview on March 10, 2015 at 4:25 p.m., CM 1 stated when they could not find a SNF, someone from Riverside came to assess Patient 1 and that person talked to the patient's family member.


2. The Patient Demographic Profile indicated Patient 2 was admitted to the facility from the skilled nursing facility on December 23, 2014, 5:30 p.m. with diagnoses that included sepsis (infection that has spread in the bloodstream, acute lower urinary tract infection (infection in the urinary system), and altered mental status.

The ED Nursing Disposition Note collected on December 23, 2014 at 6 p.m., indicated the patient was admitted to the telemetry unit.

The Initial Admission collected on December 23, 2014 at 8:30 p.m., indicated Patient 2 was paraplegic (impairment in motor and sensory function of the lower extremities), had colostomy (surgical procedure that creates an opening for feces to be removed from the body), had a foley catheter (urinary catheter that is inserted through urethra and into the bladder to drain urine), had stage III pressure ulcers (skin breakdown due to pressure on the skin and usually over the bony prominence) in the right and left buttocks and right lateral leg, and was at risk for falls and skin breakdown.

The Initial Admission collected on December 23, 2014, at 8:30 a.m., indicated that under the screenings section, Patient 2 was lethargic and unable to provide information regarding questions that included who or what is your main support system, what coping strategies do you use, and what are your concerns about your hospitalization. Patient 2's current residence was the skilled nursing facility. There was no documentation regarding anticipated discharge plan and current resource utilization.

The CM/SS DC Planning Assessment collected on January 6, 2015 at 1:48 p.m., indicated a discharge planning assessment that was completed 14 days after the patient was admitted. The discharge planning assessment indicated the patient was admitted from the skilled nursing facility (SNF #1), alert, physically functioned as partially dependent, and the discharge goal was SNF.

A review of the electronic plan of care record for Patient 2 last reviewed January 15, 2015, indicated the problems that included nutrition impairment, skin integrity impairment, fall risk, acute pain, infection risk, mobility impairment, sepsis, urinary tract infection, paraplegia and altered mental status. There was no documentation that a care plan developed for discharge planning and colostomy care.

During an interview on March 11, 2015 at 11:35 a.m. and electronic record review with RN 3, RN 3 confirmed there were no care plans developed on discharge planning and colostomy care. RN 3 stated these care plans should have been developed. RN 3 stated that discharge planning has to be added in the plan of care portion of the electronic record.


According to the CM/SS Supplemental Note collected on January 6, 2015 at 1:58 p.m., indicated CM 1 informed Patient 2 that SNF #1 was not accepting the patient back because there was no bed available. CM 1 also informed Patient 2 that SNF #2 was willing to accept the patient and the patient agreed with the discharge to SNF #2. CM 1 also informed the patient's family member and she said she wanted the patient be referred to SNF #3 and SNF #4. However, CM 1 informed the family member that SNF #3 and #4 had denied the patient and SNF #2 was willing to accept the patient. The family member agreed with the discharge plan.

The next documentation in the electronic record regarding discharge planning was the discharge instructions. The Discharge Instructions-Inpatient collected on January 15, 2015 at 6:15 p.m., by the registered nurse (RN), indicated Patient 2's discharge date was January 15, 2015 and timed 6:12 p.m.. Patient 2 was discharged to the Assisted Living with home health services and there was no documentation of the name, address and telephone number of the Assisted Living.

The Discharge Assessment with no date and time completed by an RN indicated Patient 2's discharge date was January 15, 2015, discharge time was 4 p.m. and discharge to home with home health services. The discharge time and discharge place were not consistent with Patient 2's Discharge Instructions. In addition, there was no documentation of Patient 2's continuity of care that addressed the primary diagnosis, co-morbid conditions, medications orders and treatments, follow directions, and any reports/results that were sent to the patient. In an interview with Medical Record Director on March 12, 2015 at 10:05 a.m. confirmed there was no Patient 2's continuity of care document completed when Patient 2 was discharged on January 15, 2015.

3. A review of the medical records for Patient 3, 4, 5, 6, 7, 8, 9, 10 indicated that their admission dates were as follows: September 18, 2014, November 29, 2014, December 5, 2014, January 19, 2015, March 5, 2015, March 6, 2015, March 4, 2015, and March 5, 2015. There was no documented evidence that the care plan was developed for discharge planning.


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4. Patient 11's electronic medical record was reviewed with the registered nurse clinical data analyst (RN 4). The record indicated the patient presented to the facility's emergency room by ambulance on January 16, 2015 at 9:26 p.m., from a skilled nursing facility (SNF) with asthenia (lack or loss of strength and energy), for evaluation regarding generalized weakness. The patient was transferred to the medical/surgical unit on January 17, 2015 at 10:10 a.m.

The Initial Admission Assessment dated January 17, 2015 at 8 p.m., indicated the following diagnoses: major failure to thrive (condition where people begin to decline), hypernatremia (elevated sodium level in the blood), hypokalemia (electrolyte potassium in the blood is low), acute manic phase (period of elevated mood), generalized weakness. The documentation indicated the patient was disoriented to person, time and place, cannot retain, register, recall information, anxious, alert but confused and restless. The patient has dysphagia (medical term for the symptom of difficulty in swallowing) with gastrostomy tube (GT is a tube surgically inserted into the stomach through the abdominal wall for purposes of feeding and medication administration), on Fibersource HN at 40 milliliter (ml) per hour for 20 hours and pureed diet with thickened liquid for oral gratification. The Screenings section indicated, anticipated discharge plan for SNF and MD notified of admission.

A review of the plan of care for Patient 11 dated last reviewed on January 22, 2015 at 5:17 p.m., indicated multiple problems to include altered mental status, nutrition impairment, knowledge low level, anxiety, fall risk, bi-polar, currently manic, hypernatremia, adult failure to thrive syndrome, hypokalemia and asthenia. Discharge planning was not listed in the problem list. There was no documentation a plan of care for discharge planning was developed.

During an interview on March 11, 2015 at 8:30 a.m., RN 4 stated these were the care plan for Patient 11. At the same time, Admin 1 who was present, informed RN 4 the care plan for discharge planning should be added.

A review of the Orders Report indicated an order for discharge planning to SNF by case management dated January 20, 2015 timed at 6:37 p.m. Another order dated January 22, 2015 timed at 11:53 a.m., indicated discharge planning to SNF by case management.

Review of the record indicated no case management discharge planning documentation.
The CM/SS/Discharge Planning Assessment form was not completed.

The Discharge Assessment, no date and time collected, indicated a discharge date of January 23, 2015 at 9 p.m. The documentation indicated the patient was confused and needed complete assistance with hygiene, dressing,bathing, toileting, and eating. The documentation also indicated the patient had a GT.

During an interview at 10:57 a.m., CM 2 stated she did not do discharge planning for Patient 11, that she probably did not get to it. CM 2 reviewed the CM/SS/Discharge Planning Assessment form for Patient 11 and stated the post discharge arrangement note, "Patient discharge to Board and Care 1.. " phone number and address "Patient agreeable with discharge plan...Pt (patient) advocate also spoke with pt." was written by CM 1. CM 2 stated there was no further documentation. CM 2 stated she does not know Board and Care 1.

5. A review of the ED Nursing Triage indicated Patient 12 arrived in the ED on January 16, 2015 at 8:28 p.m. The Triage Note, collected at 9 p.m., indicated a primary complaint of asthenia, from SNF for ER evaluation regarding generalized weakness. The patient was transported by ambulance and accompanied by EMS. The neurological assessment indicated alert, confused. The ED Disposition note indicated admit to medical/surgical unit. The patient left ED on January 17, 2015 at 11:15 a.m.
A review of the scanned Initial Nursing Data Base indicated the patient refused to be interviewed.

A review of the plan of care for Patient 1 dated last reviewed on January 18, 2015 at 9:01 a.m., indicated problems to include muscle weakness, acquired thrombocytopenia (decrease of thrombocytes, commonly known as platelets present in the blood) and asthenia. Discharge planning was not listed in the problem list. There was no documentation a plan of care for discharge planning was developed.

A review of the Orders Report indicated an order for discharge planning to SNF by case management dated January 19, 2015 timed at 12:27 p.m. Another order dated January 20, 2015 timed at 6:32 p.m., indicated discharge planning to SNF by case management.
Review of the record indicated no case management discharge planning documentation.

A review of the Inpatient Discharge Instruction sheet indicated discharge to assisted living, with discharge date of January 21, 2015 timed at 4 p.m.
A review of the Discharge Assessment, no date and time collected indicated the discharge date of January 21, 2015 to home at 4 p.m., by wheelchair and accompanied by ambulance. The documentation indicated the Patient 12 was alert and assistance needed after discharge to include partial assistance with hygiene, dressing, bathing, and toileting.

A review of the Nursing Notes dated collected on January 21, 2015 at 4:52 p.m., indicated the following: 3 p.m. (1500) received communication from S...that placement has been made at Board and Care 1...R...(marketing officer of Board and Care 1) aware of plan.

During an interview on March 11, 2015 at 9:30 a.m., the registered nurse Clinical Data Analyst (RN 4) stated S... is the patient advocate.
During an interview at 11 a.m., CM 2 stated she did not do discharge planning for Patient 12, that she probably did not get to it. CM 2 reviewed the record and stated Patient 12 was discharged to assisted living. CM 2 stated she does not know Board and Care 1.

6. A review of the Patient Demographic Profile indicated Patient 13 was admitted to the facility on January 9, 2015 from a Boad and Care (B & C)facility.
The ED Nursing Triage Note dated January 9, 2015 timed at 11:17 a.m., indicated a primary complaint of generalized weakness.
The ED Disposition Note dated January 9, 2015 timed at 6 p.m., indicated admit to medical surgical.

A review of the Plan of Care dated last reviewed on January 10, 2015 at 11:34 a.m., indicated problems to include acute urinary tract infection, dehydration, infection risk and hypertension. There was no documentation a plan of care for discharge planning was developed.

7. A review of the ED Triage indicated Patient 14 arrived at the facility on November 1, 2014 at 4:47 p.m.
The ED Nursing Triage Note collected on November 1, 2014 at 4:51 p.m., indicated Patient 14 presented to ED with primary complaint of hip pain, status post fall this morning.
The Patient Demographic Profile indicated the patient was from a skilled nursing facility.

A review of the Plan of Care dated last reviewed on November 2, 2014 at 4:28 p.m., indicated multiple problems to include skin integrity impairment, risk for safety/injury, pre-existing condition, physical therapy, pain, knowledge deficit, impaired physical mobility, anxiety and altered mental status/ psychosocial concerns. There was no documentation a plan of care for discharge planning was developed.

8. A review of the ED Triage indicated Patient 16 arrived at the facility on November 4, 2014 at 8:33 p.m.
The ED Nursing Triage Note collected on November 4, 2014 at 8:36 p.m., indicated Patient 16 presented to ED with altered level of consciousness.
The ED Nursing Disposition Note on November 5, 2014 at 4:16 a.m., indicated admit Patient 16 to critical care.

The Assessment Report collected November 5, 2014 at 7:43 a.m., indicated the patient was lethargic, respirations even and unlabored.
A review of the Plan of Care Report indicated, No Plans Charted for Visit.

A review of the CM/SS Supplemental Note collected on November 10, 2014 at 1:06 p.m., indicated patient going home with Hospice per family's wishes. The patient was discharged on November 10, 2014.

9. A review of the Patient Demographic Profile for Patient 18 indicated the patient was admitted to the facility on February 27, 2015 with diagnoses which included dyspnea (labored breathing), cardiomyopathy (disease of the heart muscle), cachexia (loss of body mass, progressive muscle wasting).

A review of the Plan of Care dated last reviewed on March 6, 2015 at 11:28 a.m., indicated problems to include impaired gas exchange/ ineffective airway clearance, alteration in cardiac status/ tissue perfusion. There was no documentation a plan of care for discharge planning was developed.

10. A review of the Patient Demographic Profile for Patient 19 indicated the patient was admitted to the facility on March 6, 2015 with diagnosis of cellulitis (bacterial infection involving the skin and spread to deeper tissue) abdominal wall abscess.
The Initial Admission documentation indicated the patient was alert, oriented to person, time and place and no limitation with mobility.

The Plan of Care dated last reviewed on March 10, 2015 at 2:42 p.m., indicated problems to include nutrition alteration. pre-existing condition, pain and infection. There was no documentation a plan of care for discharge planning was developed.

11. A review of the Patient Demographic Profile for Patient 20 indicated the patient was admitted to the facility on March 3, 2015 with diagnosis of chronic obstructive pulmonary disease.

A review of the Plan of Care dated last reviewed on March 11, 2015 at 1:28 p.m., indicated multiple problems. There was no documentation a plan of care for discharge planning was developed.

Based on record review and interview, the facility failed to provide a discharge planning evaluation that included community-based services that are available to meet the patient's post hospital care needs for 4 of 20 sample patients (Patient 1, 3, 11 and 12).

1. For Patient 1, who required total assistance in activities of daily living, was discharged to a board and care facility. There was no documentation of discharge planning that included community based services such home health service that is available to meet the care needs of the patient after discharged from the hospital

2. For Patient 3, there was no discharge planning evaluation completed for the patient.


3. For Patient 11, the patient needed total assistance with activities of daily living, and had a gastrostomy tube, there was no documentation of discharge planning to include evaluation of the services to meet the patient's needs.

4. For Patient 12, there was no documentation that the case management discharge planning was completed.


Findings:

1. The ED Nursing Triage Note dated January 7, 2015 at 10:50 a.m., indicated Patient 1 presented to the emergency department with complaint of pain in the lower extremity. The patient's family member brought the patient from home. The family member stated that he wanted the patient to be put in the skilled nursing facility.

The ED Physician Note collected on January 7, 2015 at 2:03 p.m., indicated the patient had pain in the lower extremity for years, patient cannot walk, disoriented to time, had garbled speech, and impaired judgement. The physician's diagnostic impression included acute urinary tract infection (infection in the urinary system) , spastic paraparesis (disorder whose parts of the body develop spasticity and weakness), dementia (gradual decline in thinking, reasoning and memory), and ataxia (lack of voluntary coordination of muscle movements). Patient 1 was not safe to go home and needed long term care. Patient 1 was admitted to a medical surgical unit.

The CM/SS/DC Planning Assessment dated January 9, 2015 at 2:57 p.m. completed by CM 2 indicated the patient was admitted from home with a family member, previously functioned as totally dependent, and was confused. The physical/medical risk factors included the patient inability to perform activities of daily living, had acute and chronic condition and had altered mental status. The discharge goal was skilled nursing facility (SNF).

The CM/SS Supplementing Note collected on January 14, 2015 at 10:46 a.m., collected by CM 2 indicated as per insurance, Patient 1 did not meet the criteria for SNF. The physician was contacted and stated the patient can be discharge home and to inform the family member.

The CM/SS/DC Planning Assessment collected January 23, 2015 at 5:23 p.m., by CM 1, indicated Patient 1 was discharged to Board and Care #1, located at the city of Riverside. There was no documentation the patient was assessed for community based services such as home health services to meet the post hospital care needs of the patient. There was no documentation of a physician order to discharge Patient 1 to Board and Care #1.

The Continuity of Care collected January 23, 2015 at 5:50 p.m., indicated Patient 1 was discharged to Board and Care #1. Patient 1 is confused, was unable to do dressing, personal hygiene, toileting, eating, bathing, walking, was incontinent of urine at risk for fall. There was no documentation the patient was assessed for community based services such as home health services to meet the post hospital care needs of the patient. There was no documentation of any communication with staff from Board and Care #1 regarding Patient 1's continuity of care.

During an interview on March 10, 2015 at 4:25 p.m., CM 1 stated when they could not find a SNF, someone from Riverside (county) came to assess Patient 1 and that person talked to the patient's family member and the family member agreed for the patient to be discharged to a board and care. When asked if the above information was documented on the patient's record, CM 1 stated she would check the record. Admin 1, who was present during the interview with CM 1, stated there was no documentation regarding the visit of the board and care staff. In another interview on March 12, 2015 at 11:45 a.m., CM 1 stated she does know about Board and Care #1.

On March 11, 2015, at 2 p.m., during an interview, Admin 1 stated that some board and care facilities have staff that assist the patients with their care. When asked about Board and Care #1, Admin 1 stated she does not know anything about Board and Care #1.

The facility's policy and procedure titled, "Discharge Planning," November 2012, indicated discharge planners who make referrals to outside services are responsible for being familiar with providers to which they are making referrals. Discharge Plan includes identifying and evaluating the patient needs and assistance in given in preparing the patient to move from one level of care to another. Discharge plan also includes determining the ability of community resources to meet the patient needs.

2. A review the Patient Demographic Profile indicated Patient 3 was admitted to the facility on September 18, 2014, from the skilled nursing facility with diagnoses that included seizure disorder (sudden disruption of brain electrical activity), hyponatremia (low sodium level in the blood) and acute urinary tract infection (infection in the urinary system).

The Admit/Discharge/Transfer indicated an order to discharge Patient 3 to the skilled nursing facility on September 21, 2014. The Discharge Assessment collected on September 21, 2014 at 2:45 p.m., indicated the patient was discharge on September 21, 2014. There was no documentation that discharge planning evaluation was completed for Patient 3. According to the facility's CM/SS/DC Planning Assessment form, discharge planning evaluation included the patient's physical function, mental status, physical/medical risk factors, advance directive, culture/religion, the patient's primary care giver, previous place that patient was admitted from, community resources, discharge goal, and patient/family plan of discharge.

During an electronic record review and interview with RN 3 on March 11, 2015 at 10:15 a.m., RN 3 stated there was no discharge planning evaluation completed for Patient 3. The form titled, "CM/SS/DC Planning Assessment was blank.



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3. A review of Patient 11's medical record indicated the patient presented to the facility's emergency room by ambulance on January 16, 2015 at 9:26 p.m., from a skilled nursing facility (SNF) with asthenia (lack or loss of strength and energy), for evaluation regarding generalized weakness. The patient was transferred to the medical/surgical unit on January 17, 2015 at 10:10 a.m.

The Initial Admission Assessment dated January 17, 2015 at 8 p.m., indicated the following diagnoses: major failure to thrive (condition where people begin to decline), hypernatremia (elevated sodium level in the blood), hypokalemia (electrolyte potassium in the blood is low), acute manic phase (period of elevated mood), generalized weakness. The documentation indicated the patient was disoriented to person, time and place, cannot retain, register, recall information, anxious, alert but confused and restless. The patient has dysphagia (medical term for the symptom of difficulty in swallowing) with gastrostomy tube (GT is a tube surgically inserted into the stomach through the abdominal wall for purposes of feeding and medication administration), on Fibersource HN at 40 milliliter (ml) per hour for 20 hours and pureed diet with thickened liquid for oral gratification. The Screenings section indicated, anticipated discharge plan for SNF and MD notified of admission.

A review of the Orders Report indicated an order for discharge planning to SNF by case management dated January 20, 2015 timed at 6:37 p.m. Another order dated January 22, 2015 timed at 11:53 a.m., indicated discharge planning to SNF by case management.

Review of the record indicated no case management discharge planning documentation.

The CM/SS/Discharge Planning Assessment form was not completed. The following information were not check off: Patient Admitted from, Primary caregiver, Assessment completed by interviewing, Assessment conducted, Emergency notification, Patient previously lived at, Physical functioned, Mental function status, Community Resources and Entitlements, Advance Directives, Culture/Religion, Physical/medical risk factors, Patient family plan of discharge, Discharge to. The information documented was a check mark for "Board and Care" and a documentation under Post discharge arrangement indicated, Patient discharge to Board and Care 1 (phone number was documented and address was in Riverside). The documetation also indicated the patient agreeable with discharge plan and the patient advocate also spoke with patient. (The documented name of patient advocate was the Director of Business Development).

The Continuity of Care collected on January 23, 2015, timed at 7 p.m., indicated transferred to Board and Care 1, notified daughter and the mode of transfer was ambulance. The activity indicated bedrest, and mental status indicated confused. The patient needs assistance with eating and the documentation for dressing, bathing, personal hygiene, toileting, ambulation and follow directions indicated "unable". The documentation indicated Fibersource HN at 40 ml/ hour for 20 hours and pureed diet with thickened liquid for oral gratification.

The Discharge Assessment, no date and time collected, indicated a discharge date of January 23, 2015 at 9 p.m. The documentation indicated the patient was confused and needed complete assistance with hygiene, dressing,bathing, toileting, and eating. The documentation also indicated the patient had a GT.

During an interview at 10:57 a.m., CM 2 stated she did not do discharge planning for Patient 11, that she probably did not get to it.

4. A review of the ED Nursing Triage indicated Patient 12 arrived in the ED on January 16, 2015 at 8:28 p.m. The Triage Note, collected at 9 p.m., indicated a primary complaint of asthenia, from SNF for ER evaluation regarding generalized weakness. The patient was transported by ambulance and accompanied by EMS. The neurological assessment indicated alert, confused. The ED Disposition note indicated admit to medical/surgical unit.

A review of the Orders Report indicated an order for discharge planning to SNF by case management dated January 19, 2015 timed at 12:27 p.m. Another order dated January 20, 2015 timed at 6:32 p.m., indicated discharge planning to SNF by case management.

Review of the record indicated no case management discharge planning documentation. There was no documented communication with the skilled nursing facility.

During an interview at 11 a.m., CM 2 stated she did not do discharge planning for Patient 12.

A review of the facility policy titled, Hospital Discharge Planning, effective date October 23, 2013 indicated, "Case managers, Social Worker or Discharge Planner provide individual discharge planning to each patient through assessment of discharge needs at admission, development of a discharge plan, implementation of the plan, evaluation of the appropriateness of the plan with on-going monitoring, and the coordination of final preparation for discharge.

Based on record review and interview, the facility failed to the ensure the discharge planning evaluations of 20 sample patients were developed by qualified personnel as per facility Position Description. For CM 3, she had no working experience in the case management. For CM 2, there was no Position Description in CM 2's employee file. For CM 1, she did not have the minimum 2 years experience as a case manager as per Position Description. This deficient practice resulted in failure to conduct discharge planning evaluations that included community-based services that are available to meet the patient's post hospital care needs and appropriateness of the discharge plan.

Findings:

1. A review of the employee file for CM 3 indicated she was hired on December 1, 2014. The facility's Department of Human Resources Applicant Introduction dated November 13, 2014, indicated CM 3 was accepted for the position, "LVN Case Manager," with the approval signature by Admin 1.

The Position Description for Case Manager dated December 2, 2014 and signed by CM 3 indicated the qualifications included a current and valid licensure as a Licensed Vocational Nurse ( LVN) with minimum of two years recent experience as a case manager in an acute care facility was required, LVN with a minimum of 2 years experiential background in case management and/or discharge planning in an acute care facility may be considered, BSN preferred, and certification in Case Management preferred. The Service Skills for case manager is considered qualified by experience, training and or expertise to coordinate effective review functions which are required for case management/discharge planning processes. The Position Summary indicated the case manager is responsible reviewing of inpatients as it related to admission appropriateness, continued stay appropriateness and discharge needs of patients. Strong clinical assessment, discharge planning and communication are required.

The Employment Application dated November 12, 2014 and signed by CM 3 indicated CM 3 had no working experience in the case management. There was no resume included in the employee file.

During an interview on March 12, 2015 at 2 p.m., Admin 1 stated CM 3 was not qualified and was being trained in discharge planning with CM 1. Admin 1 stated, "We violated the 2 years minimum requirement."

A review of Patient 2's CM/SS/DC Planning Assessment collected by CM 3 on January 26, 2015 at 10:10 a.m., indicated Patient 2 was admitted from board and care and discharge goal was board and care. However, the Initial Admission collected on January 25, 2015 at 11:35 a.m., indicated the patient's diagnoses included back pain and urinary tract infection, had colostomy, had foley catheter, had stage IV pressure ulcers on the right and left buttocks and stage III on the left lateral leg, and multiple DTI to right toes. The current residence was board and care, no current resource utilization and anticipated discharge plan was the skilled nursing facility.

2. A review of the employee file for CM 2 indicated she was hired on August 24, 2014. CM 2's resume indicated she was an LVN and worked as a case manager at an acute care hospital for 5 years.

The facility's Department of Human Resources Applicant Introduction dated August 1, 2014, indicated CM 2 accepted the position, "LVN" in Case Management Department with the approval signature by Admin 1. The 90-Day Performance Planning & Review Exempt Staff Member for CM 2 review date from August 25, 2014 to November 22, 2014, indicated CM 2's job title was LVN Case Manager. However, there was no Position Description in CM 2's employee file. During an interview on March 12, 2015 at 2:20 p.m., the Human Resources Director stated he could not find the Position Description for CM 2.

The CM/SS/DC Planning Assessment collected March 7, 2015 at 1:55 p.m., indicated Patient 2 was admitted from the skilled nursing facility (SNF), was alert and calm, and the discharge goal was the SNF. The CM/SS Supplemental Note collected on March 10, 2015 at 11:30 a.m. by CM 2 indicated per doctor order, Patient 2 is to be discharge to the long term acute care hospital (LTACH). The CM/SS Supplemental Note collected on March 10, 2015 at 5:45 p.m., indicated CM 2 informed the family member about the LTACH facility had accepted the patient and ambulance would pick up patient by 7 p.m. There was no documentation CM 2 had discussed Patient 2 regarding his discharge plan to LTACH facility. During an interview on March 11, 2015, at 10:55 a.m., CM 2 stated she did not talk with Patient 2 regarding the discharge plan to LTACH facility on March 10, 2015, and that she should have talk to the patient first before arranging an ambulance transportation.

3. A review of employee file for CM 1 indicated she was hired on May 20, 2013. The Offer Employment dated May 20, 2013, and signed by CM 3 and Human Resource staff indicated CM 3 accepted the the employment and the job title was case manager/discharge planner.

The Position Description for Case Manager dated May 20, 2013, and signed by CM 1 indicated the qualifications included a current and valid licensure as a Licensed Vocational Nurse ( LVN) with minimum of two years recent experience as a case manager in an acute care facility was required, LVN with a minimum of 2 years experiential background in case management and/or discharge planning in an acute care facility may be considered, BSN preferred, and certification in Case Management preferred. The Service Skills for case manager is considered qualified by experience, training and or expertise to coordinate effective review functions which are required for case management/discharge planning processes. The Position Summary indicated the case manager is responsible reviewing of inpatients as it related to admission appropriateness, continued stay appropriateness and discharge needs of patients. Strong clinical assessment, discharge planning and communication are required.

A review of CM 1's resume indicated she worked in acute care hospital for 1 year as a clinical case manager. During an interview on March 12, 2015 at 2:20 p.m., the Human Resource Director stated CM 1 did not have the minimum 2 years experience as a case manager as per Job Description.

A review of the facility's policy and procedure titled, "Discharge Planning," approval date November 2012, did not specify the qualifications for personnel other than registered nurses or social workers who develop or supervise the development of the evaluation. The facility's policy also indicated the discharge planning process includes the role of the social worker in identification of the patient's needs, identifying the patient's post hospital psychosocial, physical and ADL needs, determining if the patient/family can be identified as the primary caregiver of post hospitalization needs and determine the ability of community resources to meet the patient's needs.

During an interview on March 11, 2015 at 1:25 p.m., Admin 1 stated that they do not have a social worker that does the discharge planning. Admin 1 stated they do have a licensed clinical social worker (LCSW) that works with patients that had psychiatric problems.

In an interview on March 11, 2015 at 4:50 p.m., LCSW 1 stated he does not do discharge planning, but could do consultation to determine the level of care the patient needs and difficult placement.



The CM/SS/DC Planning Assessment collected January 23, 2015 at 5:23 p.m., by CM 1, indicated Patient 1 was discharged to Board and Care #1, located at the city of Riverside. There was no documentation the patient was assessed for community based services such as home health services to meet the post hospital care needs of the patient. There was no documentation of a physician order to discharge Patient 1 to Board and Care #1.

The Continuity of Care collected January 23, 2015 at 5:50 p.m., indicated Patient 1 was discharged to Board and Care #1. Patient 1 is confused, was unable to do dressing, personal hygiene, toileting, eating, bathing, walking, was incontinent of urine at risk for fall. There was no documentation the patient was assessed for community based services such as home health services to meet the post hospital care needs of the patient. There was no documentation of any communication with staff from Board and Care #1 regarding Patient 1's continuity of care.

During an interview on March 10, 2015 at 4:25 p.m., CM 1 stated when they could not find a SNF, someone from Riverside (county) came to assess Patient 1 and that person talked to the patient's family member and the family member agreed for the patient to be discharged to a board and care. When asked if the above information was documented on the patient's record, CM 1 stated she would check the record. Admin 1, who was present during the interview with CM 1, stated there was no documentation regarding the visit of the board and care staff. In another interview on March 12, 2015 at 11:45 a.m., CM 1 stated she does know about Board and Care #1.

Based on record review and interview, the facility failed to evaluate patients so that appropriate arrangements for post-hospital care are made before discharge for one of 20 sampled patients (Patient 11).

For Patient 11, the patient was admitted from a skilled nursing facility (SNF) on January 16, 2015. The patient was discharged to a different setting (Board and Care) on January 23. 2015. There were 2 physician orders for discharge planning to SNF by case management dated January 20, 2015 timed at 6:37 p.m., and dated January 22, 2015 timed at 11:53 a.m. There was no documented evidence of discharge planing by case management and documentation of any communication with the SNF. A third physician order dated January 23, 2015 at 7:35 p.m., indicated discharge patient. The order did not specify the discharge destination of the patient. The Medicine Daily Progress Note dated January 23, 2015, indicated a plan of action to DC (discharge) to Board and Care Secure Hands. Patient 11 was discharged to a Board and Care Secure Hands on January 23, 2015 at 9 p.m.

Findings:

A review of Patient 11's medical record indicated the patient presented to the facility's emergency room by ambulance on January 16, 2015 at 9:26 p.m., from a skilled nursing facility (SNF) with asthenia (lack or loss of strength and energy), for evaluation regarding generalized weakness. The patient was transferred to the medical/surgical unit on January 17, 2015 at 10:10 a.m.

The Initial Admission Assessment dated January 17, 2015 at 8 p.m., indicated the following diagnoses: major failure to thrive (condition where people begin to decline), hypernatremia (elevated sodium level in the blood), hypokalemia (electrolyte potassium in the blood is elevated), acute manic phase (period of elevated mood), generalized weakness. The documentation indicated the patient was disoriented to person, time and place, cannot retain, register, recall information, anxious, alert but confused and restless. The patient has dysphagia (medical term for the symptom of difficulty in swallowing) with gastrostomy tube (GT is a tube surgically inserted into the stomach through the abdominal wall for purposes of feeding and medication administration), on Fibersource HN at 40 milliliter (ml) per hour for 20 hours and pureed diet with thickened liquid for oral gratification. The Screenings section indicated, anticipated discharge plan for SNF and MD notified of admission.

A review of the Orders Report indicated an order for discharge planning to SNF by case management dated January 20, 2015 timed at 6:37 p.m. Another order dated January 22, 2015 timed at 11:53 a.m., indicated discharge planning to SNF by case management. A third order dated January 23, 2015 at 7:35 p.m., indicated discharge patient. The order did not specify the discharge destination of the patient.

A review of the Medicine Daily Progress Note dated January 23, 2015, indicated a plan of action to DC (discharge) to Board and Care Secure Hands.
Review of the record indicated no case management discharge planning documentation.

During an interview at 8:35 a.m., the same day, Case Manager 1 (CM 1) was asked why the patient was not transferred to the SNF. CM 1 stated she would look for the communication with the SNF.

The CM/SS/Discharge Planning Assessment form was not completed. The following information were not check off: Patient Admitted from, Primary caregiver, Assessment completed by interviewing, Assessment conducted, Emergency notification, Patient previously lived at, Physical functioned, Mental function status, Community Resources and Entitlements, Advance Directives, Culture/Religion, Physical/medical risk factors, Patient family plan of discharge, Discharge to. The information documented was a check mark for "Board and Care" and a documentation under Post discharge arrangement indicating, "Patient discharge to Board and Care 1.. " phone number and address "Patient agreeable with discharge plan...Pt (patient) advocate also spoke with pt."

The Continuity of Care collected on January 23, 2015, timed at 7 p.m., indicated transferred to Secure Hands, notified daughter and the mode of transfer was ambulance. The activity indicated bedrest, and mental status indicated confused. The patient needs assistance with eating and the documentation for dressing, bathing, personal hygiene, toileting, ambulation and follow directions indicated "unable". The documentation indicated Fibersource HN at 40 ml/ hour for 20 hours and pureed diet with thickened liquid for oral gratification.

The Discharge Assessment, no date and time collected, indicated a discharge date of January 23, 2015 at 9 p.m. The documentation indicated the patient was confused and needed complete assistance with hygiene, dressing,bathing, toileting, and eating. The documentation also indicated the patient had a GT.

During an interview on March 11, 2015 at 10:25 a.m., CM 1 was not able to provide documentation of any communication with the SNF and no documented information from Board and Care 1. CM 1 stated to speak with Case Manage 2 (CM 2).

During an interview at 10:57 a.m., the same day, CM 2 stated she did not do discharge planning for Patient 11, that she probably did not get to it. CM 2 reviewed the CM/SS/Discharge Planning Assessment form for Patient 11 and stated the post discharge arrangement note was written by CM 1. CM 2 stated there was no further documentation. When asked about Board and Care 1, CM 2 stated, she does not know about Board and Care 1. CM 2 stated she works until 4:30 p.m., and the patient advocate helps with patient placement.

During an interview on March 11, 2015 at 2 p.m., Admin 1 stated that some board and care facilities have staff that assist the patients with their care. When asked about Board and Care 1, Admin 1 stated she does not know anything about Board and Care 1.

In an interview on March 12, 2015 at 4:07 p.m., the the Director of Business Development stated he was not the patient advocate. He stated he does contract negotiation, sees patients, assists with difficult patients, talks to the patients and talks to the doctors. When asked about Board and Care 1, he denied knowledge of Board and Care 1. He stated, "Friends that I know call." He stated M... (no last name) assists with placement.

During an interview on March 12, 2015 at 4:45 p.m., the licensed clinical social worker (LCSW) stated he does no do discharge planning, he does consult to determine level of care the patient needs, identify alternate placement. The LCSW stated usually patients return to the same facility. When inform regarding Patient 11, the LCSW stated, "That should not be the case."

Based on record review and interview, the facility failed to inform the result of the discharge planning for 1 of 20 sample patients. For Patient 2, there was no documentation that the patient was informed of the discharge plan to go to a long term acute care hospital. This deficient practice did not ensure the patient's participation in his discharge planning.


Findings:


A review of the Patient Demographic Profile indicated Patient 2 was admitted to the facility on March 2, 2015, with diagnoses that included injury of toe and superficial laceration of foot.


The CM/SS/DC Planning Assessment collected March 7, 2015 at 1:55 p.m., indicated Patient 2 was admitted from the skilled nursing facility (SNF), was alert and calm, and the discharge goal was the SNF. The CM/SS Supplemental Note collected on March 10, 2015 at 11:30 a.m. by CM 2 indicated per doctor order, Patient 2 is to be discharge to the long term acute care hospital (LTACH). The CM/SS Supplemental Note collected on March 10, 2015 at 5:45 p.m., indicated CM 2 informed the family member about the LTACH facility had accepted the patient and ambulance would pick up patient by 7 p.m. There was no documentation CM 2 had discussed Patient 2 regarding his discharge plan to LTACH facility.


A physician order dated March 10, 2015 at 5:53 p.m., indicated a discharge order for Patient 2 to go to LTACH facility.


The Nursing Note collected on March 10, 2015 at 8 p.m., indicated Patient 2 refused to go to the LTACH facility. The physician was contacted and ambulance transportation was canceled, and the LTACH was contacted.


During an interview on March 11, 2015, at 10:55 a.m., CM 2 stated she did not talk with Patient 2 regarding the discharge plan to LTACH facility on March 10, 2015, and that she should have talk to the patient first before arranging an ambulance transportation.

Based on record review and interview, the facility failed to implement the patient's discharge plan for 1 of 20 sample patients (Patient 2). For Patient 2, who was paraplegic (impairment in motor or sensory function of the lower extremity), had colostomy (surgical procedure that creates an opening for feces to be removed from the body), had a foley catheter (urinary catheter that is inserted through the urethra and into the bladder to drain the urine), had stage III pressure ulcers (skin breakdown caused by pressure on the skin and usually over the bony prominence) in the right and left buttocks and right later leg, was discharged to an assisted living facility with home health service. There was no documentation in Patient 2's electronic record the discharge plan to SNF #2 was not implemented as indicated in the CM/SS Supplemental Note collected on January 6, 2015. There was no documentation for the reason why the discharge goal in the CM/SS DC Planning Assessment was not met.

Findings:

1. The Patient Demographic Profile indicated Patient 2 was admitted to the facility from the skilled nursing facility on December 23, 2014, 5:30 p.m. with diagnoses that included sepsis (infection that has spread in the bloodstream), acute lower urinary tract infection (infection in the urinary system), and altered mental status.

The ED Nursing Disposition Note collected on December 23, 2014 at 6 p.m., indicated the patient was admitted to the telemetry unit.

The Initial Admission collected on December 23, 2014 at 8:30 p.m., indicated Patient 2 was paraplegic (impairment in motor or sensory function of the lower extremity), had colostomy, had a foley catheter, had stage III pressure ulcers (skin breakdown caused by pressure on the skin and usually over the bony prominence) in the right and left buttocks and right later leg, and was at risk for falls and skin breakdown.

The CM/SS DC Planning Assessment collected on January 6, 2015 at 1:48 p.m., indicated a discharge planning assessment was completed 14 days after the patient was admitted. The discharge planning assessment indicated the patient was admitted from the skilled nursing facility (SNF #1), alert, physically functioned as partially dependent, and the discharge goal was SNF.

According to the CM/SS Supplemental Note collected on January 6, 2015 at 1:58 p.m., indicated CM 1 informed Patient 2 that SNF #1 was not accepting the patient back because there was no bed available. CM 1 also informed Patient 2 that SNF #2 was willing to accept the patient and the patient agreed with the discharge to SNF #2. CM 1 also informed the patient's family member and she said she wanted the patient be referred to SNF #3 and SNF #4. However, CM 1 informed the family member that SNF #3 and #4 had denied the patient and SNF #2 was willing to accept the patient. The family member agreed with the discharge plan.

The next documentation in the electronic record regarding discharge planning was the discharge instructions. The Discharge Instructions-Inpatient collected on January 15, 2015 at 6:15 p.m., by the registered nurse (RN), indicated Patient 2's discharge date was January 15, 2015 and timed 6:12 p.m. Patient 2 required wound care. Patient 2 was discharged to the Assisted Living with home health services and there was no documentation of the name, address and telephone number of the Assisted Living.

The Discharge Assessment with no date and time completed by an RN indicated Patient 2's discharge date was January 15, 2015, discharge time was 4 p.m. and discharge to home with home health services. The discharge time and discharge place were not consistent with Patient 2's Discharge Instructions. In addition, there was no documentation of Patient 2's continuity of care that addressed the primary diagnosis, co-morbid conditions, medications orders and treatments, follow directions, and any reports/results that were sent to the patient.


In an interview with Medical Record Director on March 12, 2015 at 10:05 a.m., confirmed there was no Patient 2's continuity of care document completed when Patient 2 was discharged on January 15, 2015.

The Nursing Note collected on January 15, 2015 at 7:10 p.m., indicated that at 2:30 p.m., CM 2 would follow up with the physician order to discharge Patient 2 to the assisted living. However, at 3 p.m., CM 2 stated that the Patient Advocate would follow up with Patient 2's discharge. At 4 p.m., per the Patient Advocate, Patient 2 would be discharge to the Assisted Living in the city of Riverside and the patient was informed of the assisted living. There was no documentation of the address and telephone number of the assisted living. Per Director of Business Development, the patient would be pick up at 7:30 p.m.

There was no documentation in Patient 2's electronic record the discharge plan to SNF #2 was not implemented as indicated in the CM/SS Supplemental Note collected on January 6, 2015. There was no documentation for the reason why the discharge goal in the CM/SS DC Planning Assessment was not met . During an interview on March 11, 2015 at 10:45 a.m., CM 2 stated she leaves the facility at 4:30 p.m. and after 4:30 p.m., the Director of Business Development would find a placement and the placement for Patient 2 was the assisted living.

Based on record review and interview, the facility failed to reassess the discharge plan to address the post discharge care needs of 1 of 20 sample patients (Patient 1). For Patient 1, the initial discharge plan was to be discharged to a skilled nursing facility due to patient required total assistance in activities of daily living. Patient 1 was discharged to a board and care facility (a lower level of care facility) and there was no reassessment for the patient's post discharge care needs. This deficient practice had a potential to result in the lack of care to meet patient's physical and psychosocial needs.

Findings:

The ED Nursing Triage Note dated January 7, 2015 at 10:50 a.m., indicated Patient 1 presented to the facility's emergency department with complaint of pain in the lower extremity. The patient's family member brought the patient from home. The family member stated that he wanted the patient to be put in the skilled nursing facility after discharged from the facility.

The ED Physician Note collected on January 7, 2015 at 2:03 p.m., indicated the patient had pain in the lower extremity for years, patient cannot walk, disoriented to time, had garbled speech, and impaired judgement. The physician's diagnostic impression included acute urinary tract infection, spastic paraparesis, dementia, and ataxia. Patient 1 was not safe to go home and needed long term care. Patient 1 was admitted to a medical surgical unit.

The CM/SS/DC Planning Assessment collected on January 9, 2015 at 2:57 p.m., completed CM 2 indicated the patient was admitted from home with a family member, physically functioned as totally dependent, and was confused. The physical/medical risk factors included the patient inability to perform activities of daily living, had acute and chronic conditions, and had altered mental status. The discharge goal was skilled nursing facility (SNF).

The CM/SS Supplementation Note dated January 9, 2015 at 3:01 p.m., indicated Patient 1's family member was informed the patient was accepted to go to SNF 1 and waiting for authorization from the patient's medical insurance.

The CM/SS Supplementing Note dated January 14, 2015 at 10:46 a.m., collected by CM 2 indicated as per insurance, Patient 1 did not meet the criteria for SNF. The physician was contacted and stated the patient can be discharge home and to inform the family member.

The CM/SS Supplemental Note collected January 14, 2015 at 1:03 p.m., indicated CM 1 had informed the family member that Patient 1 did not meet the criteria to be discharge to the SNF.

The CM/SS/DC Planning Assessment collected January 23, 2015 at 5:23 p.m., by CM 2, indicated Patient 1 was discharged to Board and Care #1 located at the city of Riverside, the family member was contacted and message was left to the family member's phone. According to the family member, any accepting facility would be ok due the family could not take care of the patient.

The Continuity of Care collected January 23, 2015 at 5:50 p.m., indicated Patient 1 was discharged to Board and Care 1. Patient 1 is confused, was unable to do dressing, personal hygiene, toileting, eating, bathing, walking, was incontinent of urine at risk for fall. There was no documentation of any communication with the staff from the board and care facility regarding the patient's continuity of care. There was no documentation of reassessment for the patient's post discharge care needs, since Patient 1 was unable to do her activities of daily living. When asked how and what documentation regarding any communication with the staff from the board and care facility on March 11, 2015, at 4:25 p.m., Admin 1 stated there was no documentation of communication with the staff from the board and care facility when the patient was being discharged to the board and care facility.

During an interview on March 10, 2015 at 4:25 p.m., CM 1 stated when they could not find a SNF for the patient, someone from Riverside (county) came to assess Patient 1 and that person talked to the patient's family member and the family member agreed for the patient to be discharged to a board and care. When asked if the above information was documented on the patient's record, CM 1 stated she would check the record. Admin 1, who was present during the interview with CM 1, stated there was no documentation regarding the visit of the board and care staff.

The facility's policy and procedure titled, "Discharge Planning," November 2012, indicated discharge planners who make referrals to outside services are responsible for being familiar with providers to which they are making referrals. Discharge Plan includes identifying and evaluating the patient needs and assistance in given in preparing the patient to move from one level of care to another. Discharge plan also includes determining the ability of community resources to meet the patient needs.