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Based on record review, document review, and staff interview, it was determined the LTCH failed to ensure a patient was transferred with all pertinent information to an appropriate facility for post-discharge care. These failures had the potential to cause undue stress and increase the likelihood of possible negative outcomes for all patients. Findings included:

Refer to A-0813 as it relates to the LTCH's failure to ensure a patient was transferred with all pertinent information to an appropriate facility for care post-discharge care.

The cumulative effect of these negative systemic practices significantly impeded the LTCH's ability to ensure discharge of patients was comprehensive and appropriate to the patients' needs.

Based on policy review, medical record review, and staff interview, it was determined the LTCH failed to ensure an adverse event was identified and analyzed for 1 of 1 patient (Patient #9) whose record included an adverse event. This resulted in the lack of analysis and evaluation of safe patient care and impeded the hospital from taking corrective action. Findings include:

An LTCH policy titled, "Incident Reporting," stated, "An incident report is to be completed for any unusual or unexpected occurence or event that causes, or increases the risk of injury or loss to the patient, visitor, staff, and/or hospital ..."

This policy was not followed.

Refer to A-0813 as it relates to Patient #9's inappropriate discharge due to the LTCH's inability to procur TPN to meet his needs.

On 7/06/22 beginning at 3:05 PM, the Director of Patient Outcome and the Director of Compliance for the LTCH were interviewed together and documents related to Patient #9's record were reviewed in their presence. When asked if the events related to Patient #9's discharge were reported as an incident and reviewed by the Compliance department, they stated, "No incident report was created."

The LTCH failed to ensure Patient #9's adverse event was identified and analyzed.

Based on record review, document review, and staff interview, it was determined the LTCH failed to ensure a patient was transferred with all pertinent information to a facility for follow up care, and ensure an effective transition of the patient from the LTCH to post-discharge care for 1 of 10 patients (Patient #9) whose records were reviewed. This resulted in a patient being discharged to an ACH's ED after the ACH denied the transfer of Patient #9 by direct admit. Findings include:

Patient #9 was a 50 year old male admitted to the LTCH on 3/15/22 for aftercare from surgery. He was discharged from the LTCH on 5/03/22 due to lack of TPN.

1. A document titled, "Timeline," which detailed the events of Patient #9's discharge, was provided. It stated the following:

- "On Saturday 4.30, we learned that we had enough supply to get pt TPN through Monday and would not be able to provide any further starting Tuesday."

- "On Monday, 5.2, We called to direct admit pt to [ACH corporation]. Transfer center denied request. Dr. [name] attempted to get pt admitted to [ACH] and was denied admission as well."

- "On Monday 5.2, [LTCH CEO] spoke to [ACH corporation employees] and was told [ACH Corporation] could not help us with TPN ... [ACH corporation employees] told they had exhausted their efforts as well and [ACH corporation] could not help us. [LTCH CEO] advised [ACH corporation employee] that we had no choice to return pt to [ACH]."

Patient #9's record included an interdisciplinary note dated 5/02/22, signed by a physician; this was reviewed. It stated the ACH would not accept the transfer of Patient #9.

Patient #9's record included a discharge order dated 5/03/22, signed by a physician. Patient #9's record did not include a transfer order.

Provider notes regarding Patient #9 from the ACH were obtained and reviewed. The ED Provider documented the following on 5/03/22:

"[LTCH] provider [PA-C] called the charge nurse this morning to 'let us know the patient was coming'.

I overheard the conversation, and called [PA-C] back to clarify that if this was a transfer, she needed to do a provider to provider consult, and get an accepting provider. [PA-C] stated this was not a transfer, and she was only making a courtesy call because the patient was being discharged from [LTCH].

After exploring the issues, which is solely a lack of TPN availability, and confirming that no new acute medical conditions existed that would require transfer to a higher level of care ... [LTCH] was attempting to circumvent the usual and legal transfer process by discharging the patient ... into an ambulance and sending the patient to [ACH].

[PA-C] repeatedly stated that this was not a transfer, because the patient was being discharged from [LTCH]. [PA-C] stated [LTCH] was discharging the patient will [sic] all his belongings, and [LTCH] had called an ambulance and specifically told the patient and EMS to take the patient to [ACH]. [PA-C] repeatedly maintains this is not a transfer because they are discharging the patient, the discharge plan is for the patient to come to [ACH] for his TPN.

I am aware that [LTCH] had been repeatedly denied this transfer by our administration and transfer center over last 24 hours."

The Director of Patient Outcomes was interviewed on 7/05/22 at 4:06 PM. She confirmed the ACH did not accept the transfer of Patient #9. She confirmed the LTCH transferred Patient #9 after the ACH denied the transfer. She stated, "we had no choice"

The PA-C noted in the ED documentation was interviewed by phone on 7/06/22 beginning at 10:53 AM. She confirmed she had a conversation with the ED provider at the ACH. When asked if Patient #9 was a discharge or transfer she stated, "discharge because we couldn't do an admit." She also said she told Patient #9, "you can't really go home you're not safe." PA-C stated they gave Patient #9 the option of where to go. She stated Patient #9 did not have anyone to take him to another facility. She stated the LTCH arranged for EMS to take Patient #9 to the ACH after they encouraged him to go there. She stated Patient #9 agreed to go to the ACH.

The Social Worker for Patient #9 was interviewed on 7/06/22 at 11:21 AM. When asked if Patient #9 was discharged or transferred, she stated it was a transfer. When asked about Patient #9's discharge plan she stated, "discharge planning on my part, there wouldn't be anything I could do for this man ... the options were very limited for him. It was a medical issue for him it wasn't a placement issue."

The Director of Patient Outcomes and 2 compliance officers were interviewed on 7/06/22 at 2:04 PM. They stated that Patient #9's transfer was an acute care emergency transfer.

The Director of Patient Outcomes and CEO were interviewed together on 7/07/22 beginning at 9:08 AM. When asked if Patient #9 was a discharge or transfer, the Director of Patient Outcomes confirmed it was documented as a discharge and there was a discharge order. The Director of Patient Outcomes stated there should have been a transfer order, and this was possibly a documentation issue. She also stated, "It was a choice of causing harm to the patient or breaking a rule." The CEO stated it should have been a transfer, not a discharge. He stated this was a documentation issue related to changing computer systems.

The LTCH failed to ensure Patient #9 was transferred to an appropriate LTCH after discharge. The LTCH failed to ensure Patient #9 was transfered to an accepting facility and discharged appropriately.

2. Patient #9's record included a document titled "Interdisciplinary Discharge instructions." The discharge instructions were dated 6/08/22, over a month after Patient #9's discharge.

The audit summary of Patient #9's discharge instructions were viewed electronically. The audit summary indicated the document was created on 6/08/22 and finished on 6/08/22. It was unclear how this information was provided to Patient #9 since it was not created until after Patient #9 discharged. Additionally, the document included a "Patient/responsible party Signature" area that was signed. It was unclear how Patient #9 or his representative would be able to sign this document over a month after he discharged from the LTCH.

The Director of Patient Outcomes was interviewed on 7/06/22 at 3:52 PM. When asked if the discharge instructions were sent with Patient #9 she stated, "probably not. Not 100 percent sure." When asked if the document was created after Patient #9 discharged from the LTCH, she said she did not know. She confirmed the document was completed on 6/08/22.

The LTCH failed to ensure all pertinent information was sent with Patient #9 after discharge.