HospitalInspections.org

Based on policy reviews, medical record reviews, observations, and patient and staff interviews, the rehabilitation staff failed to coordinate rehabilitation plan of care with nursing, medical providers, and case management to ensure delivery of rehabilitative services during inpatient hospitalization and in the home setting for 2 of 2 Behavioral Health patients (Patients #2 and #11).

The findings included:

Review on 07/24/2019 of the hospital policy, "Discharge Planning, Reviewed/Revised: 10/2018", revealed "... 5. The discharge plan is reassessed and updated every 3 business days, when there are changes to the plan, or based on clinical condition. ... VIII. DOCUMENTATION A. During the evaluation, the CM (case manager), Sr. (senior) CM, SW and/or DCP (discharge planner) will address and document findings related to support systems, cognitive abilities, and functional level prior to admission, previous use of community resources and anticipated needs at discharge. B. The CM/SR.CM/SW/DP finalizes the discharge plan, makes the appropriate arrangements for any post-acute needs and documents ..."

1. Medical record review for Patient #2, on 07/23/2019, revealed a 58-year-old male with a history of bipolar disorder (periods of extreme happiness and depression) and psychosis was transferred from a near-by hospital on 05/29/2019 and admitted to the Behavioral Health Unit (BHU). Medical record review revealed, on 05/31/2019 at 0955, an Occupational Therapy (OT) Consult was ordered by PA #1 for "Decreased functioning." Review of the "OT Acute Evaluation" by OT #1, on 05/31/2019 at 1240 revealed, "...Treatment ... Pt (patient) out of breath after LB (lower body) dressing task and required increased time for completion. Pt ambulated through environment with no AD (assistive device) but with slow gait ... OT Impairments or Limitations: Basic activity of daily living deficits, Endurance deficits, Fine motor deficits, Gross motor deficits, IADL (Instrumental Activities of Daily Living: caring for the home, medication management) deficits, Strength deficits ... Increased fatigue ... Required therapeutic breaks ... Verbal cues for safe execution of functional tasks. ..." Continued review of the evaluation revealed, "Clinical Assessment Summary: ...presents with SI (suicidal ideation), depression, and psychosis impacting appropriate participation with ADLs and IADLs. ... demonstrated disorganized thought process while describing history and PLOF (prior level of functioning). ... Pt with difficulty performing LB (lower body) dressing while seated EOB (edge of bed) and states he has difficulty with med (medication) management and self-care. Pt would benefit from skilled OT while in BHU to increase safe performance of ADLs and IADLs. ... OT Therapy Evaluation Assessment: 5 or more performance deficits relating to physical, cognitive, psychosocial limitations/restrictions. ... Plan - Frequency: 3-5x (times) per week; OT Duration Rehab (rehabilitation): 2 weeks; Planned Treatments: Basic activities of daily living, HEP (Home Exercise Program), Home Program, Patient education, Safety education, Therapeutic exercises for strengthening and ROM (range of motion). ... Self-Care/Activity: Dressing, Learner Response - Self Care/Activity: Needs follow up ..." Review revealed the initial OT evaluation was the only time Patient #2 was seen by OT prior to discharge on 06/03/2019, three (3) days post-evaluation. Medical record review of a "Therapist Individual Intervention" progress note by Licensed Clinical Social Worker Associate (LCSWA) #1, on 06/03/2019 at 0946 revealed, "... Discharge Plan: Pt will return to his apartment ... will follow up with current psychiatrist ... will be picked up....at 1300 today ..." Medical record review of the "Behavioral Health Discharge Summary" by Nurse Practitioner (NP) #1, on 06/03/2019 at 0928, revealed a follow up appointment was scheduled with Patient #2's psychiatrist and contact number for the "Peer Support Specialist" was provided. Review of the discharge orders on 06/03/2019 at 0553 by NP #1 revealed, "Discharge home to self. Voluntary status. Condition at Discharge: Stable. Reason for Discharge: Met treatment goals. May discharge when transportation available." Review of the discharging LCSWA and psychiatry note failed to reveal documented discharge planning evaluation of post-discharge, rehabilitative needs for Patient #2 following the OT initial evaluation recommendations noted on 05/31/2019.

Observation on 07/25/2019 at 1110 during a treatment team meeting on the BHU for Patient #12 revealed members of the treatment team included the charge nurse (CN), nurse manager (NM), utilization review nurse (URN), recreation therapist (RT), PA, senior psychiatric technician, and the LCSW were present. Observation revealed a member from rehabilitative services and the psychiatrist were not present during the team meeting.

Interview with OT #1 and the Director of Rehabilitation Services (DRS) on 07/24/2019 at 1413, revealed OT services were integrated as a treatment modality on the BHU, "sometime in April". OT #1 shared OT rounded weekly, on the BHU, Monday, Wednesday, and Friday and that OT attends multidisciplinary team huddles on those days. Interview revealed, OT did not attend scheduled treatment team meetings on Tuesday and Thursday. Interview revealed OT #1 could not recall whether recommendations from the initial OT evaluation on 05/31/2019 were discussed during the morning huddle on 06/03/2019, prior to Patient #2's discharge that day. Interview revealed that based on the initial OT evaluation, OT #1 felt therapy was indicated and that Patient #2 would have benefited from OT services while on the BHU but was discharged home on the Monday (06/03/2019) before additional OT therapies were provided. Interview revealed the OT shared that Patient #2 would have also benefited from strengthening and balance exercises at home but was able to perform ADLs and IADLs independently with limited noted deficits during the evaluation.

Interview on 07/24/2019 at 1445 with the attending psychiatrist, BHU Nurse Manager (NM), PA, and LCSWA (Discharge Planner) revealed there were two EMRs, a medical EMR and BHU EMR. Interview revealed the two EMRs did not interface and that members of the treatment team would not have been able to see the OT recommendations. Interview revealed the OT recommendations did not carry over to the BHU EMR and the psychiatrist nor the discharging LCSWA were aware of the OT recommendations prior to the interview. During the interview, the psychiatrist reported an OT evaluation was ordered on 05/30/2019 and that the results of the evaluation "Would have had to have been discussed during the morning meeting" (on Monday, 06/03/2019). Interview revealed the psychiatrist shared he was not aware of the recommendations from the initial OT evaluation, but he stated, "He [Patient #2] had a Peer Bridger (a community/home-based outreach service designed to be short term community support as the patient transitions from inpatient services back into the community) [set up], he made his own bed, dressed himself, and showered [on the unit]. He did not trigger an identified need at discharge." However, the psychiatrist was not aware of the ADLs and IADL deficits identified during the OT evaluation. Interview revealed the discharging LCSWA stated she was not aware of the OT recommendations for inpatient services and that had she been aware, she would have followed up with OT and coordinated outpatient OT services for Patient #2, if indicated.

Interview on 07/25/2019 at 1130 with the CN and NM revealed treatment team meetings occurred every Tuesday and Thursday and "Team Huddles" occurred every Monday, Wednesday, and Friday. Interview revealed a member from rehabilitative services and the psychiatrist did not attend treatment team meetings but were present for "Team Huddles". Interview revealed the CN, nor the NM could recall whether OT recommendations for Patient #2 were discussed prior to discharge on 06/03/2019 and could not recall having knowledge of OT #1's recommendations of the initial evaluation. The NM shared there was no "Team Huddle" documentation (topics discussed, agenda, team members present) available for review, "That would be a good improvement initiative for us."

Interview on 07/25/2019 at 1530 with the DRS and Vice President (VP)/Chief Nurse Executive (CNE) of the BH Service Line revealed the VP/CNE was not aware the medical EMR and BHU EMR did not interface. Interview revealed the issue needed to be "looked into and fixed so the OT progress notes flow over to the BHU EMR." Interview revealed that if OT recommendations were not verbally communicated, the treatment team, including the discharging provider and planner, would not be aware of patient progression or OT recommendations during the discharge planning evaluation. During the interview, the VP/CNE shared, "This is an area of opportunity for us."

Interview on 07/25/2019 at 1730 with the NM revealed she could not recall whether recommendations for inpatient OT services for Patient #11 were discussed during the morning huddle prior to discharge on 07/12/2019. Interview revealed there were two EMRs, a medical EMR and BHU EMR. Interview revealed the two EMRs did not interface and that members of the treatment team would not have been able to see the OT recommendations in the EMR due to the system interface issue.

In summary, failure of the rehabilitation services to coordinate delivery of patient care services resulted in Patient #2 being discharged home three (3) days after the OT assessment without further evaluation of home rehabilitation needs.

2. Medical record review for Patient #11, on 07/25/2019, revealed a 45-year-old female with a history of Borderline Personality Disorder (difficulty regulating emotion) and Post-Traumatic Stress Disorder (PTSD) (intense thoughts or feelings related to a traumatic event) was admitted to the BHU, on 07/09/2019 and discharged home 07/12/2019. Review of the H&P by PA #1, on 07/10/2019 at 1223, revealed Patient #11 presented with "worsening depression, cutting behavior, self-loathing (hatred), and suicidal thoughts ...She is in a wheelchair as she usually walks with crutches due to her back injury (surgical fusion of the spine). PT and OT will be consulted." Review of the provider orders revealed an OT consult was entered by PA #1, on 07/10/2019 at 1245 and performed the same day at 1431 by OT #1. Review of the "OT Acute Evaluation" revealed Patient #11 "... required increased time for supine to sit transfer d/t (due to) weakness and pain in BLE (bilateral lower extremity). ...required increased time to don/doff (put on and take off) socks... Assessment ...OT Impairments or Limitations: Balance deficits, Basic activity of daily living deficits, Endurance deficits, IADL deficits, Mobility deficits, Strength deficits ...Clinical Assessment Summary ... presents with decreased activity tolerance, balance, and strength. Pt (patient) required increased time to perform transfers and ADLs, stated she has flare up pain in BLE and BUE (bilateral upper extremity) ... minor loss of balance ... Pt would benefit from skilled OT while in hospital. ... Plan ... Frequency: 3-5x per week OT Duration Rehab (rehabilitation): 2 weeks. ..."Pt states she would like to receive more education on safety with ADLs, IADLs, and transfers, and on coping skills. Planned Treatments: Balance training, Basic activities of daily living, HEP (Home Education Program), Mobility training, Patient education, Safety education, Therapeutic activities, Transfer training." Review revealed the initial OT evaluation was the only time Patient #11 was seen by OT prior to discharge on 07/12/2019. Review of the discharge orders on 07/12/2019 at 1102 by PA #1 revealed, "May discharge when transportation ready." Review of discharge planning progress notes by LCSWA #1 on 07/11/2019 at 1103 and 07/12/2019 at 0845 and a progress note by LCSWA #2 on 07/11/2019 at 1432 failed to reveal acknowledgment of OT services. Review failed to reveal additional documentation regarding the OT initial evaluation recommendations noted on 07/10/2019 by OT #1.

Observation on 07/25/2019 at 1110 during a treatment team meeting on the BHU for Patient #12 revealed members of the treatment team included the charge nurse (CN), nurse manager (NM), utilization review nurse (URN), recreation therapist (RT), PA, senior psychiatric technician, and the LCSW were present. Observation revealed a member from rehabilitative services and the psychiatrist were not present during the team meeting.

Interview on 07/24/2019 at 1445 with the attending psychiatrist, BHU Nurse Manager (NM), and LCSWA (Discharge Planner) revealed there were two EMRs, a medical EMR and BHU EMR. Interview revealed the two EMRs did not interface and that members of the treatment team would not have been able to see the OT recommendations. Interview revealed the OT recommendations did not carry over to the BHU EMR.

Interview on 07/25/2019 at 1130 with the NM revealed treatment team meetings were held every Tuesday and Thursday and "Team Huddles" occurred every Monday, Wednesday, and Friday. Interview revealed a member from rehabilitative services and the psychiatrist did not attend treatment team meetings but were present for "Team Huddles". Interview revealed the CN, nor the NM could recall whether OT recommendations were discussed prior to discharge on 07/12/2019 and could not recall having knowledge of OT #1's recommendations of the initial evaluation. The NM shared there was no "Team Huddle" documentation (topics discussed, agenda, team members present) available for review, "That would be a good improvement initiative for us."

Interview on 07/25/2019 at 1530 with the DRS and Vice President (VP)/Chief Nurse Executive (CNE) of the BH Service Line revealed the VP/CNE were not aware of the system interface issues between the medical EMR and BHU EMR. Interview revealed the issue needed to be "looked into further and fixed" so the OT progress notes would flow over to the BHU EMR. Interview revealed that if OT recommendations were not verbally communicated, the treatment team, including the discharging provider and planner, would not be aware of patient progress or OT recommendations. During the interview, the VP/CNE shared, "This is an area of opportunity for us."

Interview on 07/25/2019 at 1730 with the NM revealed she could not recall whether recommendations for inpatient OT services for Patient #11 were discussed during the morning huddle prior to discharge on 07/12/2019. Interview revealed there were two EMRs, a medical EMR and BHU EMR. Interview revealed the two EMRs did not interface and that members of the treatment team would not have been able to see the OT recommendations in the EMR due to the system interface issue.

In summary, the failure of rehabilitation services to coordinate delivery of patient care services resulted in Patient #11 being discharged home two (2) days after the OT assessment without further evaluation of home rehabilitation needs.

NC00153440