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Based on review of records, procedures, and staff interviews, it was determined that the facility did not consistently comply with regulations for distribution of the Important Message for Medicare notices, which advise patients and/or representatives about Discharge Appeals rights.

Findings include:

1. The hospital failed to ensure compliance with regulatory requirements that mandate issuance of required initial and follow-up notices to applicable Medicare recipients about hospital discharge appeal rights. These regulations, referenced at CFR 489.27 (a) and 42 CFR 405.1205, require a first notice to be distributed within two days of admission to advise patients or their representatives of the right to file a discharge appeal. In addition, a follow up notice must be administered to applicable inpatients within 48 hours in advance of discharge.

Twelve (12) of sixteen (16) applicable current and retrospective inpatient medical and psychiatric records reviewed on 9/10/12, 9/11/12, and 9/13/12 found that the hospital did not consistently adhere to federal regulations and hospital procedures for the provision of the initial or follow-up Important Message for Medicare notices (IM) within two (2) days of admission or within 48 hours prior to discharge, where relevant.

Records lacked inclusion of initial and/or follow-up IM notices. Where patients were unable to sign or were incapacitated, no documentation of follow up efforts were noted in records to provide the required notices at a later time when patients' condition improved, nor attempts made to distribute to authorized beneficiaries' representatives.


Examples include:

MR#1:
Patient was admitted 9/4/12 for a tongue mass and had past history of dementia and Alzheimer's Disease. The IM form dated contained an "x" on the signature line. It was not signed and contained no written explanation. The patient information form receipt noted that "patient unable to sign". However a general admission consent was signed on the same date by the patient. Both the patient and her son signed consents for venous catheter and transfusion on 9/6/12. Attempted interview of the patient on 9/10/12 by surveyors found she had been released from wearing bilateral wrist restraints and appeared confused since she was unable to clearly answer questions. There was no documentation of follow up efforts noted to provide the required notices to authorized representatives.

MR#2
Patient was admitted on 9/8/12 with pneumonia. The patient signed the initial IM but the yellow tear off copy which is to be given to the patient after signature was still attached to the original document in the medical record.

MR#3
Record reviewed on 9/10/12 for a 73 year old patient admitted on 8/31/12 found no documents for the Important Message from Medicare or Acknowledgement form for Patients' Rights.

MR#4
Patient was admitted on 9/1/12 but the record contained contradictory data about the patient's ability. The patient signed the Important Message from Medicare form on 9/1/12 but was noted on the same date to be unable to sign the acknowledgement form for the Patient Information Guide. It was also noted in the admission general assessment dated 9/1/12 that staff were unable to get information about proxy and advanced directives but no reason was noted. On 9/4/12, a telephone consent was obtained from the daughter for DNR for adult patients without capacity. No follow up was evident for attempt to distribute the IM to patient's authorized representatives.

MR#5
73 year old patient admitted on 9/7/12 for inpatient psychiatric treatment for aggressive behavior. There was no evidence of distribution of the correct important Message from Medicare form in the record as of 9/11/12. The Discharge appeals rights form with an OMB #0938-0692 containing the hospital's insignia was in the record and was blank. This form did not contain the exact language as specified by regulation.

MR#8
77 year old male with dementia admitted on 7/24/12 from a nursing home for debridement of decubiti ulcers and infected right foot stump. The patient was unable to sign the IM or the patients' rights acknowledgement. The wife signed consent forms on 7/27/12 for the surgical debridement . No documentation was evident of follow up attempts to distribute the IM to the patient's representative. The patient was discharged on 8/10/12 and no follow up IM notice was evident.

MR#9
Patient was admitted 7/19/12 and signed the IM form on 7/19/12. The patient was discharged on 7/23/12 but discharge notice present in the record was not signed. The follow up discharge notice was of the incorrect type (form #IMC 70433) which is intended for distribution to patients under the case payment system.

Refer to MR #s 1-12.
2. The hospital did not ensure that consistent use of standardized forms "CMS-R-193" containing all required regulatory language were distributed to Medicare patients. Specifically, it was determined that records for Medicare patients contained both the CMS R-193 form and another discharge notice with the hospital logo (IMC form 70433). This second follow-up discharge notice (form #IMC 70433) did not conform exactly with regulatory language format as required by CMS and noted it is to be used for patients covered under the case payment system.

3. The hospital's procedures for issuance of discharge appeals notices was incomplete and did not comply with requirements for the provision of the initial and follow-up notices for the Important Message from Medicare. (IM)

The policy did not specify how required notices will be delivered when patients are unable to receive notification in instances of temporary or long-standing incapacity. The policy lacked instructions for distribution of the Important Message from Medicare notices (IM) to the proxy in instances when the patient lacks capacity.

Review of hospital procedures titled "Discharge Notice" CRM 005, for the delivery of the IM notice, on 9/13/12 did not specify how the notice would be delivered to the patient's representative or authorized proxy if the patient is unable to sign the notice. The policy did not include a mechanism to follow up when patients' condition improves to the degree that receipt and comprehension of the notice is possible.
If the patient is deemed incapable of receiving informed notices, the policy must also specify that efforts can be made to contact the next of kin or representative by fax, e-mail, or telegram, and specify actions to be taken if attempts are not successful .

4. The facility did not establish a mechanism to comply with Distribution of the required notices for the Important Message to Medicare notices in inpatient Psychiatry.
The Discharge notice policy incorrectly noted that on page #2 , procedure item 2e, that the patients admitted to the acute psychiatric unit are exempt for the Discharge Review Program. Ancillary documentation provided confirmed this was in reference to State requirements.

At interview with the Administrative Director and Clinical Directors of Nursing, and Psychiatry staff on 9/10/12, staff was not familiar with the notification requirements for the Important Message from Medicare. A third alternative discharge notice with the hospital insignia (OMB Number 0938-0692) was titled "Discharge Appeals Rights" and was provided to inpatient psychiatric patients only at discharge. However this form did not meet Medicare requirements as it contained modified language.

At follow-up interview with the Psychiatry Administrative Director on 9/13/12, it was stated that the process has been immediately corrected and forms modified.

Based on review of patient grievance records, procedures, and staff interviews, it was determined that grievance files were incomplete and did not conform to requirements in CMS Federal regulations specified at CFR ? 482.13 (a)(2)(iii).
Findings include:
1. Complaint files reviewed on 9/13/12 were incomplete in that they were lacking evidence of documented investigations of grievances. (MR #s13, 17 19, 20, 24)
2. Written grievance investigations where conducted, were incomplete for inclusion of findings resulting from departmental investigations. Files did not contain investigative findings or timely responses with results from departments.
Departmental investigations were missing complete results of interviews with all staff or complete medical record reviews.
Conclusions were not written based on analysis of facts collected with corrective actions taken, where necessary. (MR #s 15, 17, 21, 23)


3. Review of 11 of 12 grievance records on 9/13/12 found that written grievance files did not contain letters of response provided to complainants as required.
Written grievance final responses provided to patients and/or their representatives with outcomes were not included in files. (MR #s 13,14,15,16, 17,19, 20, 21, 22, 23, 24)

4. Grievance response letters to complainants were only present in 1 of 12 grievance files reviewed. The response letter was incomplete and did not include information about how to contact State Agency if the complainant is dissatisfied with the investigation. (MR # 18)

5. The facility did not consistently adhere to its procedures, titled "Patient Grievance and Investigation Process", Policy RI-02, updated 1/20/12, which specifies a turnaround time for responses to grievances with results within 30 days. (MR #13, 14, 15, 17, 19, 20, 21, 23)

Examples:

MR #13: Patient's sister complained on 4/11/12 that patient was neglected by staff and left in feces. The file recorded that the Nurse Manager was notified. There was no investigation recorded, no medical record review, and no staff interview included. Interview with the Patient Representative Director on 9/13/12 determined that the RN had left and could not be interviewed. The grievance log/spreadsheet noted response pending. No response letter was provided to the complainant as of 9/13/12.

MR #14: Mother of a pediatric patient complained on 6/25/12 that staff did not administer medications. Grievance report indicated that responses were provided by the nurse and MD. The nurse reported that the medication order was unclear and the MD found there was a mistake in not administering the medication. A specific departmental medical record review was not included with summary of specific factual findings. A verbal apology was provided and a prospective plan to educate staff was noted. No grievance response letter with findings was evident.

MR #15: Patient complained on 6/25/12 that two male patients sexually harassed her while she was an inpatient. The investigative report from the Department of Psychiatry was not included in the Patient Relations grievance report. The surveyor received the investigation report from Psychiatry on 9/13/12, which contained an undated investigation with conclusions. Review found e-mails were dated 7/3/12 and 9/12/12 between departments seeking findings and clarification. However, the grievance file did not contain a final response with the outcome of the investigation provided to the patient as of 9/13/12

MR #17: Complaint received on 6/5/12 that blood specimen was lost resulting in test delay. The physician apologized and the patient agreed to give another specimen and offered no more complaints. There was no departmental review, including medical record review nor staff interview to collect facts. No written response was provided to the complainant.

MR #19: Patient complained on 5/30/12 of witnessing being approached by housekeeping staff who allegedly claimed abuse by a supervisor. The patient also alleged that he and the staff member were verbally abused by the same supervisor. Action was taken with the employee and the complaint log indicated follow up was conducted with the patient.
However, review of the grievance file indicated a different account noting that the patient requested an investigation of the events and did not explore the allegation of verbal abuse. The grievance file included the follow up action with the employee and contained the supervisor's statement dated 8/30/12. No evidence of follow up with the patient was described.

MR#24: Patient complained twice; the first complaint on 5/2/12 to the insurance company about inappropriate discharge and the second on 6/19/12 about alleged abuse to the State Agency.
Hospital grievance log recorded patient complaint to the State Agency on 6/19/12 about alleged abuse. The log indicated that the patient representative visited the patient and observed noncompliance and verbal abuse by the patient to staff. Patient reportedly hid medications given by staff and was seen by the physician. The log noted follow up message was left with the State agency to indicate complaints were addressed. No grievance file was provided to detail the investigative actions taken for this abuse complaint noted on 6/19/12.

When asked for the grievance file with investigation, a grievance file was given for the prior complaint in May 2012 about discharge planning, which was reviewed by the insurance company. This discharge complaint file was incomplete and did not include a written summary response from the hospital to address each of the patient's concerns, including alleged inability to fill outpatient pain medication prescription following discharge.

Refer to MR #s 13-24.

Based on medical record review and interviews, it was determined that the facility did not develop policies and procedures specifically identifying and addressing medications used as restraints.

Findings include:
On 9/13/12 the closed medical record for the patient MR# 25, a 79 year old geriatric patient with diagnosis of Paranoid Schizophrenia and R/O Dementia was reviewed. During the review, it was observed that the patient was given IM STAT medication of Haldol 1mg on 5/29/12 for " refusing her medications and for displaying hostile, threatening and combative behavior ". On 6/14/12 the same patient was given IM STAT Haldol Decanoate 25mgs which was to be repeated every 3 weeks as a long standing maintenance dose. It was also observed that a history of abnormal EKG was documented in the physician's note of 5/25/12.
The review of the medical record also revealed that the patient was routinely observed during rounds every 15 minutes as a unit protocol. The observations did not show evidence of vital signs monitoring over a period of time after the IM Stat doses were given.
A review of the facility Policy# 6.10 " Guidelines for the use of Psychotropic Drugs ", effective November 20, 2010 pages 1 to 29 failed to require in paragraph 12.2 that patients who receive Stat IM psychotropic medications must have their vital signs monitored over a period of time to ensure their safety.

Additional review of the facility Policy# 9.11 " Management of Patients with Aggressive Behaviors", effective September 2007, pages 1 to 3 failed to require the monitoring of patients' vital signs over a period time after the administration of IM Stat psychotropic medications.
This resulted in a failure to protect the patient from harm since parameters for monitoring the patient's medical status, including timeframes (blood pressure, pulse, and respirations) were not established in a protocol format for staff to follow.

Based on review of records, policy, direct observation, and interview, it was determined that the hospital did not implement a system that ensured accurate documentation in electronic medical orders for justification of the use of a patient physical restraint.


Findings include:

The hospital did not accurately document a consistent reason for the use of a patient physical restraint in a medical restraint order in MR # 1. The basis for restraint orders did not match the reason indicated by staff interviewed.

During tour of the three (3) East Medical /Surgical unit on 9/10/12 at approximately 1 PM, the patient referenced in MR #1 was observed in her room wearing bilateral wrist restraints that were not tied to the bed's frame. The patient was alert and verbal with good eye contact on interview but appeared to have compromised mental status in that she could not clearly respond to questions posed by the surveyors.

At interview with the nursing staff who was caring for the patient, it was stated that the patient had been in restraints since she was on the ICU where she had been placed on restraints for pulling out her central line. It was stated that she was very confused. During observation, the patient did not have a central line and had peripheral access in her right arm.

Review of MR #1 on 9/10/12 at approximately 1pm found an order by the physician in the electronic record on 9/10/12 to have wrist restraints for 24 hours. The reason indicated was "harmful to self". This was a non behavioral routine time limited restraint for 24 hours. Verbal counseling was the only alternative intervention listed in the order as an alternative considered prior to restraint initiation.
The order was inaccurate since the reason stated by nursing staff for the restraint was to prevent the patient from pulling out IV tubes. This reason did not match the reason listed for the restraint use in the electronic order, noted as "harmful to self".

Nursing staff stated that the patient had been released but they did not report a plan to consider alternatives for the discontinuation of the restraint order or use of other less restrictive interventions at that time, such as one to one monitoring. The patient was calm but confused at the time of observation. The patient was not pulling at her IV access and was not observed to be harmful to herself.

Further review of the medical record demonstrated that the patient had dementia and was admitted to assess episode of oropharyngeal mass with bleeding. Bilateral wrist restraints were ordered on 9/7/12 which indicated a 12 hour time for reason of "harmful to self". This order did not specify the precise behavior that justified restraint use. Medical notes dated 9/7/12 indicated that the patient "is alert but demented and pulled out the IJV line. A peripheral line was placed and the patient is on soft wrist restraints." However, the electronic medical restraint order noted reason for restraint as "harmful to self". No further explanation was evident.

The hospital did not adequately comply with its policy and procedure for "Restraint Management", Policy #PC-03, which notes under section 2.4 the need for assessment, including the patient's mental/physical status, clinical justification for use of restraints.

Based on a tour of the inpatient Pediatric unit on the 4th floor and interview, the facility failed to implement a system for effective removal of unusable and expired medications and biologicals from patient care areas.

Findings include:
1. Seven (7) yellow Vacutainers with the expiration date of 3/2012 were found in a storage cabinet on 9/11/12 at 3:03PM.
2. A bottle of opened 2 fluid ounce of Benzoin compound tincture, with the expiration date of 11/2010 was found in the storage cabinet at 3:10PM.
3. An opened package of suction catheters was found in a supply cart at 3:12PM.

These findings were witnessed by the Director of Performance Improvement.

Based on review of records, observation and staff interview the food service director did not take responsibility for the daily management of the service to ensure that (a) proper safety practices for handling food are maintained and, (b) that an effective food emergency/disaster preparedness program was maintained.
Findings include:
(a) During tour of the main kitchen on 9/12/12, the following observations were made.
1. There was no evidence that temperature monitoring of the warming cabinet was maintained to ensure that hot food is being held at the required temperature.
2. On 9/12/12 1 and 9/13/12 the cold cut refrigerator temperature was observed held at 47 degree F and not at 41 degree F or below.
3. Food items were observed not labeled with the day or date the food was prepared or date or day the food must be discarded. No label was observed on fruit cups, grapes and yogurt cups, cottage cheese cups, apple sauce cups, jello cups and vegetable salad plates.

(b) Emergency food supplies
A tour of the main kitchen was conducted on 9/12/12. During the tour the surveyor requested to see where the emergency food supply is stored. The surveyor was taken to the dry food storage area and was told that the disaster food was included with the regular daily food supply. A list of stored disaster food supply inventory by type was not available, so there was no way to know the type of food items not included in the daily meal computation. Surveyor was told that the disaster water supply was stored in Central supply.
The Nutritional Services Disaster and Fire plan Policy and Procedure was reviewed and it was noted that potable water is stored in Central Supply. The policy did not indicate the location where the the emergency food supplies would be stored and paper goods were not listed. The three day menu list the food items without portions, although powdered milk is on the menu at breakfast there is no instructions on how it will be reconstituted to milk.
A returned visit was made to the kitchen on 9/13/12 by the surveyor to re-visit the emergency supplies food storage process. The surveyor asked to be taken to to the emergency food supplies storage and was directed to the central supply room by the food service director. In the central supply room the surveyor was shown boxes of various food items all wrapped with plastic together with delivery dates of 9/12/12 and 9/13/12. The surveyor was informed that this is the emergency food supplies. The day before the surveyor was shown the emergency food stored in a storage room in the kitchen and she was informed that the disaster food was not separated from the regular food supplies. There was no list of the stored disaster food supply inventory in the central supply room and the department disaster and fire plan did not list the central supply room as the location where the emergency food supplies will be stored.
The nutrition department's disaster and fire plan does not have an effective process for emergency food supplies and would not meet the standard to deal with a disaster.

Based on staff interview and review of pertinent record it was noted that the nutrition policy was not in accordance with recognized dietary practices.

Findings include:

Review of the patient nutritional care policy on 9/13/12 noted that the policy did not include the screening criteria to identify patients at nutritional risk.

Based on observation and staff interviews, the facility failed to maintain the physical plant in a manner to ensure an environment of patient safety.

Findings include:

During the tour of the emergency department on 09/10/12 at approximately 10:30 AM, the following were noted:

The nurse call bell system of the bathroom inside the exam room E105-16 did not emit an audio signal upon activation. Therefore the emergency room staff did not respond to the alarm when activated.

The patient bathroom in the hallway opposite to the exam room did not have a nurse call system.

The patient bathroom in the Pediatric Emergency room did not have a pull cord to allow activation.

Three (3) low lying duplex electical outlets in the 5 bedded emergency room were not of the tamper-resistant type.

In addition, the facility failed to provide a safe environment for the treatment of psychiatric patients in the emergency department and on the inpatient floors 9East and 9West.The following physical hazards were noted in these areas:

CPEP:

A pair of emergency electrical outlet and one regular electrical outlet outside the triage area were found to be non tamper-resistant.

The door to the waiting area had a door closure and had pivot hinges. The door handle of this door was a regular door handle that could potentially be used for looping. This type of door arrangement had a potential of creating ligatures.

The handwashing sink in the patient bathroom was protruding out of the wall approximately 18 inches and was observed to be a looping hazard. A surface mounted paper towel dispenser and a soap dispenser with flat top surface was observed to be installed in the room.These devices are potential looping hazards as there were possibilities of creating a ligature around them.

Three (3) regular sprinkler heads were observed in this area and the cover was missing on one of them. The sprinkler heads in psychiatric areas must be of the concealed type and must be capped properly.

A padded seclusion room (E-107-2) was observed as being used as a storage room for a wheel chair, a removable chair, a metal supply cart and a medical bed. The door was found to be unlocked and the room to be unoccupied. The equipment stored in this room were potential of being used for weaponization and looping.

The two seclusion rooms (E107-1 and E107-2) had regular door hinges (pivot type) and were potential of creating ligatures.

9East and 9West

During the tour of 9W and 9E on 09/13/12 at approximately 10:00AM-12:30 PM the following were noted:

The facility was using light weight chairs in the day rooms and in the music room. These chairs were capable of being used as weapons.

A corian handwashing sink was observed in the activity room on 9W and this sink was observed to be protruding and was about 4 ft high from the ground. This sink is potential of becoming a looping hazard.
Similar handwashing sinks were observed in patient rooms on 9W.

The facility was observed to be using a moveable lightweight chair in the shower room.

A flat top surface mounted bathroom tissue dispenser was observed in all patient bathrooms on 9E and 9W.This type of tissue dispenser is capable of becoming a looping hazard in a psychiatric unit.

The door handles on doors of rooms 901-911 were of the type that had the potential of being used to create a loop that would hang on the other side of the door.

The hinges on patient closets in rooms 901-911 were of the pivot type and had potential of becoming a looping hazard in the unit.

The side table in patient rooms on 9E and 9W had drawers that were removable. These drawers are potential of weaponization.

The smoke detectors in the patient rooms and the hallway on 9W were observed to enclosed in a plastic cover with holes . These smoke detector covers had potential of creating ligatures.

Two public phones were observed to be installed in the hallway on 9E and 9W. These phones had long mettalic cords with potential for weaponization and looping hazard.

A round speaker, approximately a foot in diameter, was observed to be installed in the hallway at the height of approximately 8 feet from the ground on 9 W. This speaker was a looping hazard in the unit.

A dark corner at the side of room 901A was observed to be an unseen corner from the hallway and there was no type of monitoring in this corner. This corner could potentially be used by psychiatric patients to hide and harm someone while entering the room from the back.

The two day rooms on 9E had a television set enclosed in a wooden box and was observed to be installed at approximately 8 feet from ground. These devices were observed to be potential for looping hazards.

Shower curtains were observed in shower rooms on 9E, which could potentially be used for suffocation by patient with suicidal tendencies.

Sprinkler heads on 9E were not concelaed.

The facility failed to ensure an environment free of safety hazards for the treatment of psychiatric patients.

Based on observations, the hospital did not ensure that the facilities' environment, supplies, and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

1. On 9/11/12 at 11:10AM, Room # 12 on the Medical Surgical ICU was noted empty and cleaned in readiness for a new patient. It was observed that the bedside drawer and bedside table were not cleaned. The drawer was noted dusty and the bedside table was smeared with liquid whitish matter. Clean supplies, a Foley catheter and a Chloraprep pad were also found in the wardrobe.

2. At 11:45AM on 9/11/12 Room 215 on the Telemetry Step Down unit there was an empty clean room. It was observed that a used piece of suctioning material remained in the bedside drawer, dust and hair pieces were also noted. An unused irrigation set was also noted in the window sill of the room. This irrigation set appeared to have been left behind when the room was cleaned.

These findings were witnessed by the Director of Performance Improvement.

Based on observation and staff interview, the facility failed to follow CDC recommendations to prevent cross contamination and transmission of infections. The following are the identified breach in infection control practices observed during the survey

Findings include:

During the tour of the Endoscopy suite on 09/11/12, it was noted that the decontamination room for the scopes did not have a handwashing sink.

During the tour of the decontamination room, it was noted that the scope washing machine olympus was installed adjacent to the decontamination sink.

Upon demonstration of the manual wash of scopes by a surgical technician, it was revealed that the one decontamination sink was used for scrubbing and cleaning as well as for soaking and rinsing.The surveyor did not observe the staff washing hands in between processes and did not observe change of PPE between tasks.

Therefore it was revealed that there was no distinction and separation of clean and dirty tasks involved in the cleaning of the scopes.

In addition, the facility failed to comply with CDC requirements on the temperature of water in the scrub sinks of the Operating rooms. During the tour of the Operating room on 09/11/12 at approximately 2:30PM, it was noted that the scrub sinks outside OR #1,2, and 3 did not have hot water.

The handwashing sink in the chemotherapy drug mixing room of the pharmacy department was observed to be blocked by a metal cart storing supplies and two plastic trays containing six (6) small bottles of 1gm and 2gm Magnesium Sulphide was stored on the handwashing sink.

The bathrooms of patient rooms on 3East and 3West did not have a handwashing sink.

The thirteen (13) bed (single bedded rooms) ICU unit did not have an isolation room for airborne isolation of patients.

The facility did not monitor the airflow in rooms to ensure the prevention of transmission of infections. For example, the decontamination room of the Central Sterile department and the soiled utility room of the emergency department had positive airflow. Negative airflow is recommended by AIA and CDC for these rooms.

Review of hemodialysis records on 09/12/12 at approximately 2:30 PM. revealed that a sample for dialysate bacteriology was collected from machine #1KOS172958 on 07/11/12 and the results reported on 07/14/12 indicated above 200 CFU. Further review of testing results and interview of the Chief Technician revealed that the facility did not repeat the test on the dialysate of that machine.The abnormal test results was signed by a physician with no comments. The machine was observed to be in use at station #3 during the survey.

In addition, the facility failed to provide the chemical analysis test results for 2011 and 2012 on the product water collected from the Central Reverse Osmosis System and the two (2) Portable Reverse Osmosis systems.

Moreover, the facility did not have washable/cleanable tiles in the ICU and Central Sterile areas.

Based on review of procedures, records, and staff interview, it was determined that the hospital did not implement consistent screening and assessment criteria for discharge planning between disciplines responsible for identification and assessment of discharge planning needs.

Findings include:

1. Risk factors requiring screening and assessment for psychosocial and discharge planning purposes as outlined in procedures and electronic medical record templates were not fully consistent.

Review of the procedure titled, "Medical Record Documentation" CRM PC.01.02.03 on 9/13/12 found that it detailed criteria for assessments of patients by social workers for purposes of discharge planning. The policy indicated need for assessment within 72 hours of admission for those patients meeting one of 16 possible risk factors.
These risk factors include, but were not limited to, persons who are over 60 years of age living alone with signs of physical /social/emotional deterioration, as well as those patients with trauma or homelessness.

Review of procedure titled, "Patient Admission Assessment and Reassessment" PC 201.2012 found that the registered nurse screens for abuse and other psychosocial needs and is responsible for initiating appropriate discharge planning /social service referrals on patients within 24 hours of admission. This policy did not cross reference all of the specific risk criteria requiring social work assessment as delineated on the medical record documentation policy noted above. In addition, this policy included risk criteria in acute psychiatry that was not referenced in the social work assessment policy (hypersexuality, seizures, fire setting)

The review of the template for electronic medical record format of the "general admission assessment" found a lack of consistent risk criteria as delineated in the medical records documentation policy referenced above.

For example, referral criteria on the general admission template includes ages 65 or older and living alone whereas the medical record policy requires referral for persons who are over 60 years of age living alone with signs of physical /social/emotional deterioration. The admissions template in social service screening section made no reference to the need for social service referral for persons who are undocumented or uninsured. The policy for medical record documentation requires a referral for these issues. Children with a newly diagnosed illness including sickle cell or asthma were not referenced in the social service screening section of the template despite a requirement to assess these patients in the medical records assessment policy.

2. Review of four (4) of sixteen (16) medical records on all dates of the survey found the admission assessment did not correctly screen or identify high risk discharge needs nor document discharge planning /social services referrals as required .

MR #1: 77 year old patient with dementia was admitted for orophyngeal bleeding mass. The admission assessment dated 9/4/12 determined that she met criteria as she was 65 years of age and living alone. However, the section for social work referral was blank during review of patient's concurrent chart on 9/10/12. The patient was assessed by social work the next day and was found to require reinstatement of 24 hour home care upon discharge.

MR #11: 83 year old patient living alone with gait disturbance was assessed on admission on 7/1/12 as not requiring a referral for social services. The patient was assessed by social work on 7/3/12 and was noted to require reinstatement of home care services prior to discharge.

MR #26: 79 year old male was screened on admission assessment on 6/28/12 as 65 or older and living alone. The admission assessment indicated no referral need for social services. The patient signed out of the hospital against advice on 7/2/12 despite lack of completion of work up to rule out malignancy. The patient was explained the risks of leaving . No referral was considered at that time.

Review of MR # 9 found that this 77 year old male was admitted for assessment of syncope. Patient's admission assessment on 7/20/12 noted history includes drinking 2-3 pints of vodka every day. The patient resides alone. In the section for social service screening, it was noted that the patient is 65 or older and lives alone; however, the patient was not referred to social work for evaluation. The screening did not refer for social service assessment despite meeting a high risk criteria that would warrant referral.

The patient was assessed by the social worker on 7/21/12 but the assessment was incomplete. Social work assessment notes that the patient walks with a cane. Patient was discharged to his home and it was noted that there were no social work needs. The assessment lacked exploration of the patient's history of heavy alcohol use and whether this persisted. The assessment did not specifically address how he would provide self care given his high risk for falls.

Based on review of records, procedures, and staff interview, it was determined that the facility has not met all regulatory requirements to ensure compliance with referral choices to post hospital providers of home health or skilled nursing care.

Findings include:

The facility has not met all regulatory requirements to ensure:

Provision of lists to patients or representatives promoting freedom of choice for post hospital care providers.
Implementation of a structured process to validate objective selection of home care agency providers.


1. The facility did not fully document compliance in medical records with requirements for the distribution of listings to patients or representatives about available options for certified home health care agencies and skilled nursing facilities. This applies to 2/2 applicable records for patients referred for new agency or placement referrals.


Review of MR#10 found that the patient was hospitalized for treatment of disorganized behavior in context of dementia. The patient resided in a nursing home prior to arrival. This nursing home refused to accept the patient back. The patient was noted to be confused. A niece was involved with the patient but there was no documentation of the niece's agreement with the change in placement or documented reasons why this was not considered. There was also no evidence that a list of placement options had been provided for alternative skilled nursing facilities, which is required by the regulation. The patient was referred to a different nursing home and was discharged there on 8/7/12.

Review of MR #23 found this patient was referred for home care services to the on-site agency nurse. No documented evidence of choice was provided for selection of home care agencies.

2. The facility has not implemented a practice to ensure freedom of choice among providers of home care in that the current process is to delegate coordination of referrals for certified home care agencies to an on-site intake nurse from a home care agency.

Review of the policy titled "Discharge Notice" CRM-005 found that it contained a statement that incorporated provision of patient choice in nursing home or home health care agencies. However this process did not adequately explain how the lists are provided to patients and their representatives and did not require that this activity must be documented in the patient medical record.
While the policy noted that there is no limit to available qualified providers to patients, there was no description of the hospital's existing practice to delegate the decision for home care referrals to an on-site nurse working in the hospital who represents a home care agency. Following a referral to the staff of the on-site home care agency provider, this nurse is then responsible to refer the patient to other available home care agencies if the patient is not accepted by the on-site contracted agency provider.

3. At interview with the Director of Case Management on 9/13/12, it was acknowledged that there are nursing staff from two home care agencies working on-site in the hospital representing agencies that have an arrangement with the hospital. It was also stated that the social worker distributes a list of agency options but the actual coordination of referrals is performed by the on-site home care agency nurse.
It was stated that it is the responsibility of the on-site agency nurses to process referrals to all home care agencies, even if they are referred to other providers of care. This practice does not promote objectivity in referral and ensure a reduction in risk of steering agency referrals.

Based on review of Case Management Department quality assurance reports and staff interviews, it was determined that the department did not sufficiently monitor discharge planning services and processes provided to patients.

Findings include:

1. The Department of Case Management did not develop sufficient clinical indicators for review of the timeliness or quality of discharge planning assessments provided to patients in order to ensure these plans were responsive to patients' discharge needs.

Review of Utilization Management/ Case Management statistical report for the period of 1/1/12 through 6/30/12, found no indicators to measure timeliness of discharge planning assessments nor any clinical indicators to measure whether assessments and discharge plans met patients' needs.

The indicators in reports provided were limited to length of stay and reimbursement data for denials and appeals. The report quantified the number of discharges and listed the four top reasons for extended stays. It was noted barriers to discharge were related to denials. The only indicator applicable was a Utilization Review report dated 8/27/12 that included July 2012 data which tabulated numbers of discharges to nursing homes. There was a prospective plan noted to track PRI referrals to identify reasons for denials.

At interview with the Director of Case Management on 9/13/12, it was stated that the timeliness of assessment from the time of admission is in the process of being monitored for both social work and case management staff as data is currently being collected. However, the Director had no documentation yet of the results of this activity. It was also stated there are plans to monitor the quality of clinical assessments for discharge planning, but no indicators have yet been developed.
Consequently, no reports were completed for indicators that measured the timeliness and clinical aspects of discharge planning provided by Case Management and Social Work.

Review of departmental reports submitted to the hospital's Quality Council for 2012 found that besides the Case Management/Utilization Review reports referenced above, there was no report submitted for quality review of clinical discharge plans provided to patients.

2. The facility did not formally monitor referrals to certified home health care agencies to ensure patient freedom of choice among providers. At interview with the Director of Case Management on 9/13/12, it was acknowledged that there are nursing staff from two home care agencies working on-site in the hospital whose responsibility includes processing of referrals to all external home care agencies. It was acknowledged that the agencies refer equitably to all providers but that the hospital's review of this process is not formalized. The hospital therefore did not monitor the process to promote objectivity in referral .