HospitalInspections.org

Based on document review and interview, it was determined that the Hospital's Governing Body who is legally responsible for the Medical Staff failed to be accountable and carry out the functions described for the quality of care and continuity of care for patients in the hospital, in accordance with the Hospital's Professional Staff Bylaws & Rules and Regulations. As a result, the Condition of Participation, 42 CFR 482.12 Governing Body, was not in compliance.

Findings include:

1. The Governing Body failed to ensure for the quality of care and post-discharge continuity of care provided to patients discharged by physicians as required by the Bylaws & Rules and Regulations. See A-0049.

An IJ was identified on 11/4/2021 at 1:15 PM, for the Hospital failure to ensure the Medical Staff was accountable for quality of care and post-discharge continuity of care for 4 (Pt. #28, #29, #30, and #31) of 5 patients identified as high risk for needs of discharge planning on Medical-Surgical/Telemetry Unit. The IJ was cited at 42 CFR 482.12, Governing Body. The IJ was identified and announced on 11/04/2021 at 1:15 PM, during a meeting with the Assistant Administrator (E #8) and Director of Quality (E #14). The IJ was not removed by the survey exit date of 11/04/2021.

Based on document review and interview it was determined that for 4 (Pt. #28, #29, #30, and #31) of 5 patients discharged between 10/25/2021- 11/02/2021 from the Medical-Surgical/Telemetry Unit, the Governing Body failed to ensure that the medical staff be accountable for the quality of care and post- discharge continuity of care provided to patients discharged by physicians as required by the Bylaws & Rules and Regulations.

Findings include:

1. On 11/02/2021 at approximately 1:30 PM, the Hospital's "Amended and Restated Bylaws of Hospital Corporation" dated 01/15/2019 was reviewed and included, "The Governing Body requires the hospital and medical staff to implement and report on the activities and the mechanisms for monitoring and evaluating patient safety practices and quality of patient care, for identifying and resolving problems and for identifying opportunities to improve patient care and services or performances throughout the facility ..."

2. On 11/3/2021, the Board of Directors Meeting minutes from March 16, 2021 to July 27, 2021 were reviewed and indicated:

-On 3/16/2021 at 3:02 PM indicated "Appendices Staff leadership will be actively supporting the hospital in dialing in appropriate length of stays ..."

-On 7/27/2021 at 3:11 PM, "Report of the President of Medical Staff: ...One-third of the open records and over half of the closed records contained poor or no documentation to justify admission or continued stay ..."

3. On 11/02/2021, the Hospital's Discharge Log, dated 10/25/2021 to 11/02/2021, was reviewed and indicated that there had been 51 patients discharged to the community/homes/Nursing homes/other hospital for this timeframe from the Medical-Surgical/Telemetry unit. From the log four (Pt. #28, #29, #30, #31) of 5 clinical records reviewed were identified as high risk for discharge needs. The clinical records lacked documentation of discharge planning needs assessment and Social Worker's psycho-social assessments, re-assessment of patients, and social worker's documentation.

- Pt. #28 was admitted to the Hospital on 10/16/2021 at 2:59 PM, from the Skilled Nursing Facility (SNF) with diagnoses of Aggressive Behavior and elevated troponin (indicator of heart problems). Pt. #28 was discharged to the SNF on 10/29/2021 at 7:28 AM via ambulance.

Pt. #28's clinical record lacked the Social Service High-risk screening, lacked Social Worker (SW) documentation regarding arranging transportation/ambulance for patient, discharge planning physician order, and discharge planning needs assessment.

- Pt. #29 was admitted on 10/14/2021 at 11:35 PM, from Nursing Home - A with a diagnosis of Coronary Artery Disease. Pt. #29 was discharged home on 10/29/2021 at 7:46 PM.

Pt. #29's clinical record lacked the Social Service High-risk screening, Nursing Home list provided to the patient, continued stay social worker notes, reasons for change in nursing home, lacked Social Worker (SW) documentation regarding arranging transportation/ambulance for patient, discharge planning needs assessment, discharge instructions, and transfer notes.

- Pt. #30 was admitted to the Hospital on 10/07/2021 at 10:12 AM, with a diagnosis of cellulitis (infection of the skin) to right leg. Pt. #30 was discharged/transferred to another hospital on 10/30/2021 at 6:40 PM via ambulance.

Pt. #30's clinical record lacked the social service high-risk screening, social worker reassessment during patient condition change, social worker check list, and discharge planning needs assessment.

-Pt. #31 was admitted on 10/07/2021 with the diagnosis of aggressive behavior and renal insufficiency and discharged on 10/27/2021.

Physician's progress note dated 10/08/2021 at 1:20 PM included, " ...Pt. #31 with bipolar disorder, psychosis, dementia, pancreatic ca (cancer) sent from NH (nursing home) for aggressive behavior ..."

The clinical record lacked documentation by the social worker for high-risk assessment, and discharge planning needs assessment was completed prior to discharge.

4. On 11/02/2021 at approximately 10:30 AM, the Chief Nurse Executive (E #7) was interviewed. E #7 stated that at the Board Meetings, 95 percent of the time the talk is about the financial management, and not about the patient care and quality of care. E #7 stated that he has had several discussions with the Board of Directors, about the challenges with the discharge process but things move very slow.

5. On 11/02/2021 at approximately 2:30 PM, the Director of Quality (E #14) was interviewed. E #14 stated that there is no coordination of care, the doctors, social workers and nurses are not in coordination to ensure an adequate discharge planning for the patients. E #14 stated that the in-patient length-of-stay has been high, and administration had been made aware of it. E #14 stated that she had suggested to the Chief Nurse Executive to hire a Discharge Planning Coordinator to look into the whole process. E #14 stated that nothing has been done.

6. On 11/02/2021 at approximately 3:00 PM, the Chief Executive Officer (E #15) was interviewed. E #15 stated that he is surprised and shocked to know that discharge planning was an issue, this has a financial impact on the hospital if the process is not being followed. E #15 stated that it is totally about teamwork.

7. On 11/03/2021 at approximately 9:15 AM, the Social Worker/Discharge Planner (E #18) was interviewed. E #18 stated that the High-risk patient assessment should have been done for all the four (4) patients (Pt. #28, #29, and #30 and #31). E #18 stated that there should have been discharge planning orders from the physician for further intervention from the Social Worker. E #18 stated that whenever there is change in patient condition there should have been reassessment of the patient.

8. On 11/03/2021 at approximately 10:20 AM, the Director of 3 East/Intensive Care Unit (E #5) was interviewed. E #5 stated that there should be a responsible person to make sure these patients are dispositioned in a safe and timely manner.

A. Based on document review and interview, it was determined that for 1 of 2 (Pt. #19) clinical records reviewed, the Hospital failed to ensure that the registered nurse supervised the patient care by failing to conduct a pain reassessment after medication administration, as required to ensure nursing care was provided for each patient.

Findings include:

1. On 10/28/2021, the clinical record of Pt. #19 was reviewed. Pt. #19 was admitted to the Hospital on 10/06/2021 for cocaine dependence. The clinical record included.

-A physician's order dated 10/19/2021 for Naprosyn (non-steroidal medication used for pain) 250 mg (milligrams) every 8 hours as needed. The MAR (Medication Administration Record) indicated that Naprosyn was given 10/25/2021 at 9:13 AM, 10/26/2021 at 9:08 AM, 10/27/2021 at 8:35 AM, and 10/28/2021 at 10:21 PM. The medical record lacked documentation of pain reassessment after medication was administered.

2. The Hospital's policy titled, "Medication Administration" (revised 02/2021) was reviewed and required, " ...16...pain-relieving med's (medications) will be given to individual patients as needed per protocol and a pain assessment will be in the MAR at that time. Patients will be reassessed 30 minutes after receiving... PRN (as needed) pain relieving medications per protocol ...Documentation ...4. When PRN medications for pain are administered, the following documentation is provided: The assessment of pain and or other symptoms for which the medication was given will be documented in the MAR ...Results achieved (30-minute pain reassessment) from giving the dose and the time results will also be documented in the MAR."

3. On 10/29/2021 at 11:25 AM, an interview was conducted with E #10 (Manager of Chemical Dependency Unit). E #10 stated that the pain reassessment will auto populate (in the electronic medical record) when protocol medications are administered. However, Pt. #19's Naprosyn is not a protocol medication and the pain reassessment did not auto populate. E #10 could not provide documentation of the pain reassessment after the medications were administered.

B. Based on observation, document review and interview, it was determined that the Hospital failed to ensure the registered nurse supervised the patient care, by failing to ensure the call light system was adequately functioning, potentially affecting 9 of 9 patients on the Geriatric Psychiatric Behavioral Health Unit.

Findings include:

1. On 10/28/2021 at 11:45 AM, an observational tour was conducted on the 4th floor-Geriatric Psychiatric Unit (4 West). There was one centrally located nursing station with a call light box that did not alarm when tested.

2. On 11/03/2021, the Hospital's policy titled, "Safety Rules and Regulation" (revised 09/17) was reviewed and required, "All employees are required to adhere to safety rules and regulations, whereby creating an environment that is safe for everyone ...6. Explain to each patient how to use the nurses call system and keep the light within the patients reach.

3. On 11/03/2021 at 9:30 AM, an interview was conducted with the Program Director of Geriatric Psychiatric Unit/ E #11. E #11 stated that the call light does not ring (not audible), the call light only flashes and has been this way for a least a year. E #11 stated the alarm should be sound (be audible), to ensure patient safety.

Based on document review and interview, it was determined that for 5 of 5 personnel files of contracted/agency nurses file review, the Hospital failed to ensure that the Director of Nursing supervised and evaluated the nursing services provided by all contracted nurses.

Findings include:

1. On 10/28/2021 at approximately 10:00 AM, the Hospital's policy titled, " Agency/Contractor Orientation" dated 09/2021 was reviewed and included, " ...Agency/Contracted staff evaluations and checklists are performed and retained by the management and or staff in their assigned work area..."

2. On 10/29/2021 at approximately 10:30 AM, the employee personnel files for five (5) agency/contracted nurses were reviewed and included the agency nurses were contracted with the Hospital from 08/27/2021-10/27/2021. All the five (5) agency/contracted nurses files lacked any type of evaluation by the charge nurse, or nurse manager.

3. On 10/29/2021 at approximately 10:30 AM, the Human Resources Director (E #9) was interviewed. E #9 stated that he is not aware of why the evaluations for agency/contracted nurses were not conducted. E #9 stated that he assumed the Director of Nursing on the units conducted the agency/contracted nurses' evaluations.

4. On 10/29/2021 at approximately 11:15 AM, the Chief Nurse Executive (E #7) was interviewed. E #7 stated that it crucial to evaluate the agency/contracted nurses and nursing assistants, but we failed to do the daily/weekly evaluations of the contracted staff. E #7 stated that they do not have any nursing policy regarding the agency/contracted nurse orientation or evaluation.

Based on document review and interview, it was determined that the Hospital failed to ensure an appropriate discharge planning process. As a result, it was determined that the Condition of Participation for 42 CFR 482.43, Discharge Planning was not in compliance.

Findings include:

1. The Hospital failed to initiate the discharge planning process, at an early stage of hospitalization. See A-0800.

2. The Hospital failed to ensure the discharge planning orders and/or referral were documented for the development and implementation of a discharge plan for the patient. See A-0801.

3. The Hospital failed to ensure that discharge planning evaluation was completed and included in the patient's medical record. See A-0808.

An IJ was identified on 11/04/2021 and cited at 42 CFR 482.43, Discharge Planning. The IJ is due to the Hospital's failure to ensure an appropriate discharge planning process was implemented, and as a result a total 4 (Pt. #28, #29, #30, and #31) of 5 patients identified as high risk for needs of discharge planning on Medical-Surgical/Telemetry Unit were discharged without appropriate discharge evaluations and planning. The IJ was identified and announced on 11/04/2021 at 1:15 PM, during a meeting with the Assistant Administrator (E #8) and Director of Quality (E #14). The IJ was not removed by the survey exit date of 11/04/2021.

Based on document review and interview, it was determined that for 4 of 5 (Pt. #28, #29, #30 and #31) clinical records reviewed for discharge planning process, the Hospital failed to initiate the discharge planning process at an early stage of hospitalization.

Findings include:

1. On 11/02/2021 at approximately 4:00 PM, the Hospital's policy titled, "Discharge Planning Needs Assessment" was reviewed and included, "...1. Discharge planning/social service needs screening is done at the time of admission by the admitting nurse ...2. Patients with identified needs are referred to the Social Service Department ...3. A discharge planning assessment is performed on patients identified as high-risk ... 4. Social and psychological need assessment is done as soon as referral/identification by social service staff during normal department operating hours ...5. High-Risk Criteria (as identified on admission): a. Patients 65 years or older identified as high risk ... d. Alcohol/drug ...f. Psychiatric diagnosis ...h. High risk diagnosis ...cancer ... Transfers from extended care ..."

2. On 11/02/2021, the Hospital's Discharge Log, dated 10/25/2021 to 11/02/2021, was reviewed and indicated that there had been 51 patients discharged from the 3 East Medical-Surgical Telemetry Unit to the community/homes/Nursing homes/other hospital since 10/25/2021. From the log 4 (Pt. #28, #29, #30, and #31) of the 5 clinical records were reviewed for discharge planning and continuity of care were identified as high risk for needs of discharge planning.

-At approximately 12:00 PM, Pt. #28's clinical record was reviewed. Pt. #28 was admitted to the Hospital on 10/16/2021 at 2:59 PM, from the Skilled Nursing Facility (SNF) with diagnoses of Aggressive Behavior and elevated troponin (indicator of heart problems). Pt. #28 was discharged to the SNF on 10/29/2021 at 7:28 AM via ambulance (length of stay 14 days).

Pt. #28's clinical record lacked the Social Service High-risk screening, lacked Social Worker (SW) documentation regarding arranging transportation/ambulance for patient, discharge planning, and discharge planning needs assessment.

-At approximately 12:15 PM, Pt. #29's clinical record was reviewed. Pt. #29 was admitted on 10/14/2021 at 11:35 PM, from Nursing Home - A with a diagnosis of Coronary Artery Disease. Pt. #29 was discharged home on 10/29/2021 at 7:46 PM (length of stay 15 days).

Pt. #29's clinical record lacked the Social Service High-risk screening, lacked Social Worker (SW) documentation regarding arranging transportation/ambulance for patient, discharge planning, and discharge planning needs assessment.

-At approximately 12:30 PM, Pt. #30's clinical record was reviewed. Pt. #30 was admitted to the Hospital on 10/07/2021 at 10:12 AM, with a diagnosis of cellulitis to right leg. Pt. #30 was discharged/transferred to another hospital on 10/30/2021 at 6:40 PM via ambulance (length of stay 24 days).

Pt. #30's clinical record lacked the Social Service High-risk screening, lacked Social Worker (SW) documentation regarding arranging transportation/ambulance for patient, discharge planning, and discharge planning needs assessment.

-At approximately 12:40 PM, Pt #31's clinical record was reviewed. Pt. #31 was admitted on 10/07/2021 with the diagnosis of aggressive behavior and renal insufficiency and discharged on 10/27/2021 (length of stay 20 days).

Pt. #31's clinical record lacked the Social Service High-risk screening, lacked Social Worker (SW) documentation regarding arranging transportation/ambulance for patient, discharge planning, and discharge planning needs assessment.

6. On 11/02/2021 at approximately 2:30 PM, the Director of Quality (E #14) was interviewed. E #14 stated that there is no coordination of care, the doctors, social workers' and nurses are not in coordination to ensure an adequate discharge planning for the patients. E #14 stated that the in-patient length-of-stay has been high, and administration had been made aware of it. On 11/2/2021, E #14 stated that she had suggested to the Chief Nurse Executive to hire a Discharge Planning Coordinator to look into the whole process. E #14 stated that nothing has been done.

7. On 11/03/2021 at approximately 9:15 AM, the Social Worker/Discharge Planner (E #18) was interviewed. E #18 stated after reviewing the clinical records for Pt. #28, #29, #30 and #31, stated that these patients were identified as high risk for discharge needs. E #18 stated that she is not sure why it was not done. E #18 stated that Monday through Friday the admission list is printed, and patients identified as high risk or referral are seen within 24 hours from admission.

Based on document review and interview, it was determined that for 4 of 5 clinical records (Pt #28, #29, #30 and #31) identified as high risk for discharge planning needs, the Hospital failed to ensure that discharge planning evaluation was completed and included in the patient's medical record.

Findings include:

1. On 11/02/20221 at approximately 1:45 PM, the Hospital's policy titled, "Discharge Planning" dated 07/2020 was reviewed and included, " ...F. ...after a patient has been identified as needing a Discharge Plan Evaluation, or after a request for an evaluation has been made by the physician, patient and/or patient's representative, the evaluation is completed on a timely basis so that appropriate arrangements for post-hospital care are made before discharge and also to avoid unnecessary delays in discharge ..."

2. On 11/02/2021 the Hospital's Discharge Log, dated 10/25/2021 to 11/02/2021, was reviewed and 4 patients (Pt. #28, #29, #30, and #31) of 5 clinical records were reviewed for discharge planning did not include a discharge planning evaluation prior to discharge.

-At approximately 12:00 PM, Pt. #28's clinical record was reviewed. Pt. #28 was admitted to the Hospital on 10/16/2021 at 2:59 PM, from the Skilled Nursing Facility (SNF) with diagnoses of Aggressive Behavior and elevated troponin (indicator of heart problems). Pt. #28 was discharged to the SNF on 10/29/2021 at 7:28 AM via ambulance (length of stay 14 days).

-At approximately 12:15 PM, Pt. #29's clinical record was reviewed. Pt. #29 was admitted on 10/14/2021 at 11:35 PM, from Nursing Home - A with a diagnosis of Coronary Artery Disease. Pt. #29 was discharged home on 10/29/2021 at 7:46 PM (length of stay 15 days).

-At approximately 12:30 PM, Pt. #30's clinical record was reviewed. Pt. #30 was admitted to the Hospital on 10/07/2021 at 10:12 AM, with a diagnosis of cellulitis to right leg. Pt. #30 was discharged/transferred to another hospital on 10/30/2021 at 6:40 PM via ambulance (length of stay 24 days).

-At approximately 12:40 PM, Pt #31's clinical record was reviewed. Pt. #31 was admitted on 10/07/2021 with the diagnosis of aggressive behavior and renal insufficiency and discharged on 10/27/2021 (length of stay 20 days).

3. On 11/02/2021 at approximately 2:30 PM, the Director of Quality (E #14) was interviewed. E #14 stated that there is no coordination of care, the doctors, social workers' and nurses are not in coordination to ensure an adequate discharge planning for the patients.

4. On 11/03/2021 at approximately 9:15 AM, the Social Worker/Discharge Planner (E #18) was interviewed. E #18 stated that the discharge planning evaluation should have been done for all the four patients prior to discharge. E #18 stated that she is not sure why it was not done.

A. Based on observation, document review and interview, it was determined that for 3 (Pt #4, Pt #9 and Pt #10) out of 11 emergency room "hold bed" patients the Hospital failed to ensure the policies and procedures governing the care provided in the emergency department (ED) were followed by failing to ensure monitoring occurred for patients in the emergency room, as required.

Findings include:

1. On 10/28/2021, the Hospital's policy titled, "Vital Signs Monitoring and Reassessment" (effective April 2020) was reviewed and required, "The Hospital ED utilizes a 5 level Emergency Severity Index (ESI) - ESI level 1& 2 (vital signs should be reassessed every 2 hours if clinically stable), ESI level 3 &4 (vital signs should be reassessed every 4 hours if clinically stable)

2. On 10/28/2021, the clinical record of Pt #4, Pt. #9 and Pt. #10 were reviewed and indicated:

-Pt #4 was admitted to the emergency room on 10/25/2021 with the diagnosis of abdominal pain and epididymitis (inflammation of the testicle). Pt #4's vital sign assessment was dated 10/25/2021 at 10:08 PM and the next vital sign assessment was 10/26/2021 at 8:05 AM (approximately 10 hours later). Pt #4 was assessed on 10/26/2021 at 11:00 PM and the next assessment was documented at 10/27/2021 at 5:56 AM. There was no further documentation of assessments as of 10/28/2021 at 10:00 AM (approximately 28 hours later). ESI level not listed on Pt #4's clinical record.

-Pt #9 was admitted to the emergency room on 10/26/2021 with the diagnosis of acute mental status change, congestive heart failure and acute renal failure. Pt #9's vital signs were documented on 10/26/2021 at 6:07 PM and the next vital sign documentation was on 10/27/2021 at 7:18 AM (approximately 13 hours later). Pt #9's ESI was documented as a 3 on 10/26/2021 (vital signs should be monitored every 4 hours).

-Pt #10 was admitted to the emergency room on 10/26/2021 at 6:08 PM with the diagnosis of chest pain. Pt #10's triage note was documented on 10/27/2021 at 9:43 AM and the next vital signs were documented at 5:40 PM (approximately 8 hours later). ESI level not listed on Pt #10's clinical record.

3. On 10/28/2021 at 11:30 AM, E #1 stated that vital signs should be taken according to the ESI level or at least every 4 hours.

B. Based on document review and interview, it was determined that for 1 of 1 emergency room patient (Pt #6), the Hospital failed to ensure the policies and procedures governing the care provided in the emergency department were followed by failing to ensure a patient was triaged in a timely manner, as required.

Findings include:

1. On 10/28/2021, the Hospital's policy titled "Triage" (April 2020) was reviewed and required, "...Patients will straightforward presenting problems, which are to be seen in immediate care or acute, are appropriate to triage directly to a treatment room..."

2. On 10/28/2021, Pt #6's clinical record dated 10/27/2021 to 10/28/2021 was reviewed and indicated:
-Pt #6's ambulance run documentation dated 10/27/2021 noted "Upon arrival of the Hospital, crew was told that Pt #6 would not be accepted at the time, crew was delayed at the destination for about 2 hours and 30 minutes..."
-Pt #6 was admitted to emergency room with the diagnosis of aggressive behavior on 10/27/2021.

3. On 10/28/2021, an interview was conducted with the ED Clinical Manager (E #1). E #1 stated that it is not acceptable for a patient to wait in an ambulance bay for 2 and 1/2 hours before being seen in the ED. E #1 stated that the reason Pt #6 waited in the ambulance bay that evening is that there were 12 hold patients in the ED. E #1 stated that this rarely happens.