Based on interview and record review, the facility failed to follow written policies and procedures regarding the visitation restriction for 1 (SP#1) of 3 sample patient (SP). Findings include: Review of COVID-19 Visitor Policy dated 09/21/2021 documented patients are limited to one adult (age 16 and over) visitor at a time. Review of SP#1 Designation of Healthcare Proxy dated 08/31/2021 at 10:00PM documented an adult child of the patient was assigned to make healthcare decisions. Interview with Vice President Quality on 11/19/2021 at 12:00PM revealed on 10/23/2021 at 2:00PM the family member of SP#1 continued to make verbal threats towards staff. Review of SP#1 Nurse Notes dated 10/27/2021 at 4:37PM documented call placed to SP#1 family member, in the presence of Vice President Quality, Director of Patient Safety, Director of Security and Director Intensive Care Unit, to discuss from this point forward visitation is suspended. SP#1 family member was instructed that the physician from the care team would be calling with updates as to the patient's condition and any change in condition. Review of SP#1 Nurse Notes dated 10/28/2021 at 12:39PM documented call placed to SP#1 family member. SP#1 family member requested email stating that (family member) is not allowed to visit so (family member) can appeal. Director of Security reiterated to SP#1 family member that visitation remains suspended and SP#1 family member may not come into the hospital and an email will not be sent. Review of SP#1 Nurse Notes dated 10/29/2021 at 12:27PM documented SP#1 family member requesting to visit but due to threats made to staff, visitation remains restricted. Review of SP#1 Nurse Notes dated 11/03/2021 at 6:02PM documented SP#1 family member requesting videoconference with administration to plead case for visitation. Review of SP#1 Death Summary Note dated 11/11/2021 at 1:15AM documented pronouncement of death date: 11/11/2021, time: 1:09AM. SP#1 family member was called twice and message for call back was left shortly thereafter. Review of the Patient Rights Policy, Effective 01/01/2020, documented all patients have the right and authority to designate who may or may not visit including, but not limited to, another family member. Review of the Trespass Warning Policy, Last reviewed: 08/2018, documented a Trespass Warning will be issued to those persons that are deemed a danger or threat to employees, patients, visitors and/or medical staff. The facility did not provide a Trespass Warning to SP#1 family member and denied visitation to SP#1. The facility did not allow visitation to SP#1s family member.
Based on observation, interview and record review, the facility failed to promote safety in the preparation and administration of drugs. Each medication was not administered separately via percutaneous endoscopic gastrostomy (PEG) tube and flushed with water before and after use in accordance with the administration instructions and standards of nursing practice for 1 (SP#2) of 3 sampled patients (SP); the facility also failed verify PEG tube placement prior to medication administration in accordance with the administration instructions and standards of nursing practice for 1 (SP#2) of 3 sample patients. Findings include: Review of the Physician orders for SP#2 dated 11/19/2021 at 11:25 a.m. documented the following medications scheduled for administration via the percutaneous endoscopic gastrostomy (PEG) tube. Sertraline HCl 25mg tablet daily via feeding tube, Gabapentin 100mg capsule twice daily via feeding tube Medication administration observation of SP#2 on 11/19/2021 at 11:33 a.m. revealed, Staff A, Registered Nurse(RN) combined both crushed scheduled medications in a Styrofoam cup and poured an unmeasured amount of water to dissolve medications. The medications were administered via percutaneous endoscopic gastrostomy (PEG) tube and the (PEG) tube was flushed immediately with an unmeasured amount of water. Interview with Staff B, Nurse Manager, on 11/19/2021 at 11:39 a.m. revealed, when patients come from another facility with a percutaneous endoscopic gastrostomy (PEG) tube and have multiple medications, all medications can be crushed and administered together. Review of the Nursing Procedures Manual last revised 08/18 documented: OBJECTIVE: To provide guidelines for nursing staff to carry out safe nursing practice and promote patient safety. SCOPE: Nursing Department POLICY: Aventura Hospital and Medical Center adopts the {E...} Nursing Procedures Manual based on current recommended evidence based nursing practice. Review of the Nursing Procedure steps for Administering Capsules and Tablets through Enteral Feeding Tubes documented: (1) Prepare each medication one at a time to reduce the risk for error. Do not combine medications when crushing or dissolving. (2) Do Not mix different medications due to the risk of possible physical chemical incompatibilities, altered drug reaction, or tube obstruction. Review of the Nursing Procedure steps for Administering Medications Through an Enteral Feeding Tube documented: (1) Verify Enteral Feeding Tube (EFT) placement prior to medication administration according to unit specific/facility protocol. Interview with the Associate Chief Nursing Officer on 11/19/2021 at 3 p.m. revealed, the medication administration via percutaneous endoscopic gastrostomy (PEG) tube was not performed according to current policy and procedures. and PEG tube placement was not verified.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record and policy review, the facility failed to discuss the discharge planning process to the legal guardian acting on the behalf of 1 (SP#3) out of 7 sample patients (SP). Findings include: Review of SP#3 Case Management Notes dated 11/29/2018 at 11:36 AM documented case discussed in interdisciplinary team and a request for Guardianship will be filled out due to patient's mental condition and the fact that the family has not been in contact with the facility and patient is unable to provide any reliable information in reference to family. Review of SP#3 Case Management Notes dated 12/06/2018 at 5:15PM documented patient started a process for guardianship. Review of SP#3 Case Management Notes dated from 12/06/2018 to 06/26/2019 documented patient in the process for guardianship. Review of SP#3 Petition to Determine Incapacity and seek Plenary Guardianship executed on 02/05/2019 by Director of Utilization Review/Case Management was electronically filed on 02/06/2019 at 3:34 PM. Review of SP#3 Plenary Guardian was done and ordered on [DATE] and electronically filed 04/01/2019 at 12:15PM. Review of SP#3 Psychiatric Progress Notes dated 06/27/2019 at 7:19 PM documented patient indicates doing okay. States not hearing any voices. States does not want to harm self or anyone else. States does not know any family in the area. Patient appears to be competent at time of assessment. Patient has not been agitated or psychotic. Patient does not need inpatient psychiatric treatment. Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented order for Case Management Consultation. Reason for Consult: Discharge Planning. Comment: Homeless Patient. Please assist with shelter and clothing. Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented Discharge Order, Discharge to Home. Review of SP#3 Discharge Instructions dated discharge date : 06/28/2019 at Discharge Time: 7:25AM documented Patient Unable to Sign on 06/28/2019 at 12:16PM. Review of SP#3 Case Management Notes dated 06/28/2019 at 10:51AM for Discharge Planning documented patient was reevaluated by psychiatrist who said that patient look competent. Physician ordered discharge home. Patient was not accepted for the owner of the place previously living. Patient will be sent with a taxi to [named] Outreach to obtain a shelter. Patient will be evaluated by the task force outreach according to the staff who answered the phone when case management contacted to ask for the process. Review of SP#3 Discharge Summary dated 07/08/2019 at 4:41PM documented patient was Baker-acted by police department for abnormal behavior and incoherent speech. Patient admitted to medicine for acute metabolic versus infectious [DIAGNOSES REDACTED] and evaluation of abnormal lab values. Guardianship for placement initiated. Patient is now alert and awake times three, more coherent. Patient reevaluated by psychiatry and is now has capacity to be discharged to self-care. Case management consulted and followed the patient. Patient is stable to be discharged with outpatient follow up. Interview with Chief Financial Officer on 09/09/2019 at 1:15PM revealed that if the patient has a guardian, the guardian is fully aware of the patient's care. The guardian participates in the discharge planning and works with the case management department. Prior to the patient's discharge, case management contacts the guardian to identify the location where the patient will be discharged . Interview with Vice President of Quality Management on 09/11/2019 at 10:23AM revealed that there was no evidence of communication from the case management department to the guardian regarding the discharge plan for SP#3. Review of Policy Title: Discharge Planning Process, last revised 01/19 documented Procedure, on page 2 of 5, G. Implement plan and communicate to patient /family. 2. Discuss Discharge Planning for patients 16 years of age or older with both the patient and their next of kin or legal guardian. Discharge, on page 4 of 5, b. Reassessment of vulnerable populations will be completed as needed prior to discharge such as homeless, victims of domestic violence and Behavioral Health.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record and policy review, the facility failed to reassess the patient's discharge plan for factors that may affect the appropriateness of the discharge plan for 1 (SP#3) out of 7 sample patients (SP). Findings include: Review of SP#3 Case Management Notes dated 11/29/2018 at 11:36 AM documented case discussed in interdisciplinary team and a request for Guardianship will be filled out due to patient's mental condition and the fact that the family has not been in contact with the facility and patient is unable to provide any reliable information in reference to family. Review of SP#3 Case Management Notes dated 12/06/2018 at 5:15PM documented patient started a process for guardianship. Review of SP#3 Case Management Notes dated from 12/06/2018 to 06/26/2019 documented patient in the process for guardianship. Review of SP#3 Petition to Determine Incapacity and seek Plenary Guardianship executed on 02/05/2019 by Director of Utilization Review/Case Management was electronically filed on 02/06/2019 at 3:34 PM. Review of SP#3 Plenary Guardian was done and ordered on [DATE] and electronically filed 04/01/2019 at 12:15PM. Review of SP#3 Psychiatric Progress Notes dated 06/27/2019 at 7:19 PM documented patient indicates doing okay. States not hearing any voices. States does not want to harm self or anyone else. States does not know any family in the area. Patient appears to be competent at time of assessment. Patient has not been agitated or psychotic. Patient does not need inpatient psychiatric treatment. Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented order for Case Management Consultation. Reason for Consult: Discharge Planning. Comment: Homeless Patient. Please assist with shelter and clothing. Review of SP#3 Physician Order dated 06/28/2019 at 7:25AM documented Discharge Order, Discharge to Home. Review of SP#3 Discharge Instructions dated discharge date : 06/28/2019 at Discharge Time: 7:25AM documented Patient Unable to Sign on 06/28/2019 at 12:16PM. Review of SP#3 Case Management Notes dated 06/28/2019 at 10:51AM for Discharge Planning documented patient was reevaluated by psychiatrist who said that patient look competent. Physician ordered discharge home. Patient was not accepted for the owner of the place previously living. Patient will be sent with a taxi to [named] Outreach to obtain a shelter. Patient will be evaluated by the task force outreach according to the staff who answered the phone when case management contacted to ask for the process. Review of SP#3 Discharge Summary dated 07/08/2019 at 4:41PM documented patient was Baker-acted by police department for abnormal behavior and incoherent speech. Patient admitted to medicine for acute metabolic versus infectious [DIAGNOSES REDACTED] and evaluation of abnormal lab values. Guardianship for placement initiated. Patient is now alert and awake times three, more coherent. Patient reevaluated by psychiatry and is now has capacity to be discharged to self-care. Case management consulted and followed the patient. Patient is stable to be discharged with outpatient follow up. Interview with Chief Financial Officer on 09/09/2019 at 1:15PM revealed that if the patient has a guardian, the guardian is fully aware of the patient's care. The guardian participates in the discharge planning and works with the case management department. Prior to the patient's discharge, case management contacts the guardian to identify the location where the patient will be discharged . Interview with Vice President of Quality Management on 09/11/2019 at 10:23AM revealed that there was no evidence of communication from the case management department to the guardian regarding the discharge plan for SP#3. Review of Policy Title: Discharge Planning Process, last revised 01/19 documented Procedure, on page 2 of 5, G. Implement plan and communicate to patient /family. 2. Discuss Discharge Planning for patients 16 years of age or older with both the patient and their next of kin or legal guardian. Discharge, on page 4 of 5, b. Reassessment of vulnerable populations will be completed as needed prior to discharge such as homeless, victims of domestic violence and Behavioral Health.
Based on interview and record review the facility failed to reassess 1 (SP#1) of 4 sample patients (SP) discharge plan for the appropriateness of the discharge plan. Findings include: Review of sample patient (SP) #1 Discharge Summary dated 03/24/2019 at 7:11 PM revealed the date of admission: 03/19/2019. The discharge date : 03/24/2019. Record review showed on 03/24/2019, Patient (SP #1) was discharged back to the Assisted Living Facility today due to transportation issues the previous night. Discharge medications prescribed for deep vein thrombosis prophylaxis, seizure disorder, cholesterol, blood pressure and infection. Discharge instructions for dressing of low extremities with thera-honey, kerlix and ace bandage daily and follow-up appointment with neurology in 1-2 weeks. Record review showed on 03/24/2019 at 10:00 AM documented that the transport came to pick up (SP #1) patient by 11:00 PM and since patient was going to an ALF, the discharge had to be held because there was no receiving staff at the location. Case Manager called ALF and talked to the owner whom agreed to take the patient back. Transportation by 11:00 AM, the nurse and the patient were made aware. Record review showed on 03/24/2019 at 12:15 PM documented order for home health. Case Management talked to (SP #1) patient and sent referrals to home care agency as per insurance regulations. The transportation arrived to pick up the patient. Talked to the owner of the ALF who wanted physical therapy, registered nurse, shower chair and a raised toilet seat. Case management got the order and send to the home health agency. Record review 03/24/2019 at 12:16 PM documented that the medications for the (SP #1) patient will be picked up per the owner of the ALF who will also make sure that the patient takes the anticonvulsant regularly. Review of SP#1 Order Record dated 03/23/2019 at 2:24 PM documented new response set entered at 10:51AM for Disposition - Assisted Living Facility (ALF), Home Health Dressing Change and at 12:11 PM for please provide a shower chair and a raise toilet set for this patient at the ALF. Interview with Vice President of Quality on 06/12/2019 at12:46 PM revealed that SP #1 was discharged to an Independent Living Facility. Facility did not verify licensure of the discharge location. Interview with Case Management Director on 06/10/2019 at 12:35 PM revealed The Agency for Health Care Administration (AHCA) facility locator is used for discharge placement. The information from the AHCA website is copied and pasted in the case manager notes to verify the facility is licensed. Interview with Staff-B on 06/10/2019 at 12:55 PM revealed if a patient was admitted from an ALF and had experienced too much decline during the hospital stay, the patient will not be able to return to the ALF. If the physician has ordered discharge to ALF, the ALF is verified through the Agency for Health Care Administration (AHCA) website. The provider's license is printed, and contact is made with the facility's administrator or director of nursing. Recalls SP#1 and states patient was awake, alert and oriented times three and choice was to go back to the ALF. Did not copy and paste the licensure verification on the case management notes.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review and the Medical Staff Bylaws (approved October 19, 2017) the facility failed to provide quality care one (SP#1) out of 4 sample patients (SP), and fully implement the corrective action plan as a result of an adverse incident involving the physician. Findings include: Review of sample patient (SP) #1 medical record showed she (MDS) dated [DATE] at 9:21 PM. The Lab work resulted at 10:53 PM with an INR (International Normalized Ratio) of 2.85. Patient was found to be hypertensive and was admitted . On 10/12/2018 at 6:01 AM patient is noted to have right sided weakness and facial droop and a stroke alert was initiated. CAT scan of the head and neck show abrupt cutoff of the left carotid terminus, highly probable this is acute. At 7:21 AM Alteplase is ordered by Physician A and a 9 mg intravenous bolus was administered by Staff J in the interventional radiology lab at 8:19 AM. MRI of brain at 3:52 PM showed a hemorrhage. It was determined that Physician A inadvertently did not review the patient's lab results prior to ordering the Alteplase. Also the Registered Nurse Staff J administered the Alteplase without obtaining a two licensed verification co-signature. Corrective Action: Intensivists and Cath Lab/Interventional Radiology Registered Nurse will receive stroke certification and education to include thrombolytics. Review of the Corrective Action Plan dated November 2018 revealed the plan was developed based on the findings on 10/19/2018. Topics identified include: Process deviation noted by the Critical Care Physician and also the Cath Lab Nurse. The Action plan did not include completion dates,. Interview with Stroke Coordinator on 04/08/2019 at 12:05 PM confirmed audits for abnormal labs results prior to ordering the Alteplase were not completed to evaluate the compliance of the strategies/actions of the identified goals for the physicians. Review of In-House Stroke Alert Altepase Administration Audit for only Physician A was provided on 04/09/2019 at 12:55 PM. The Audit revealed the identification of the Inclusion/Exclusion Criteria review and the Altepase administration ordered by Physician A for the period of 12/08/2018 to 03/30/2019. Physician A had no outliers. Sixty percent (60%) of the Critical Care Physicians/Residents completed, 2 Remaining Physicians for Stroke Alerts/1 Requires Validation of Competency. The Medical Staff Bylaws (approved October 19, 2017), states the purposes and responsibilities of the Medical Staff are to provide patients with the quality of care that is commensurate with acceptable standards and available community resources.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review the facility failed to administer drugs in accordance to the accepted standards of practice in one (SP#1) out of 4 sample patients (SP) and fully implement the corrective action plan as a result of an adverse incident involving Cath Lab/Interventional Radiology Registered Nurse. Findings include: Review of sample patient (SP) #1 medical record showed she (MDS) dated [DATE] at 9:21 PM. The Lab work resulted at 10:53 PM with an INR (International Normalized Ratio) of 2.85. Patient was found to be hypertensive and was admitted . On 10/12/2018 at 6:01 AM patient is noted to have right sided weakness and facial droop and a stroke alert was initiated. CAT scan of the head and neck show abrupt cutoff of the left carotid terminus, highly probable this is acute. At 7:21 AM Alteplase is ordered by Physician A and a 9 mg intravenous bolus was administered by Staff J in the interventional radiology lab at 8:19 AM. MRI of brain at 3:52 PM showed a hemorrhage. It was determined that Physician A inadvertently did not review the patient's lab results prior to ordering the Alteplase. Also the Registered Nurse Staff J administered the Alteplase without obtaining a two licensed verification co-signature. Corrective Action: Intensivists and Cath Lab/Interventional Radiology Registered Nurse will receive stroke certification and education to include thrombolytics. Review of the Corrective Action Plan dated November 2018 revealed the plan was developed based on the findings on 10/19/2018. Topics identified include: Process deviation noted by the Critical Care Physician and also the Cath Lab Nurse. The Action plan did not include completion dates,. Interview with Stroke Coordinator on 04/08/2019 at 12:05 PM confirmed no audits for obtaining a two licensed verification co-signature prior to adminstering Alteplase were not completed to evaluate the compliance of the strategies/actions of the identified goals. Review of In-House Stroke Alert Altepase Administration Audit for only Physician A provided on 04/09/2019 at 12:55 PM revealed the identification of the Inclusion/Exclusion Criteria review and the Altepase administration ordered by Physician A for the period of 12/08/2018 to 03/30/2019. No audits was completed for Interventional Radiology Registered Nurse -Staff J and the Cath Lab/Interventional Radiology Registered Nurses was noted.
Based on interviews and record review the facility failed to implement an appropriate discharge plan, reassess the patient's discharge plan, and transfer or refer the patient to an appropriate facility for follow-up care in one (SP#1) out of 6 sampled patients (SP). (Refer to A-0806, A-0821, and A-0837)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record reviews the facility failed to provide a discharge planning evaluation that include evaluation of the likelihood of a patient's capacity for self-care, the likelihood of a patient needing post-hospital services and the availability of the services in 1 (SP#1) out of 6 sampled patients (SP). Findings include: Review of sample patient (SP) #1 Emergency Provider Report dated 10/27/18 revealed that 911 was called by a third party stating that (patient) pt. was wandering on the road. On initial evaluation showed the patient is alert, but not completely oriented and without any complaint. There were no past history noted. Physical Exam showed that pt. is unkempt and has poor hygiene. Unable to contact any family and patient may be disoriented at baseline however it is unsafe for discharge and will admit patient for observation. Review of the History and Physical dated 10/27/2018 at 03:55 am showed appears patient may have had prior brain injury, patient unable to provide history (hx). The notes further stated the CM (Case Manager) consulted for further information/family contact. Review of SP#1 Case Management Report: Discharge Planning Evaluation (DPE) dated 10/27/18 showed that information was obtained from the patient. The patient was alert and oriented, homeless, does not have medical equipment, No activity of daily living limits, and pt. is self-care. Patient on evaluation has no community services prior to admission Patient. discharge risk showed patient does not have insurance, homeless, and to discharge to shelter. Based on the information gathered, the patient's care needs can be met at the environment from which he entered from. The discharge plan was discussed with the pt. Review SP#1 Clinical Documentation Record showed: On 10/27/18 at 5:51 am: Admission/Shift Assessment showed patient was oriented to person, with unsteady gait and balance. SP#1 is high risk for falls. At 10:45 am, the patient with weak lower extremities. Gait is unsteady. On ambulation, SP#1 requires one person assist. Pt thought process showed disorganized, illogical, and helpless. Pt memory assessment showed unable to comprehend and follow directions. On 10/28/18 at 5:02 AM showed the patient was in bed, with period of confusion and disorientation persist. SP#1 ambulated in the room with unsteady gait and safety was maintained. At 10:50 am, the patient oriented to person, lower extremities weak and remains with unsteady balance and gait. Standby assist required. Falls risk assessment showed the patient is able to comprehend and follow direction and is high risk for falls. Pt intervention include supervision/assistance to ambulate. At 10:06 PM, the patient is in bed, confuse, alert oriented, calm and cooperative. Pt unable to give personal information. Pt in close monitoring. On 10/28/2018 at 08:48 showed SP#1 discharge order to other facility. Then on 10/29/2018 09:05 am another order showed to discharge to home. On 10/28/2018 at 08:48 am showed an order for a Case Management consult for discharge planning to DC to shelter. Another order dated 10/29/2018 at 11:19 am showed OT/Rehab Plan of care, Inpatient Rehabilitation versus Skilled Nursing Facility (SNF) for rehab. 10/29/18 at 9:20 am the Occupational Therapy (OT)/REHAB (Rehabilitation): Initial Evaluation showed the patient unable to follow command, oriented to name, patient is confused and unable to follow simple one step commands will need assistance for medication management, patient feeding with moderate assistance due to right upper extremity (RUE) tremor and decreased endurance, patient unable to locate objects in room requiring maximum verbal cues. Discharge Recommendations: Inpatient Rehab versus Skilled Nursing Facility (SNF) for rehab. On 10/29/2018 at 1:19 pm, SP#1 was discharge home and left via wheelchair with staff on duty to the first floor. Review of SP#1 Discharge Summary dated 10/29/18 revealed patient was determine to likely be at his baseline after thorough examination and screening. SP#1 Discharge Diagnosis showed Chronic [DIAGNOSES REDACTED]. Review of the ED provider notes from hospital #2 showed patient SP (#1) presents to ED (Emergency department) with psychiatric evaluation onset today. Patient was brought in by (Emergency Medical Services) EMS after running through traffic on I-95 (Interstate highway). Patient was transferred to the Behavioral Health Unit (BHU) for psychiatric evaluation and discharged on [DATE]. Interview on 12/10/2018 at 12:48 pm 12:11 pm with Risk Management Coordinator revealed that Risk Management was made aware of SP#1 discharge on 10/30/18 from a report. A call was received from another hospital that SP#1 was found wandering and was taken by police. Interview on 12/10/18 at 12:40 pm with the Assistant Director for Case Management revealed that he recalls SP#1. He was covering for the case manager on that floor. He said that the patient said he lived with family, he spoke with the patient who said that he has a brother, there was no address and the patient provided telephone number of the brother to the nurse and it was not working. Patient understands the discussion and the instructions in Spanish. He recalls that information for shelter and community resources was given, and patient was discharged . The next day, a hospital (name provided) called and asked about the patient. Discharge of homeless patients, a list of shelters is provided to patient and initial call is done by case manager and the patient also has to call the shelter. The shelter space is first come first serve. Interview with Nurse/Staff M on 12/11/2018 at 11:22 am revealed (she was the nurse assigned to SP#1 at the day of discharge) that she does not recall SP#1. Staff M explains that if patient is confused, the case manager is informed and we find a family or if there is no one available, we have to get guardianship. She said that patients are provided with discharge instructions on different topics. Transportation is arranged by case manager at discharge if it is needed. Review of the Case Management report of SP#1 from 10/27/2018 to 10/30/2018 revealed that there was no transportation arrangement for SP#1. There was no documentation noted that shelters was contacted. There was no documentation noted that a space is available at the shelter. There was no evidence that a facility, agency or outpatient service referral was contacted for SP#1 post hospital needs. Interview on 12:48 pm 12:11 pm with Risk Management Coordinator revealed that Risk Management was made aware of SP#1 discharge on 10/30/18 from a report. A call was received from another hospital that SP#1 was found wandering and was taken by police. The Director of Utilization Management was made aware and reviewed the case with Case Manager. The case do not have any corrective action submitted or required at this time. Review of the Policy Title: Advance Directives: Health Care Surrogate/Proxy, Determine of Capacity/Competency. Revision Date (07/2012) revealed the policy states that all patients are presume to be capable of making health care decision for herself or himself unless she or he is determined to be incapacitated. The Determination of Capacity: If a patient's capacity to make health care decisions is in question for herself or himself or provide informed consent is in question, the attending physician shall evaluate the patient's capacity and if the physician concludes that the patient lacks capacity, he/she will documented the findings enter the evaluation on the Verification of Patient Incapacity to make Health Care Decisions. The facility failed to follow their own policy. Review of the Policy Title: Discharge Planning Process, Revision Date: (09/2017) states, Discharge Planning involves the evaluation of the patient and family needs, strengths, limitations and resources. Components of Discharge Planning are education, identification of needs, and coordination of post-hospital care in collaboration with other members of the healthcare team. (Page 4 of 4) d. Necessary referrals to post-acute services will be made by the case manager or social worker (home health agencies skilled nursing facility, LTACHs, DMEs). e. The anticipated discharge date is discussed and confirmed with the family and preparations are finalized for discharge (transportation arrangements made, transfer to another level of care in outside facility confirmed, home health arrangements confirmed, etc.). The facility failed to follow their own policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to reassess the discharge plan for factors that may affect the continuing care needs and appropriateness of the discharge plan in one (SP#1) out of 6 sampled patients (SP). Findings include: Review of sample patient (SP) #1 Emergency Provider Report dated 10/27/18 revealed that 911 was called by a third party stating that (patient) pt. was wandering on the road. On initial evaluation the patient is alert, but not completely oriented and without any complaint. There were no past history noted. Physical Exam showed that pt. is unkempt and has poor hygiene. Unable to contact any family and patient may be disoriented at baseline however it is unsafe for discharge and will admit patient for observation. Review of the History and Physical dated 10/27/2018 at 03:55 am showed appears patient may have had prior brain injury, patient unable to provide history (hx). The notes further stated the CM (Case Manager) consulted for further information/family contact. Review of SP#1 Case Management Report: Discharge Planning Evaluation (DPE) dated 10/27/18 showed that information was obtained from the patient. The patient was alert and oriented, homeless, does not have medical equipment, No activity of daily living limits, and patient is self-care. Patient on evaluation has no community services prior to admission Patient discharge risk showed patient does not have insurance, homeless, and to discharge to shelter. Based on the information gathered, the patient's care needs can be met at the environment from which he entered from. Name of brother was identified but there is no cellphone number available.The discharge plan was discussed with the pt. 10/29/18 at 9:20 am the Occupational Therapy (OT)/REHAB (Rehabilitation): Initial Evaluation showed the patient unable to follow command, oriented to name, patient is confused and unable to follow simple one step commands will need assistance for medication management, patient feeding with moderate assistance due to right upper extremity (RUE) tremor and decreased endurance, patient unable to locate objects in room requiring maximum verbal cues. Discharge Recommendations: Inpatient Rehab versus Skilled Nursing Facility (SNF) for rehab. On 10/29/2018 at 1:19 pm, SP#1 was discharge home and left via wheelchair with staff on duty to the first floor. Review of SP#1 Discharge Summary dated 10/29/18 revealed patient was determine to likely be at his baseline after thorough examination and screening. SP#1 Discharge Diagnosis showed Chronic [DIAGNOSES REDACTED]. On 10/30/18 at 9:57 am, SP#1 Case Management Report showed in the comments: Orders for discharge home per attending. Unable to contact next of kin, Patient at baseline per care team, provided with information of shelters and community resources. Case Management Report Documentation Updated by Assistant Director of Case Management. Review of the ED provider notes from hospital #2 showed patient SP (#1) presents to ED (Emergency Department) with psychiatric evaluation onset today. Patient was brought in by (Emergency Medical Services) EMS after running through traffic on I-95 (Interstate Highway). Patient was transferred to the Behavioral Health Unit (BHU) for psychiatric evaluation and discharged on [DATE]. Interview on 12/10/2018 at 12:48 pm 12:11 pm with Risk Management Coordinator revealed that Risk Management was made aware of SP#1 discharge on 10/30/18 from a report. A call was received from another hospital that SP#1 was found wandering and was taken by police. Interview on 12/10/18 at 12:40 pm with the Assistant Director for Case Management revealed that he recalls SP#1. He was covering for the Case Manager on that floor. He said that the patient said he lived with family, he spoke with the patient who said that he has a brother, there was no address and the patient provided telephone number of the brother to the nurse and it was not working. Patient understands the discussion and the instructions in Spanish. He recalls that information for shelter and community resources was given, and patient was discharged . The next day, a hospital (name provided) called and asked about the patient. Discharge of homeless patients, a list of shelters is provided to patient and initial call is done by Case Manager and the patient also has to call the shelter. The shelter space is first come first serve. Phone interview with Case Manager B on 12/12/18 at 10:47 revealed that he does not recall SP#1. (Case Manager B took part with the discharge planning of SP#1). He explains that discharge of a homeless patient, the patient is provided with a list of shelters and let them know what is on the area. He said that the patient is referred to shelter. He explains that if he runs into pt. and is a little confuse, he ask certain questions make sure they are there, ask who they live with, ask number, simple question. Get more information and if patient stumbling or hesitant, see if patient was medicated, see if there is a family to talk to. It there is no family call the doctor and see if psychiatric evaluation is appropriate. Discharge plans are discussed with doctors, patients and family and make sure that they approve. He explains his role on discharge planning such as obtaining information about patient get information and verify address of patient, and family/ nearest of kin and phone numbers. He assist and work on patient needs after discharge. He also reach out to family members about discharge plans and call family members. He also explains that transportation is arranged by case management. Review of the Case Management report of SP#1 from 10/27/2018 to 10/30/2018 revealed that there was no transportation arrangement for SP#1. There was no documentation noted that shelters was contacted. There was no documentation noted that a space is available at the shelter. There was no evidence that a facility, agency or outpatient service referral was contacted for SP#1 post hospital needs. Review of the Policy Titled: Discharge Planning Process, Revision Date: (09/2017) states, Discharge Planning involves the evaluation of the patient and family needs, strengths, limitations and resources. Components of Discharge Planning are education, identification of needs, and coordination of post-hospital care in collaboration with other members of the healthcare team. (Page 4 of 4) d. Necessary referrals to post-acute services will be made by the case manager or social worker (home health agencies skilled nursing facility, LTACHs, DMEs). e. The anticipated discharge date is discussed and confirmed with the family and preparations are finalized for discharge (transportation arrangements made, transfer to another level of care in outside facility confirmed, home health arrangements confirmed, etc.). The facility failed to follow their own policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review the facility failed to refer the patient to an appropriate facility for follow-up care in 1 (SP#1) out of 6 sampled patients (SP). Findings include: Review of sample patient (SP) #1 Case Management Report showed on 10/28/18 at 12:53 pm a Case Management consult for shelter. Case Manager-C documentation showed she met with the patient and Patient Care Assistant (PCA) and patient was given information to Shelters. Pt said that he does not have identification. Further review of SP#1 Case Management Report showed on Comments: Orders for discharge home per Attending (physician). Unable to contact next of kin, Patient at baseline per care team, provided with information of shelters and community resources. Case Management Report Documentation Updated by Assistant Director of Case Management on 10/30/18 at 9:57 am. Review of SP#1 Discharge Summary showed the admitting diagnosis Acute [DIAGNOSES REDACTED]. Discharge diagnosis showed Chronic [DIAGNOSES REDACTED], patient is oriented to person only. Patient has previous history of craniotomy and found that this is his baseline mental status. Review of the Case Management report of SP#1 from 10/27/2018 to 10/30/2018 revealed that there was no transportation arrangement for SP#1. There was no documentation noted that shelters was contacted. There was no documentation noted that a space is available at the shelter. There was no evidence that a facility, agency or outpatient service referral was contacted for SP#1 post hospital needs. Phone interview with Case Manager-B on 12/12/18 at 10:47 revealed that he does not recall SP#1. (Case Manager B took part with the discharge planning of SP#1). He explains that discharge of a homeless patient, the patient is provided with a list of shelters and let them know what is on the area. He said that the patient is referred to shelter. He explains that if he runs into pt. and is a little confuse, he ask certain questions make sure they are there, ask who they live with, ask number, simple question. Get more information and if patient stumbling or hesitant, see if patient was medicated, see if there is a family to talk to. It there is no family call the doctor and see if psychiatric evaluation is appropriate. Discharge plans are discussed with doctors, patients and family and make sure that they approve. He explains his role on discharge planning such as obtaining information about patient get information and verify address of patient, and family/ nearest of kin and phone numbers. He assist and work on patient needs after discharge. He also reach out to family members about discharge plans and call family members. He also explains that transportation is arranged by case management. Review of the Policy Titled: Discharge Planning Process, Revision Date: (09/2017) states, Discharge Planning involves the evaluation of the patient and family needs, strengths, limitations and resources. Components of Discharge Planning are education, identification of needs, and coordination of post-hospital care in collaboration with other members of the healthcare team. (Page 4 of 4) d. Necessary referrals to post-acute services will be made by the case manager or social worker (home health agencies skilled nursing facility, LTACHs, DMEs). e. The anticipated discharge date is discussed and confirmed with the family and preparations are finalized for discharge (transportation arrangements made, transfer to another level of care in outside facility confirmed, home health arrangements confirmed, etc.). The facility failed to follow their own policy.
1. Based on medical records reviews, On Call logs, Hospital License list of services, Policies and Procedures, and Medical Staff Rules and Regulations and Physician interviews, the facility failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/ or treatment necessary to stabilize individuals with an emergency medical condition; and failed to implement procedures to respond to situations in which the Obstetrics Trauma specialty is not available or when the on-call physician cannot respond for 3 out of 20 sampled patients (SP #10, #12, #18). (Refer to findings in Tag A-2404). 2. Based on medical records reviews, Hospital License list of services, medical staff privileges, Active Medical Staff (Gynecology) GYN Roster, On-Call logs, policies and procedures, and physician's interviews, the facility failed to ensure that the on-call physician provided further medical examination and treatment as required to stabilize the medical condition for 3 of 20 sampled patients (SP #10, #12, #18) within the capabilities of the staff and facilities available at the hospital. (Refer to finding in Tag A-2407)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical records reviews, On Call logs, Hospital License list of services, Policies and Procedures, and Medical Staff Rules and Regulations and Physician interviews, the facility failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/ or treatment necessary to stabilize individuals with an emergency medical condition; and failed to implement procedures to respond to situations in which the Obstetrics Trauma specialty is not available or when the on-call physician cannot respond for 3 out of 20 sampled patients (SP #10, #12, #18). Findings include: 1. The facility self- reported uninsured sample patient (SP) #10. Review of sample patient (SP) #10 Emergency Provider Report dated 4/24/18 revealed that she presented to Emergency Department (ED) via ambulance with sudden lower abdominal pain. The ED physician listed the patient's Chief complaint as abdominal pain, Nausea and pelvic pain. Documentation by the ED physician revealed the patient reported that earlier today she felt pressure in her left lower abdominal quadrant, and then just prior to arrival she awoke with sudden severe intense abdominal pain with nausea and weakness. The patient arrived in the ED in moderate distress in moderate pain and hypotensive. She was noted to be hypotensive with blood pressure of 90/60. SP #10 was evaluated by the Emergency Department Physician and showed on physical examination of the abdomen revealed diffuse tenderness on palpation to the abdomen, no rebound or guarding. The patient had no bleeding or discharge noted. The patient was provided with intravenous fluids, oxygen, monitoring, medications for pain, and intravenous broad spectrum, antibiotics were administered. Diagnostics tests were performed and resulted. Results of the transvaginal and pelvic ultrasound showed differential diagnosis of ruptured hemorrhagic cysts versus torsion. (Twisting of the ovary due to the influence of another condition or disease. This results in extreme lower abdominal pain. Ovarian torso is a medical emergency. If not treated quickly, it can result in loss of ovary.) The Computed Tomography (CT) scan of the abdomen showed in the pelvis characteristic of blood products or infection. Differential finding include ruptured hemorrhagic ovarian cyst. Physician D (Trauma Obstetrics on-call) OB Trauma surgeon was called by the ED Physician , and he responded right away and reported that he is on call for trauma obstetrics only. Another physician was called Physician E (OB/GYN not on-call) and responded to the call right away however was unavailable to assist with the care of the patient. A receiving facility was contacted and the accepting physician at the receiving the facility agreed to accept the transfer. Reviewed SP#10 vital signs on the Emergency Patient Record showed that the vital signs was monitored and the blood pressure improved 99/57, 112/68, and 107/63. Pt pain intensity is 0 at the time of the transfer. Record review of the Emergency Provider Report for sample patient (SP) #10 revealed on 04/24/2018 the OB/GYN (OB Trauma on-call physician D) was called at 4:21 AM on 04/25/2018 stated he is currently in a procedure, and unavailable to assist. Review of the hospital's April 2018 Trauma OB log revealed that Physician D was on call for Trauma OB on 4/24/2018 when SP#10 presented to the ED. The facility failed to ensure that it met the needs of the hospital patients who are receiving services available, to include the OB on-call for Trauma services for SP #10 when she (MDS) dated [DATE]. Record review of SP #10 Memorandum of Transfer (MOT) - on 04/24/2018 reads: Emergency Medical Condition (EMC) identified: I. Medical condition: Diagnosis Ovarian torsion. b. Unstable Patient Request for Transfer: The patient has been examined and an EMC has been identified and the patient is not stable. The hospital has the capability and capacity to provide the care needed but the patient has specifically requested to be transferred to another facility after being notified that the hospital can and is willing to provide the care needed to stabilize and treat the EMC. The RISKS AND BENEFITS FOR TRANSFER: Obtain level of care/ service unavailable at this facility. Service: Gynecology. Reason for transfer: Specialist not available, Service not offered. Services required for transfer: Gynecology. The portion of the form for consent for request for transfer was not completed by the patient. Review of the ED provider notes from the receiving hospital showed on 04/24/2018 at 7:30 AM the OB/GYN physician saw the patient (SP#10) at bedside, will admit and take the patient to surgery. At 7:40 am the physician noted that SP #10 present with acute onset abdominal pain at 11:00 PM last night. Was initially evaluated at Aventura Hospital and Medical Center (transferring hospital) and noted to have a hemoperitoneum consistent with a possible ruptured hemorrhagic cyst. She was transferred to the receiving hospital as there is no GYN available to care for the patient at transferring hospital. The Op (operative) notes showed SP #10 had a pre-op diagnosis acute abdomen. Hemoperitoneum (is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs.) Right ruptured ovarian cyst. Post-Op diagnosis same. Bilateral cysts. Sample patient #10 had evacuation of 650 cc hemoperitoneum. 2. SP#12 Medical Record Review Review of SP#12 medical record Emergency Provider Report dated 06/05/2018 revealed that the patient who is uninsured presented to the ED with abdominal pain, nausea and mild vomiting. Pt. was seen and evaluated by an Advanced Registered Nurse Practitioner, and documentation showed a right lower quadrant severe tenderness for the past days 2 with involuntary guarding. Documentation also revealed the patient reported that the pain had worsened overnight, had chills but no fever, and pain was a 10/10 (worst pain on a scale of 1-10), non- radiating, and pain was aggravated by palpating the areas and nothing relieved the pain. SP#12's initial VS were: Blood Pressure: 138/76, Pulse -93, Respirations-20, Oxygen saturation -100% on room air. Diagnostic tests were performed which showed on pelvic ultrasound and CT scan of the abdomen and pelvis a complex structure in the right hemipelvis consistent with cysts. Pt was medicated for pain (Morphine Sulfate IV x2), vital signs were stable and disposition to transfer to another facility for surgical intervention. Pt. Primary Clinical Impression is Dermoid cyst of right ovary, Secondary Impression: Intractable pelvic pain. Pt disposition for transfer to possible OR intervention to a sister facility of the hospital for GYN services. There was no evidence that pt. was evaluated by a gynecologist at the ED prior to transfer. Review of the hospital's April 2018 Trauma OB log revealed that Physician D was on call for Trauma OB on 6/05/2018 when SP#12 presented to the ED. The facility failed to ensure that it met the needs of the hospital patients who are receiving services available, to include the OB on-call for Trauma services for SP #12 when she (MDS) dated [DATE]. Review of SP#12 MOT form revealed that physician certification for pt. to transfer to a receiving facility with the name of an accepting physician noted. Pt is stable for transfer and the medical benefit of the transfer is for pt. to obtain Gynecology service that is not available at the facility. Risk and benefits reviewed, appropriate transportation and documents were provided on transfer. 3. SP #18 Medical Record Review of SP#18 medical record Emergency Provider Report revealed that she is uninsured patient who presented on 7.7.2018 at 3:41 with a chief complaint of left lower quadrant abdominal pain, which stated today. Pt was seen and evaluated by a Physician's Assistant (PA) and noted that there is left lower quadrant and suprapubic tenderness. The pelvic examination revealed Right Adnexal Tenderness. Other body systems exam are unremarkable. The patient's initial VS in the ED were B/P 186/106, Pulse- 79; Respirations- 16 oxygen saturation 98% on room air. SP #12 was provided Medications for pain and nausea, and intravenous fluids while in the ED. Diagnostic laboratory tests were performed and it is noted on the pelvic ultrasound and transvaginal ultrasound reports completed on 7/7/2018, revealed in part, Impression: 1. Lack of color Doppler flow with the right Ovary which was concerning for right ovarian torsion; ...2. Complex right ovarian cysts ...3. Mild pelvic fluid. The case was then discussed telephonically with the diagnostic Radiologist, who is a part of the patient care team and his her impression of the findings were consistent with right ovarian torsion; and that there was no arterial or venous blood flow was demonstrated. Further review of the record revealed in part, The medical screening examination was incomplete. Further evaluation and/or treatment is required. Physician D (on-call OB Trauma Physician) was called on 7/7/2018 at 6:55 p.m., by the PA and he (Ob Trauma on-call Physician) promptly returned the call at 6:55 p.m. Physician D recommended to transfer SP#18 to a facility with GYN service, and that he was not available since he is heading to deliver at another facility at this time. Documentation by the PA revealed that SP#18 disposition is to transfer to another facility with the Impression is Right Ovarian Torsion. There was no evidence in the medical record to indicate that SP#18 was evaluated by a gynecologist at the ED prior to transfer. Review of SP#18 the Memorandum of Transfer (MOT) form showed a physician certification for transfer to a receiving facility with the accepting physician. The medical benefits of the transfer is for pt. to obtain GYN service which is not available at the facility. Pt was stable for transfer for transfer and appropriate transportation and documents were provided on transfer. Review of the facility's license effective date 11/5/2017 revealed list of services that the facility provide which include but not limited to: Dedicated Emergency Department Level 2 trauma Center Emergency Services, Emergency Medicine, and Gynecology. On- Call Logs Review of the On Call log titled CentralLogic for July 2018 revealed that there is an On Call for every service line listed on the facility license list of services except for Gynecology. There is no On Call log for Gynecology. It is noted that there is an On Call log for Trauma OB. It is also noted during review of the On-Call log that on 7/7/2018 Physician D was the assigned physician on-call for Trauma OB. The facility failed to ensure that it met the needs of the hospital patients who are receiving services available, to include the OB on-call for Trauma services for SP #18 when she (MDS) dated [DATE]. Interviews Interview on 11/14/18 at 12:36 pm of the Emergency Department (ED) Medical Director who stated that all patients. that presents to ED are seen and evaluated by a qualified medical practitioner and treated. On a gynecology (GYN) case on presentation at ED, there is no specific GYN On - Call but only a Trauma Obstetrics (OB) On Call. Interview on 11/14/18 at 1:14 PM with the Chief of Surgery who stated that he oversees the GYN department. He said that there are gynecologic surgeons mostly doing gynecologic oncology, and no (Obstetrics) OB service line. There is no On Call gynecologist. Interview on 11/14/18 at 1:34 pm with the Chief Medical Officer (CMO) who stated that there is no currently On Call for GYN. In situation that a gynecologic patient presents to the ED with immediate threat for loss of life, the team here will be called to evaluate and intervene if it is emergent. Policy and Procedure Record review of Policy Description: EMTALA- Definitions and General Requirements, Effective Date February 1, 2016, Reference number LL.EM.001, page 14 of 18, reads On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs (Emergency Medical Conditions). The facility did not follow their own guidelines as evidenced by failing to ensure that the OB trauma on call specialty provided further evaluation and treatment as required for SP #10, SP#12 and SP#18. Medical Staff Rules and Regulations Review of the Medical Staff Rules and Regulations approved Oct. 19, 2017, page 11 of 12 Section I. Hospital On-Call Service which showed that 1. Hospital administration will organize on-call services to meet hospital coverage needs for Emergency Services. The facility failed to follow their own Medical Staff Rules and Regulations by as evidenced by failure to provide on-call services to meet the gynecologic service needs at Emergency Services for SP #10, SP#12 and SP#18 when the presented to the ED seeking gynecological services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical records reviews, Hospital License list of services, medical staff privileges, Active Medical Staff (Gynecology) GYN Roster, On-Call logs, policies and procedures, and physician's interviews, the facility failed to ensure that the on-call physician provided further medical examination and treatment as required to stabilize the medical condition for 3 of 20 sampled patients (SP #10, SP#12, SP#18) that was within the capabilities of the staff and facilities available at the hospital. Based on medical records reviews, License list of services, medical staff privileges, Active Medical Staff (Gynecology) GYN Roster, On-Call logs, policies and procedures, and physician's interviews, the facility failed to ensure that an individual is provided further medical examination and treatment to stabilize the medical condition for 3 of 20 sampled patients (SP #10, SP #12, SP #18) within the capabilities of the staff and facilities. Findings Include: 1. This the self -reported patient (SP #10). Review sample patient (SP) #10 Emergency Provider Report dated 4/24/18 revealed that she presented to Emergency Department (ED) via ambulance with sudden lower abdominal pain. She was noted to be hypotensive with blood pressure of 90/60. SP #10 was evaluated by the qualified medical professional and showed on physical exam diffuse tenderness on palpation to the abdomen, no rebound or guarding. The patient had no bleeding or discharge noted. The patient was provided with intravenous fluids, oxygen, monitoring, medications for pain, intravenous fluid, antibiotics were administered. Diagnostics tests were performed and resulted. Results of the transvaginal and pelvic ultrasound showed differential diagnosis of [DIAGNOSES REDACTED]. Another physician was called Physician E and responded to the call right away however was unavailable to assist with the care of the patient. A receiving facility was contacted and the accepting physician agreed to accept the transfer. Reviewed SP#10 vital signs on the Emergency Patient Record and showed that the vital signs was monitored and the blood pressure improved 99/57, 112/68, and 107/63. Pt pain intensity is 0 at the time of the transfer. Record review of the Emergency Provider Report for sample patient (SP) #10 revealed on 04/24/2018 the OB/GYN (OB Trauma on-call physician D) was called at 4:21 AM on 04/25/2018 stated he is currently in a procedure - and unavailable to assist. Review of the ED provider notes from the receiving hospital showed on 04/24/2018 at 7:30 AM the OB/GYN physician saw the patient (SP#10) at bedside, will admit and take the patient to surgery. At 7:40 am the physician noted that SP #10 present with acute onset abdominal pain at 11:00 PM last night. Was initially evaluated at (transferring hospital) and noted to have a hemoperitoneum consistent with a possible ruptured hemorrhagic cyst. She was transferred to the receiving hospital as there is no GYN available to care for the patient at transferring hospital. The Op (operative) notes showed SP #10 had a pre-op diagnosis acute abdomen. Hemoperitoneum (is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs.) Right ruptured ovarian cyst. Post-Op diagnosis same. Bilateral cysts. Sample patient #10 had evacuation of 650 cc hemoperitoneum. 2. Review of SP#12 medical record Emergency Provider Report dated 06/05/2018 revealed that the patient who is uninsured presented to the ED with abdominal pain, nausea and mild vomiting. Pt. was seen and evaluated and showed a right lower quadrant severe tenderness with involuntary guarding. Diagnostic tests were performed which showed on pelvic ultrasound and CT scan of the abdomen and pelvis a complex structure in the right hemipelvis consistent with cysts. Pt was medicated for pain, vital signs were stable and disposition to transfer to another facility for surgical intervention. Pt. Primary Clinical Impression is Dermoid cyst of right ovary, Secondary Impression: Intractable pelvic pain. Pt disposition for transfer to possible OR intervention to a sister facility of the hospital for GYN services. 3. Review of SP#18 medical record Emergency Provider Report revealed that she is uninsured patient who presented to the ED with left lower quadrant abdominal pain. Pt was seen and evaluated and noted that there is left lower quadrant and suprapubic tenderness. Other body systems exam are unremarkable. Diagnostic tests were performed and it is noted on the pelvic ultrasound and transvaginal ultrasound a concern for right ovarian torsion. Medications for pain, intravenous fluid, and for nausea was provided at ED. Physician D was called and he recommends to transfer to facility with GYN service and he was not available since he is heading to deliver at another facility at this time. Disposition is to transfer to another facility with the Impression is Right Ovarian Torsion. Review of the facility's license effective date 11/5/2017 revealed list of services that the facility provide which include but not limited to: Dedicated Emergency Department Level 2 trauma Center Emergency Services, Emergency Medicine, and Gynecology. Review of the On Call log titled CentralLogic from April 2018 revealed that there is an on call for every service line listed on the facility license list of services except for Gynecology. There is no On Call log for Gynecology. It is noted that there is an On Call log for Trauma OB. It is noted on the review of the On-Call log that on April 23 to 24, 2018, Physician D is the assigned physician on-call for Trauma OB. Interview on 11/14/18 at 12:36 pm of the ED Medical Director who stated that all patients (pt.) that presents to ED are seen and evaluated by a qualified medical practitioner and treated. On a GYN (Gynecology) case on presentation at ED, there is no specific GYN on call but only a trauma OB on call. GYN pt. presenting to ED, a complete MSE (Medical Screening Evaluation) is done, stabilize and treated, and if meets criteria for discharge, pt. can be discharged for outpatient follow up. If the pt. requires inpatient surgical, the Trauma OBGYN On Call are called and if available can take care of the pt. Otherwise if not available the pt. have to be transferred to a facility with the capability to take care of the pt. There is no GYN (gynecology) on call for ED only for trauma OB. The OB trauma On Call takes cases for blunt trauma or qualifies for trauma who is at the same time pregnant. The OB trauma On Call calls back and comes in if asked within 30 minutes. If there was a GYN case at ED that the ED doctor would require the expertise of a gynecologist, there is no On Call but would seek the assistance and expertise by calling the OB Trauma On Call and see if he is available. Most of the time he gets himself available however if he is not, then the pt. when stable has to be transferred to a receiving facility with the services for GYN. Interview on 11/14/18 at 1:14 PM with the Chief of Surgery what stated that he oversees the GYN department. He said that there are gynecologic surgeons mostly doing gynecologic oncology, and no OB service line. There is no On Call gynecologist. He does not take part of developing the On Call list. On patients that presents with an acute abdomen with a question of sepsis or shock, diagnostics will be run and there are options to be taken by the ED practitioner. Call gynecologist on staff if available or trauma team can take care of it. Acute abdomen is condition that requires immediate intervention. Abdominal pain presentation and once you identify a gynecologic problem, however if not immediate life threatening, the patient is not septic or in shock, an ED doctor can reach out to the gynecologist staff if available otherwise we can arrange for transfer to the sister facility or any facility which can provide the service Medical Staff Roster Review of the Active Medical Staff GYN Roster provided by the Quality Department Manager on 11/13/18 at 9:53 am revealed that there are 24 active medical staff with Obstetrics and Gynecology Specialty. Gynecology Core Privileges Review of the Privilege Application: Gynecology Core Privileges showed there were 15 active medical staff approved for GYNECOLOGY with privilege to perform the following: Admit, perform history and Physical Examination, evaluate, diagnose, consult, and pre, intra-and post-operative care necessary to correct or treat female patients of all ages presenting with illnesses, injuries and disorders of the gynecological or genitourinary system and non-surgically treat disorders and injuries of the mammary glands and operative laparoscopy; including treatment of endometriosis, [DIAGNOSES REDACTED] and benign ovarian neoplasm. The facility showed the service capability to examine, diagnose, evaluate, and treat the gynecologic conditions. Policies and Procedures Review of the Policy Titled: EMTALA Medical Screening Examination and Stabilization, effective 10/2001, last revision 04/01/2018, revealed that EMTALA obligation is triggered when an individual or representative on the individual's behalf, including EMS or a transferring hospital requests emergency services and care. Further if a prudent layperson observer would believe that the individual experience an emergency medical condition (EMC), then an appropriate medical screening exam (MSE), within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The facility failed to follow their own policy as evidenced by failing to ensure that further medical examination and treatment stabilizing treatment was provided as required to stabilize the emergency medical conditions or SP#10, SP#12, and SP#18, with identified emergency medical conditions. The hospital was equipped with such staff services and equipment necessary to stabilize SP#10, SP#12 and SP#18's emergency condition to include the services of the OB on-call trauma physician. Record review of Policy Description: EMTALA- Definitions and General Requirements, Effective Date February 1, 2016, Reference number LL.EM.001, page 14 of 18, reads On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs (Emergency Medical Conditions). The facility did not follow their own guidelines.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to reassess the patient's discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan in 2 (SP#6 and SP#8) out of 8 sampled patients (SP). Findings include: 1. Review of SP#8 Podiatry Consultation Report dated 03/22/2018 revealed patient has a history of a stroke with right-sided right arm hemiparesis, mostly wheelchair bound. Reflexes are diminished at the ankle joint. The patient's right arm and hand are contracted and edematous. Review of SP#8 Psychiatric Evaluation Notes dated 03/23/2018 revealed that patient requires assistance for activities of daily living (ADLs). Review of SP#8 Occupational Therapy (OT)/Behavioral Health (BH): Initial Evaluation Patient assessment dated [DATE] revealed that patient needs assistance with food preparation, driving and community mobility. Requires maximal assistance for toileting and moderate assistance with transfer bed/chair/wheelchair/toilet. Patient needs supervision/set-up with eating, moderate assistance with grooming and maximal assistance with bathing, upper body dressing and lower body dressing. Problem list: decreased with activities of daily living (ADLs). Treatment diagnosis: Functional decline. Discharge recommendations: Inpatient facility. Review of SP#8 Physical Therapy (PT)/Rehab: Initial Evaluation Patient assessment dated [DATE] revealed Transfer segments: bed mobility with maximal assist, supine to sit with maximal assist, sit to stand with moderate assist. Transfer comment: slow, unsteady transition, assistance for safety. Maximal assistance for gait with human support or assistive device. Gait deviations and safety: uneven step length, decreased cadence, decreased stride length. Discharge recommendations: Inpatient rehab. Review of SP#8 Social Work Discharge Planning Note dated 03/23/2018 revealed that patient is currently homeless. Patient reported she was going to a motel upon discharge, patient has not reported source of income or means to pay for motel. Review of SP#8 Social Work Discharge Planning Update dated 04/02/2018 revealed that an individual met with patient in person and deemed her a fall risk. Stated that she is only providing transitional housing and does not have the capability of an Assisted Living Facility to help with Activities of Daily Living. Review of SP#8 Social Work Discharge Planning Update Notes dated 04/18/2018 revealed that per staff, patient requires assistance with attending to her activities of daily living (ADLs). Other option of Independent Living Facility (ILF) with home health was discussed. Review of SP#8 Social Work Discharge Planning Notes dated 04/24/2018 revealed writer inquired about home health possibilities for placement in an independent living facility due to funding. Home Health Agency related that home health services are not covered if patient was to go to an independent living. It would need to be medically necessary and not in an independent living facility. Review of SP#8 Social Work Discharge Note dated 07/25/2018 revealed that patient has been accepted into supportive housing. Review of SP#8 Social Work Discharge Planning Notes Addendum dated 07/28/2018 revealed that writer met with representative from supportive housing and confirmed patient's bed at the location. Review of SP#8 Behavioral Health (BH): Discharge Instructions Home dated 07/30/2018 revealed that patient was discharged to supportive housing location. Interview with Licensed Clinical Social Worker on 10/25/2018 at 10:20AM revealed the criteria to determine placement for Independent Living Facility include that the patient is able to function on their own by taking medications, preparing basic meals for self, and conducting activities of daily living (ADLs) independently. 2. Review of SP#6 History and Physical dated 10/19/2018 revealed that patient presented to emergency department for evaluation of syncope. Past medical history includes syncope, functional decline. Review of SP#6 Admission Health History dated 10/19/2018 revealed that patient designated spouse as the caregiver. Patient identified as unable to function independently or live independently. Present with decrease in activities of daily living function/upper limb mobility and recent decline in mobility or ambulation past 7 days. Falls within the past 3 months with a history of musculoskeletal chronic conditions: generalized weakness to bilateral lower extremities. Assistive device used: wheelchair. Current living situation in assisted living. Review of SP#6 Case Manager Notes dated 10/21/2018 revealed that case manager (CM) acknowledged an order for discharge planning to skilled nursing facility (SNF). The Case Manager spoke with the patient's spouse who is refusing SNF placement. Patient to return to Assisted Living Facility. Patient needs assistance with all activities of daily living (ADLs). Discharge risk: bedbound. Current mental status/cognition: alert and disoriented. Review of SP#6 Admission/Shift assessment dated [DATE] revealed patient oriented to person and place, weak motor strength to left and right leg and foot, non-ambulatory, not continent of urine for developmental age without catheter, does not have full range of motion, bedbound. Review of SP#6 Discharge Summary dated 10/23/2018 revealed that patient was discharged to Assisted Living Facility. Interview with Case Manager B on 10/23/2018 at 1:30PM revealed that for an Assisted Living Facility placement patient does not have support at home, cannot live alone, or does not have family support to receive care at home. Patient should not be bed bound. The policy Discharge Planning Process (revision date: 09/17) states in accordance with the utilization review plan, the case manager will identify and implement a realistic; coordinated plan for continuity of post-hospital care for patient of all ages. The policy further states discharge planning involves the evaluation of the patient and family needs, strengths, limitations and resources. The discharge plan must take into account all realities of both the patient's condition and existing laws, rules, regulations and regulated agency requirements, along with availability of community resources.
Based on interview and record review, the facility failed to: 1) Provide a discharge planning evaluation to include an evaluation of the patient's need for post-hospital services, the availability of those services, and include an evaluation of the likelihood of the patient's capacity for self-care and the possibility of the patient being cared for in the environment from which he entered the hospital. 2.) Discuss the results of the discharge evaluation with the individual acting on the patient's behalf. 3.) Reassess the patient's discharge plan for factors that may affect continuing care needs and the appropriateness of the discharge plan. 4.) Transfer or refer the patient to an appropriate facility for follow-up care. This affected 1(one) of 10 sampled patient # 1. ( refer to A-0806, A-811, A-0821, and A-0837)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide a discharge planning evaluation to include an evaluation of the patient's need for post-hospital services, the availability of those services, and include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he entered the hospital for 1 (one) out 10 sampled patients (SP) #1. The findings: Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission. On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration). Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes. The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note. On 3/26/17, the day of the pt. discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube. The pt. was discharged on [DATE] via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions. Interview with the Director of Case Management on 7/24/17 at 2:20pm revealed SP#1 initial Discharge Planning Evaluation was performed on 3/10/17 and then the next reevaluation in the medical record was on 3/24/17. She further stated that discharge planning reevaluations are done every 72 hours and at every patient change of condition. Further interview revealed that SP#1 came from the assisted living facility (ALF) on 3/10/17 and was discharged back to the same ALF on 3/26/17. Record review also showed that SP #1 was readmitted on [DATE], and the patient expired on [DATE]. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration. Review of the facility's policy: Documentation; Dept.: Utilization Management, Review date: 10/15 revealed that the Case Manager will (A) obtain information from the pt. family, and other relevant sources to make an accurate evaluation, (E) Frequency of documentation in the medical record will be documented on the discharge plans and updated at least every 72 hours. (F) The final disposition and follow-up will be documented once the pt. is discharged in the Case Management Discharge note. The facility failed to follow this policy Review of the facility's policy Discharge Planning Process (revised 10/15) state that Discharge Planning involves the evaluation of the patient and family needs, strength, limitations and resources. Components of Discharge Planning are education, identification of needs and coordination of post-hospital care in collaboration with other members of the healthcare team. The discharge plan must take into account all realties of both the patient's condition and existing laws, rules, regulations and regulated agency requirements, along with availability of community resources.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to discuss the results of the discharge evaluation with the individual acting on the behalf of 1 (one) out of 10 sample patients (SP) #1. The findings: Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission. On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes. The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note. On 3/26/17, the day of the pt. discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube. The pt. was discharged on [DATE] via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions. Record review showed that SP#1 capacity to consent to care and services was evaluated on 3/16/17 and determined that the patient is incapacitated. On 3/16/17, the Designation of Proxy Form show the Proxy designation was the brother. Interview with the Director of Case Management on 7/24/17 at 2:20 pm revealed that SP#1 came from the ALF on 3/10/17 and was discharged back to the same ALF on 3/26/17. Record review also showed that SP #1 was readmitted on [DATE], and the patient expired on [DATE]. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration. The policy Discharge Planning Process, (revision date: 10/15) state the Case Manager will identity and implement a realistic; coordinated plan for continuity of post-hospital care for patient of all ages. The policy further state the patient/family understanding of their role in implementing the discharge plan is verified and documented in the [named] system.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to reassess the patient's discharge plan for factors that may affect continuing care needs and the appropriateness of the discharge plan for 1 out of 10 sampled patients (SP) #1. The findings: Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission. On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes. The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note. On 3/26/17, the day of the SP#1 discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube. The pt. was discharged on [DATE] via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions. The patient was returned to the previous ALF which had no licensed staff to provide feedings via the peg tube. Record review also showed that SP #1 was readmitted on [DATE], and the patient expired on [DATE]. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration. Interview with the Director of Case Management on 7/24/17 at 2:20pm revealed SP#1 initial Discharge Planning Evaluation was performed on 3/10/17 and then the next reevaluation in the medical record was on 3/24/17. She further stated that discharge planning reevaluations are done every 72 hours and at every patient change of condition. Further interview revealed that SP#1 came from the assisted living facility (ALF) on 3/10/17 and was discharged back to the same ALF on 3/26/17. The policy: titled Documentation Dept.: Utilization Management, (Revision date: 10/15) state that the Case Manager will (A) obtain information from the patient family, and other relevant sources to make an accurate evaluation, (E) Frequency of documentation in the medical record will be documented on the discharge plans and updated at least every 72 hours. (F) The final disposition and follow-up will be documented once the patient is discharged in the Case Management Discharge note. The facility failed to follow this policy. Review of the facility's policy Discharge Planning Process (revised 10/15) state that Discharge Planning involves the evaluation of the patient and family needs, strength, limitations and resources. Components of Discharge Planning are education, identification of needs and coordination of post-hospital care in collaboration with other members of the healthcare team. The discharge plan must take into account all realties of both the patient's condition and existing laws, rules, regulations and regulated agency requirements, along with availability of community resources.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to transfer or refer the patient to an appropriate facility for follow-up care in 1 out 10 sampled patients (SP) #1. The findings: Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission. On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes. The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note. On 3/26/17, the day of the SP#1 discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube. The pt. was discharged on [DATE] via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions. The patient was returned to the previous ALF which had no licensed staff to provide feedings via the peg tube. Record review also showed that SP #1 was readmitted on [DATE], and the patient expired on [DATE]. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration. Interview with the Director of Case Management on 7/24/17 at 2:20pm revealed SP#1 initial Discharge Planning Evaluation was performed on 3/10/17 and then the next reevaluation in the medical record was on 3/24/17. She further stated that discharge planning reevaluations are done every 72 hours and at every patient change of condition. Further interview revealed that SP#1 came from the assisted living facility (ALF) on 3/10/17 and was discharged back to the same ALF on 3/26/17. The policy Discharge Planning Process, (revision date: 10/15) state the Case Manager will identity and implement a realistic; coordinated plan for continuity of post-hospital care for patient of all ages. The procedure includes: Necessary referrals to post acute services will be made by the case manager or social worker (home health agencies, skilled nursing facility, LTACH (Long-term Acute Care Hospitals), DME (Durable Medical Equipment). The patients must be informed of Medicare certified providers in their geographical area who provide the level of service required at discharge. A choice letter will be signed by the patient/family prior to discharge.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to ensure the (triage acuity assessment) policies and procedures governing the medical care provided in the emergency department (ED) are enforced in 1 sampled patient (SP) #1 of 11 sampled ED patients. The findings: Medical record review showed sampled patient #1 was brought to the emergency department (ED) on 8/16/15 by fire rescue. The fire rescue report SP #1 was in a bicycle accident with an impact type: head-on; Patient vehicle speed: 20 MPH; other vehicle type: pedestrian. The patient was found lying on his back. The last rescue vitals taken at 18:03 PM show the pulse 94, B/P 114/P, and respiration 18. The HPI-General Trauma notes report on 08/16/2015 at 18:13 PM the patient complaint is a bicycle crash. The location is a head injury. The notes then state the patient stated he was thrown from his bicycle going approximately 20 miles per hour. There is a possible loss or suspected loss of consciousness. The patient was brought on a back board and a C-collar. The assessment also showed a hematoma of the left thigh. Review of the Emergency Patient Record also showed that on 08/16/2015 the patient was not triaged until 20:06 PM. The ED rapid assessment showed SP #1 complained of a bicycle accident, plus loss of consciousness (LOC), plus headache, and a left nose road rash. The patient was assigned an acuity level ESI (Emergency Severity Index) priority level 3/ urgent. Review of the emergency triage ESI (Emergency Severity Index) show that the vital signs is included in the assessment when assigning an acuity level. If level 3 and (equal) = 2 or more resources (consider danger zone vitals for possible escalation to level 2). There were no vitals taken on arrival for SP #1. Sampled patient #1 also required more than 2 resources, he required Labs (X-rays, IM medications, and specialty consultations (Neurologist consult was called on 08/16/2015 at 22:13 PM). Review of the policy Trauma Alert Patients, (effective 01/15) state the following patients will be identified as Trauma Alert patients, as per Florida Trauma Score Care Methodology- the following criteria are considered an Adult Trauma Alert when two criteria listed below are met: (F) the patient is greater than or equal to 55 years of age. (G) Mechanism of injury: the patient has been ejected from a bicycle. Sampled patient #1 met both criteria for trauma alert patients. There were no vital signs taken immediately upon arrival to the ED. The initial vital signs were taken on 08/16/2015 at 20:06 PM one hour and forty-seven minutes later. The readings were 158/ 94 blood pressure, temperature 98.0 (Fahrenheit), 80 pulses, 18 respirations, pulse oximetry 100. There was no telemetry monitor strips documented. The next vital signs were taken at 23:00 PM. The readings were: 150/92 blood pressure, 90 pulse, 18 respirations. There was no telemetry monitor documented. The vital signs taken on 08/16/2015 at 23:31 PM were: 160/89 blood pressure, 102 pulse, 18 respirations, pulse oximetry 100. There were no telemetry monitors reading documented. The vital signs taken on 08/17/2015 at 01:27 AM were: 149/ 87 blood pressure, 67 pulse, 18 respiration. There were telemetry monitor reading was documented. Review of the Clinical Review audit of sampled patient physician and consultation visits showed the patient was seen by the ED provider on 08/16/2015 at 18:13 PM, a trauma consult was ordered on [DATE] at 21:30 PM, and the patient was then seen by the trauma physician on 08/16/2015 at 22:54 PM. Review of the discharge summary showed the patient was admitted with an isolated C6 spinous (Clay) fracture, multiple facial and nasal abrasions, and abrasion ' s with contusions, hematoma, to left mid distal thigh, rule out syncope, and closed head injury-mild concussion. On 10/5/2015 at 3:43 PM, Staff Nurse F (the Registered Nurse who triaged sampled patient #1) stated that we get a report from the ambulance staff. She stated that I had a pretty sick septic patient occupying my time. I saw his vitals on the EMS run sheet. When the patient came in I did an initial assessment, I eyeballed him. The doctor saw the patient at 18:13 PM. At 21:31 PM I got a detailed assessment, his previous medical condition, nursing assessment, he was assigned a priority 3. She also stated that the initial vital signs were completed at 20:06 PM. She further stated that the patient was on the monitor but she did not record any telemetry strips. During the same interview, the Director of the Emergency Services stated that a rapid initial was completed by Staff Nurse E, a rapid initial assessment. The initial vital signs were completed at 20:06 PM. She further stated that the vital signs are usually done within 10-15 minutes.
Based on record review and interview, the facility failed ensure sampled patient #1 (SP #1) who was an incoming transfer was provided a medical screening examination when she presented to the facility. Sampled patient #1 is one of twenty-three sampled patients who presented to the facility for a medical screening examination. The patient had a diagnosis of a Myocardial Infarction. Refer to A2406.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of medical records, policies and procedures, transfer logs, surveillance video, local ambulance run sheet, e-mails, Air Ambulance Progress Review and interviews, the facility failed to ensure sampled patient #1 (SP #1) who was an incoming transfer was provided a medical screening examination when she presented to the facility. Sampled patient #1 is one of twenty-three sampled patients who presented to the facility for a medical screening examination. The patient had a diagnosis of a Myocardial Infarction and was in need of a interventional catheter lab for a cardiac stent. The findings included: Review of the facility's policy titled, EMTALA (Emergency Medical Treatment and Labor Act) -Florida Medical Screening Examination and Stabilization policy, dated 03/01/13, stated that the hospital must provide an appropriate medical screening examination to determine whether or not an emergency condition exists to any individual who requests such an examination or an individual who has such a request made on his or her behalf. The policy also documented that if an individual arrives as a transfer from another hospital or health care facility, upon arrival of a transfer, a physician or qualified medical person must perform an appropriate medical screening examination. The medical screening of the individual must be documented. The policy further documents, such obligation is further extended to those individuals presenting elsewhere on the hospital property requesting examination or treatment. The medical record for SP (#1) from Hospital #2 was reviewed. Review of the section titled Patient Demographic indicated that SP#1 was a [AGE] year old individual with an address in another City and State in the United States of America. Further review of the medical record indicated that SP (#1) arrived at Hospital #2 on 3/7/2015 at 1:23 a.m., as urgent. SP#1's Chief Complaint Patient presents with Chest Pain. The patient's initial Vital Signs were Temperature 36.8; Heart rate: 65; Respirations: 18; Blood Pressure: 133/77; oxygen saturation- 98% and pain scale was 5. The physical examination revealed in part, ...Cardiovascular: Normal rate regular rhythm, normal heart sounds, and intact distal pulses ... Cervical back she exhibits tenderness. L (left) cervical paraspinal tenderness ... Laboratory Evaluation: CBC with Diff - Abnormal ...Basic Metabolic Panel: Abnormal ...Clinical Impression: Diagnoses Headache ...Neck pain on left side Cervical disc herniation Cervical radiculopathy Palpitations ...ED Disposition: Disposition: Admit: Discussed ER findings, diagnosis and treatment plan. Informed on plan for admission for further evaluation and treatment... This patient had an emergency medical condition: yes. On 03/18/15 at 9:51 AM, the Vice President (VP) of Quality Management stated, sampled Patient (SP)#1 was transferred from the Island of Anguilla which is a part of the British territory. She stated, the transfer process was not finalized between the two facilities, and the sending hospital did not notify the facility that the patient was en route to the facility. She stated that last weekend around midnight an ambulance arrived to the emergency room (ER) but did not park where the vehicle was visible. They parked on the end of the curve. She stated, the paramedic staff came into the ER without the patient and asked for the nursing supervisor. She stated that the nursing supervisor and the ER staff did not know that the patient was outside the facility in the ambulance. She stated that after the ambulance staff left the facility, the ambulance staff called the physician who was accepting the patient and stated that they were taking the patient to Hospital #2 because the facility did not accept the case. Review of the Travel Instructions -Air Ambulance indicated that (SP) #1 diagnosis was Acute Myocardial Infarction (Heart Attack) and EKG and labs were completed. The patient's acuity was listed as Emergent. The patient's destination facility was Aventura Hospital in Aventura, Florida. Record review of the Air Ambulance Progress Review showed that on 03/06/15 at 4:15PM, the air ambulance contacted the hospitals (Aventura Hospital and Medical Center) nursing supervisor who was the receiving nurse and the patient's clinicals were faxed. Record review of the local ambulance Run Sheet dated 03/07/15 at 12:33AM revealed, crew advising ... Hosp (Hospital) is not accepting this pt (patient) now due to an insurance issue. The flt (flight) medic is trying to resolve the issue-crew advising that the patient is still in their unit. On 03/07/15 at 12:58AM, per flight crew rerouting to (Hospital #2). Review of a fax from SP#1's insurance carrier to the nursing supervisor at ... Hospital, on 03/06/15, the fax documented the patient's anticipated arrival time will be at 12:45AM on March 7, 2015 being delivered by [name] Air Ambulance. Review of the SP #1's medical update from the insurance carrier [name] to [name] Hospital and dated 3/6/15 revealed, the patient was given a diagnosis of a Myocardial Infarction on 3/6/15 while on the Island of Anguilla. The patient had the onset of symptoms on 2/26/15. Review of an email provided by the VP of Quality dated 03/10/2015, from the local ambulance company revealed SP #1 was transported to the hospital, and documented according to the EMT (emergency medical technician) during transport, a member of the flight crew was on the phone with the hospital trying to solidify the admission because they were previously aware of an insurance issue. The email further documents this conversation was not successful, so upon arrival to the hospital, one member of the flight team went into the hospital in an attempt to get resolution. The email documented, our crew, the patient, other team member, and a family member stayed in the ambulance waiting for more solid information. They waited about one half hour to 45 minutes. During the wait, the family member got restless and wanted to know what was going on. Our driver took the family member into the hospital to meet up with the flight crew member. The email documented, when the flight crew came out, he directed our crew to take the patient to hospital #2 because he was being told that the patient's insurance would not cover the patient being admitted to the hospital. The patient was transported to hospital #2. During interview on 03/18/15 at 1:30PM with the ER physician, revealed he worked for the patient's insurance company (name) He reported, that the insurance company provides insurance to business and cruise ship travelers. He stated, the insurance company makes the transfer arrangements for patients, including communication with hospital staff. He stated, Travel Guard had offices all over the world, including one in Houston, Texas. He stated that, this facility accepts everything. He stated, SP#1 lived in the United States and was probably on vacation on the Island of Anguilla. He stated, SP#1 was already accepted and the facility was waiting for confirmation of arrival time. However, before he left the facility, the Friday evening around twelve midnight, he called the insurance company's On-call, to get an estimated time of arrival for the patient. He stated, the insurance company told him that the patient was no longer coming to this facility and that the patient was going to another acute care hospital. He stated, he never got a call from the air ambulance staff regarding the patient's transfer. He stated, usually, the air ambulance calls and informs the Travel insurance company with an estimated time of arrival. He stated that the air ambulance did not communicate with the insurance company regarding the transfer, which was unusual. He stated, he was not in the ER when the ambulance staff arrived. He found out that the patient was outside in the ambulance, when he returned to the ER the following morning. During interview on 03/18/15 at 2:08 PM, the nursing supervisor reported, before international patients are transferred to the facility she verifies the patient's insurance information and provides acceptance for the patients. She stated, before air ambulance staff brings patients to the facility, they usually call and inform the facility about an estimated time of arrival. She reported for SP#1, the patient's insurance information was still in process of being verified. She stated, she had spoken with an insurance provider representative earlier that night and had asked them for a down payment for the patient because the facility was unable to verify SP#1's insurance. She stated, the insurance provider representative never called back regarding the down payment. She stated, the same night one of the facility's staff told her that there was a gentleman in the ER who wanted to talk to me. She stated, the gentleman was wearing a shirt with a [name] Logo. She stated that she thought the gentleman was from the airline that was making travel arrangements for SP#1. She stated, at no point did it cross her mind that the patient was outside because the gentleman did not tell her that. She stated, the gentleman asked what we were going to do for the patient. When she asked which patient, he said the name of SP#1. She stated, she told the gentleman to hold on while she went to check with registration. However, when she returned, the gentleman was gone. She stated, the gentleman did not bring the patient inside the facility nor did he say that the patient was outside. She stated, after the gentleman had left, she received a call from the physician who told her that the patient was outside. She stated, she called [name of air ambulance company] and asked them to bring the patient back. However, they stated that they were taking the patient to Hospital #2. On 03/18/15 at 2:48 PM, the facility's surveillance video of the ER was reviewed. Review of the video showed that on 03/07/15 at 12:22AM, the ambulance arrived to the ambulance ramp. A Paramedic entered the ambulance entrance, spoke to facility staff. On 12:27 AM - on phone, 12:30 AM - goes outside to ambulance, 12:57 AM departed. However, it was observed the ambulance was parked away from the ambulance entrance. The video did not show the patient was carried into the ER by the ambulance staff. The video showed an individual, identified by the facility as the patient's family member, departed from the ambulance and went inside the ER. The individual talked with the ambulance staff inside the ER and then went back into the ambulance. During interview on 03/18/15 at 3:24 PM, the accepting physician for SP#1 reported, he had received a call, from the facility, the day before the patient was transferred. He stated, he knew that the patient was coming at some point and that he had accepted the patient. He stated, around 1:00 AM, on the day of the incident (March 7, 2015), he got a call from the insurance company stating that the patient was outside and not being let into the facility. He stated, he called the ER and spoke with the nursing supervisor who told him that she was not aware that the patient was outside the facility. He reported, the nursing supervisor stated, when she came back from registration, the ambulance staff had left the hospital. During interview on 03/18/15 at 3:46PM, Staff A, the ER Registrar, stated that when patients are being transferred via air ambulance, air ambulance sends a fax to the nursing supervisor, who then follows up with registration. She stated, registration would then verify the insurance after which the nursing supervisor would give confirmation of acceptance to the air ambulance. She stated, when the nursing supervisor came to her that night, she called the insurance company to verify SP#1's insurance, but no one answered. Staff A stated, she did not know that SP#1 was at the facility, outside in the ambulance. She stated, if the patient was at the facility, the patient would be accepted and insurance details would be verified later. During interview on 03/18/15 at 4:01PM, Staff B, the ER Charge Nurse stated, when the air ambulance staff for SP#1 came to the registration desk, he asked for the nursing supervisor by name. She stated that the ambulance staff did not bring any patient inside. She stated, she was not directly involved in the conversation between the nursing supervisor and the air ambulance staff. However, since she was at the charge nurse desk, she could over hear the conversation. She stated, the air ambulance staff did not mention to the nursing supervisor or to the ER staff that the patient was outside the facility. She stated, if the patient was outside, the facility would have accepted the patient. Review of the facility's Transfer Log from November 2014 to present did not show the name of SP#1. Review of the facility's ER log from for March 1-18, 2015, did not show that SP#1 presented to the ER. The facility failed to ensure that on 3/7/2015 SP#1 received an appropriate medical screening examination when he/she presented to the hospital's property.
Based on record review and interview the facility failed to meet the Condition of Participation on Patient Rights as evidenced by the facility failed to ensure the policies were followed to monitor behavioral health patients every 15 minutes, and to provide safe care and treatment to sampled patients (SP#2) to prevent abuse and death in 1 of 10 sampled patients, and to provide level 3 (1:1) monitoring for 1 of 10 sampled patients (SP) #1 who admitted to committing a violent act against SP #2. (Refer to A-145 and A-396)
Based on interview and record review, the facility failed to ensure policies were followed to monitor behavioral health patients every 15 minutes, and provide safe care and treatment to sampled patient (SP#2) to prevent abuse (death) in 1 of 10 sampled patients, and to provide level 3 (1:1) monitoring for 1 of 10 sampled patients (SP) #1 who admitted to committing a violent act against SP #2. Findings include: 1. Sampled Patient #2 medical record showed he was Baker Acted on 06/05/2014 with bizarre behavior. According to the discharge summary dated 07/01/2014, the patient was seen and evaluated, was grossly psychotic, and internally preoccupied. There was no interactions with peers. The summary further stated that on 06/23/2014, the patient reported feeling better, psychosis was less intrusive, more interactive, no depressive symptoms and no side effects to medications. According to the Behavioral Health Services 24 hour Intensive Monitoring Log, the patient was on Q (every) 15 minutes observation rounding as ordered since admission on 06/05/2014. On 06/26/2014 there was no documentation to show that SP#2 was observed from 2:45pm to 3:35pm (approximately 50 minutes during the time of the emergency incident). On June 26, 2014 the physician note documented that SP# 2 was found on the floor by the RN (Registered Nurse). A Code Blue was called (at 3:38 PM), and SP #2 was in cardio-pulmonary arrest. Initial rhythm was asystole (no rhythm, no pulse). The RN found the patient (SP#2) on the floor with the bed sheet around his neck. The patient's face and upper neck were swollen and cyanotic. Epistaxis (nose bleed) was evident. Patient was unresponsive, cold, and pulseless. CPR (Cardio Pulmonary Resuscitation) was initiated. All attempts at resuscitation were unsuccessful. On July 2, 2014 at 10:30 AM during interview, the ACNO (Assistant Chief Nursing Officer) and the Director of BHU (Behavioral Health Unit) it was stated that SP#1 was admitted around 10:00 AM on June 26, 2014 and was placed in the same room with SP#2 who was later found on the floor next to his bed by the housekeeper around 3:35 PM, while making a final round prior to the end of the shift. The nurse (NS#7) on duty was notified and found SP#2 unresponsive. A Code Blue was called with prompt response and ACLS (Advanced Cardiac Life Support) protocol was followed but was unsuccessful. SP#1 was found in the bathroom taking a shower and was escorted out to the next room. The staff originally thought SP #2 injuries were self-inflicted due to the sheet around SP #2's neck and was not tied to anything. Everyone was interviewed but management couldn't determine how the incident could have happened. Police assistance was eventually requested after an hour and they responded promptly. The area was secured and nothing was removed. Police took over the investigation and started to conduct their own interviews. No one initially suspected that SP#1 could have something to do with the death of SP#2. No one noticed anything unusual with SP#1. The ACNO and Director of BHU further reported, that sometime close to dinner time SP#1 confided to SP#3 that he had done something really bad and that he killed somebody. SP#3 then told the MHT (Mental Health Technician (NS#9) and the Director of BHU what SP#1 had told her, that he had did something wrong and that he killed somebody. Interview via phone on 7/3/2014 at 11:05 am, (Nurse Sample) NS#7 stated that she was sitting at the corner of the nurse's station and behind her was the room for SP#2. The distance could not have been more than 10 feet. The room door was open. NS#7 stated that she could have easily heard something if they were fighting or struggling inside the room, but she did not hear anything. NS#7 further stated that she knew SP#2 was in the room but I didn't actually check at 3:15 PM. On 7/3/2014 at 12 noon the Mental Health Technician (MHT) (NS#9) who was on duty on 6/26/2014 stated that it was a busy day and she took a late lunch break around 3PM. She was giving care to a patient in the adjacent room and SP#2 was visible from where she was, and that she even spoke with SP #2 right before she clocked out for lunch break around 3 PM. She reports, SP#2 was in the room lying in bed talking to himself. NS#9 stated that she failed to record the rounding at 3:00 pm since she was leaving already. NS#9 also stated that there was nothing suspicious about the actions of SP#1. 2. Clinical record review showed that SP #1 arrived at the (Emergency Department) ED at 04:46 am on 06/26/2014 after being baker acted by the police department. The local police Baker Act report titled Report of Law Enforcement Officer Initiating Involuntary Examination noted that there is substantial likelihood that without care and treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behavior. The Police noted that they were dispatched to an apartment building who reported an unwanted person wandering around. When the police tried to talk to SP#1, he started walking into traffic but they were able to stop the patient. SP#1 stated to police that he was seeing and hearing things and he had a date on the 13th floor of the apartment. Security at the apartment advised police that there was no 13th floor and that SP#1 was also asked to leave the premises the previous day as well. At 05:30 am on 06/26/2014, an emergency department assessment was completed on SP #1, and a suicide screening was done. His presenting signs included hallucinations. The patient was placed near security, with a sitter, and in a psychiatric safe room while in the ED. He was medically cleared on 06/26/2014 to go to the facility's psychiatric unit for a psychiatric evaluation. The emergency admission orders on 06/26/2014 at 07:30 am, document SP #1 condition as guarded. He was admitted to the general psychiatric floor (room 412-1) with a diagnosis of psychosis. On 06/26/2014 at 10:38 am, the nursing admission note document, SP #1 was admitted to the floor at 10:15 am under Baker Act with delusional thoughts, bizarre behavior, and suicide gesture. The patient was admitted in the same room as SP #2. On 06/26/2014 at 13:12 PM, Sampled Patient #1's Behavioral Health Assessment showed: SP#1 was dirty, and had a disheveled appearance. The patient was easily distractible, suspicious and grandiose. Patient was Baker Acted by police. Patient is delusional, guarded, and suspicious. Alerts: Self Harm Potential. SP #1's complaint/arrest affidavit dated June 27, 2014, documented that the witness (named stated that the def. (defendant) told her that he had done something wrong. She noticed that he was trying to clean what appeared to be blood off of his fingers with napkins. The report further stated that on Thursday, June 26, 2014, the above named def. (defendant) committed the following violation of law on the 26th day of June 2014 at 3:00 pm. The police report also documented that SP#1 was interviewed by the police and he (SP#1) admitted to killing SP#2 by strangling SP#2 with his hands and a bed sheet. On 06/27/2014 at 5:03 pm the discharge instruction showed that the patient is being transferred to another facility (police department). The Discharge summary dated 07/03/2014 further noted that SP#1 had prior psychiatric admissions, and that he was baker acted due to bizarre behaviors. Review of the policy, Psychiatric Patient Neglect and Abuse, (revised 2/2010 and reviewed on 06/2012) showed that abuse is mistreatment, physical, psychological or civil. The policy does not address procedures for prevention of abuse.
Based on interview and record review the facility failed to meet the Condition of Participation of Nursing Services as evidenced by the failure to ensure that the patient was monitored and supervised in 2 ( SP#1 and SP#2) of 10 Sampled Patients. (Refer to A-395, and A-145)
Based on facility and medical record review, and interview, the facility failed to ensure that the patient was adequately supervised and nursing care was adequately evaluated for 2 (SP#1 and SP#2) of 10 Sampled Patients. Findings Include: 1. Sampled Patient #2 medical record showed he was Baker Acted on 06/05/2014 with bizarre behavior. According to the discharge summary dated 07/01/2014, the patient was seen and evaluated, was grossly psychotic, and internally preoccupied. There was no interactions with peers. The summary further stated that on 06/23/2014, the patient reported feeling better, psychosis was less intrusive, more interactive, no depressive symptoms and no side effects to medications. According to the Behavioral Health Services 24 hour Intensive Monitoring Log, the patient was on Q (every) 15 minutes observation rounding as ordered since admission on 06/05/2014. On 06/26/2014 there was no documentation to show that SP#2 was observed from 2:45pm to 3:35pm (approximately 50 minutes during the time of the emergency incident). On June 26, 2014 the physician note documented that SP# 2 was found on the floor by the RN (Registered Nurse). A Code Blue was called (at 3:38 PM), and SP #2 was in cardio-pulmonary arrest. Initial rhythm was asystole (no rhythm, no pulse). The RN found the patient (SP#2) on the floor with the bed sheet around his neck. The patient's face and upper neck were swollen and cyanotic. Epistaxis (nose bleed) was evident. Patient was unresponsive, cold, and pulseless. CPR (Cardio Pulmonary Resuscitation) was initiated. All attempts at resuscitation were unsuccessful. On July 2, 2014 at 10:30 AM during interview, the ACNO (Assistant Chief Nursing Officer) and the Director of BHU (Behavioral Health Unit) it was stated that SP#1 was admitted around 10:00 AM on June 26, 2014 and was placed in the same room with SP#2 who was later found on the floor next to his bed by the housekeeper around 3:35 PM, while making a final round prior to the end of the shift. The nurse (NS#7) on duty was notified and found SP#2 unresponsive. A Code Blue was called with prompt response and ACLS (Advanced Cardiac Life Support) protocol was followed but was unsuccessful. SP#1 was found in the bathroom taking a shower and was escorted out to the next room. The staff originally thought SP #2 injuries were self-inflicted due to the sheet around SP #2's neck and was not tied to anything. Everyone was interviewed but management couldn't determine how the incident could have happened. Police assistance was eventually requested after an hour and they responded promptly. The area was secured and nothing was removed. Police took over the investigation and started to conduct their own interviews. No one initially suspected that SP#1 could have something to do with the death of SP#2. No one noticed anything unusual with SP#1. The ACNO and Director of BHU further reported, that sometime close to dinner time SP#1 confided to SP#3 that he had done something really bad and that he killed somebody. SP#3 then told the MHT (Mental Health Technician (NS#9) and the Director of BHU what SP#1 had told her, that he had did something wrong and that he killed somebody. Interview via phone on 7/3/2014 at 11:05 am, (Nurse Sample) NS#7 stated that she was sitting at the corner of the nurse's station and behind her was the room for SP#2. The distance could not have been more than 10 feet. The room door was open. NS#7 stated that she could have easily heard something if they were fighting or struggling inside the room, but she did not hear anything. NS#7 further stated that she knew SP#2 was in the room but I didn't actually check at 3:15 PM. On 7/3/2014 at 12 noon the Mental Health Technician (MHT) (NS#9) who was on duty on 6/26/2014 stated that it was a busy day and she took a late lunch break around 3PM. She was giving care to a patient in the adjacent room and SP#2 was visible from where she was, and that she even spoke with SP #2 right before she clocked out for lunch break around 3 PM. She reports, SP#2 was in the room lying in bed talking to himself. NS#9 stated that she failed to record the rounding at 3:00 pm since she was leaving already. NS#9 also stated that there was nothing suspicious about the actions of SP#1. 2. Clinical record review showed that SP #1 arrived at the (Emergency Department) ED at 04:46 am on 06/26/2014 after being baker acted by the police department. The local police Baker Act report titled Report of Law Enforcement Officer Initiating Involuntary Examination noted that there is substantial likelihood that without care and treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behavior. The Police noted that they were dispatched to an apartment building who reported an unwanted person wandering around. When the police tried to talk to SP#1, he started walking into traffic but they were able to stop the patient. SP#1 stated to police that he was seeing and hearing things and he had a date on the 13th floor of the apartment. Security at the apartment advised police that there was no 13th floor and that SP#1 was also asked to leave the premises the previous day as well. At 05:30 am on 06/26/2014, an emergency department assessment was completed on SP #1, and a suicide screening was done. His presenting signs included hallucinations. The patient was placed near security, with a sitter, and in a psychiatric safe room while in the ED. He was medically cleared on 06/26/2014 to go to the facility's psychiatric unit for a psychiatric evaluation. The emergency admission orders on 06/26/2014 at 07:30 am, document SP #1 condition as guarded. He was admitted to the general psychiatric floor (room 412-1) with a diagnosis of psychosis. On 06/26/2014 at 10:38 am, the nursing admission note document, SP #1 was admitted to the floor at 10:15 am under Baker Act with delusional thoughts, bizarre behavior, and suicide gesture. The patient was admitted in the same room as SP #2. On 06/26/2014 at 13:12 PM, Sampled Patient #1's Behavioral Health Assessment showed: SP#1 was dirty, and had a disheveled appearance. The patient was easily distractible, suspicious and grandiose. Patient was Baker Acted by police. Patient is delusional, guarded, and suspicious. Alerts: Self Harm Potential. SP #1's complaint/arrest affidavit dated June 27, 2014, documented that the witness (named stated that the def. (defendant) told her that he had done something wrong. She noticed that he was trying to clean what appeared to be blood off of his fingers with napkins. The report further stated that on Thursday, June 26, 2014, the above named def. (defendant) committed the following violation of law on the 26th day of June 2014 at 3:00 pm. The police report also documented that SP#1 was interviewed by the police and he (SP#1) admitted to killing SP#2 by strangling SP#2 with his hands and a bed sheet. On 06/27/2014 at 5:03 pm the discharge instruction showed that the patient is being transferred to another facility (police department). The Discharge summary dated 07/03/2014 further noted that SP#1 had prior psychiatric admissions, and that he was baker acted due to bizarre behaviors. 3. Review of the policy,Suicide, Elopement and Assaultive Precaution, (last review date of 06/12) showed that all patients will be evaluated for the level of observation required to insure patient safety. This will be done each shift and if the patient behavior indicates a change in observation level the nursing staff will contact the attending physician or their designee to discuss recommended changes. The policy further noted that when a patient verbalizes increased feelings or threats of wanting to harm themselves or others, staff will notify physician to discuss any increased levels of observation, such as Line of Sight or a 1:1 sitter. The policy further noted that Q (every) 15 minutes checks are required as a minimal level of observation for all patients. A patient's whereabouts through direct visual contact is documented every 15 minutes on the 24 hour Intensive monitoring log. Review of the Suicide Prevention Plan policy (last reviewed 05/2014) revealed that all patients presenting with any behaviors that may place the patient at risk for suicide will be screened. Examples of screening include: psychotic episode, and injury consistent with attempt to harm one ' s self. The patients who are screened/ assessed to be at risk for suicidality will be placed on patient observation and monitoring as assigned by the RN or assigned LIP assessment is completed. Level one (every 15 minutes monitoring (standard precautions): staff visually observes the patient at least every 15 minutes, verifies their well-being, and ensures that they are safe both physically and mentally. Patients who have displayed any self-injurious behaviors in the last 12 hours are noted under Level 3 = 1:1 (one to one) monitoring and observation. The patient is never to be out of arms reach of the assigned and dedicated staff member. These policies/procedures were not followed when SP #1 was admitted to the general psychiatric unit, when less than 12 hours earlier, on June 26, 2014 at 4:10 am, the Report of Law Enforcement Officer Initiating Involuntary Examination, noted that there is substantial likelihood that without care and treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behavior. When police tried to talk to SP#1 he started walking into traffic but they were able to stop the patient. These policies/procedures were not followed immediately after SP#1 verbalized that he had done something wrong. Review of sampled patient # 1 Behavioral Health Services: 24 hours Intensive Monitoring Log dated 06/26/2014 at 4:00 pm after the incident was reported, revealed that the patient continued on every 15 minute precaution checks until 06/27/2014. The patient was noted in the in the hall and in the patient dining room during the evening of 06/26/2014. The patient was not placed on 1:1 observation until 06/27/2014. This allowed the potential for other patients to be harmed by SP #1.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to prevent the worsening of a stage I pressure ulcer in one sampled patient (SP #1) of 11 sampled patients . The findings include: Review of the SP #1 Emergency Department triage documentation on 01/16/2014 at 15:41 pm, revealed, that SP #1 was sent from a skilled facility for syncopal episode. The patient was noted to be awake, alert, with a history of dementia. SP#1 was admitted to the facility on [DATE] for syncope and subarachnoid bleed. The admission assessment nursing notes dated 01/16/2014 at 22:51 pm revealed a stage I pressure ulcer to the sacrum area. Nursing Assessments from 01/19/14 at 8:00 AM to 01/22/14 at 8:00 AM showed that the patient had a stage 1 pressure ulcer to the sacrum. The Braden Pressure Ulcer Risk Assessment skin score was reassessed on 01/20/2014, the risk decreased from 15 to 11, and the risk level changed from low to high. Review of the Nutrition Notes dated 01/28/14 at 12:38 PM noted that there was an Unstageable and stage 1 wounds per chart. The nursing notes dated 01/29/14 at 2:11 PM reported that there was a picture of SP #1 coccyx ulcer and that a copy was sent in the patient's medical record with the discharge information, and that a dressing to the coccyx for stage I ulcer was changed. Review of the Photographic Wound Documentation (picture) dated 01/29/2014 revealed a reddened area, with open areas (skin loss), and with darken areas to the coccyx/buttocks area. Review of the nursing notes in the hospital record, and the discharge summary revealed that there is no assessments and documentation of any treatments of SP #1 sacral pressure ulcer and of the reddened area, with open areas (skin loss) to the coccyx/buttocks with darken areas to the coccyx/buttocks area. Further review of the patient's medical record did not show that a consult for wound care was completed and that further treatment suggestions were provided. Review of the medical record from the Skilled Nursing Facility that SP #1 was discharge/transferred to, also revealed that on 01/29/2014, the SP #1 was admitted with an open wound to the sacral area. The record further noted that the stage of the sacral pressure ulcer as unstageable, and the cm (centimeters) length 8.5 cm X width 8.5 cm X depth 0.2 cm, with 50% granular, and 50% necrotic. The pressure ulcer was also noted to have a moderate amount of sero-sanguineous drainage. On 08/21/14 at 5:14 PM, the Risk Manager Coordinator stated that the SP#1 sacral wound was not caused by pressure, but from incontinence.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record and policy review, the facility failed to ensure that the medications (Precedex and Haldol) were given as ordered in one (Sampled Patient (SP) #1) of 11 sampled patients. The findings include: Review of the facility's policy, Medication Use-Process,(reviewed 09/2013) has documented, the nurse will follow the 7 rights for medication administration [right patient, right route, right drug, right amount, right time, right documentation, and the right to refuse treatment]. 1. Review of SP#1 medical records showed that on 01/16/14 at 3:32 PM, the patient was received in the (ED) Emergency Department. Nurse ' s Rapid Initial Assessment on 01/16/14 at 3:41 PM stated, sent here for syncopal episode, per facility out for 10-15 min (minutes). Awake, alert, hx (history of) dementia pt trying to climb out of bed. The Physician Orders dated 01/17/2014 showed Precedex intravenous (IV) 50 ML (milliliter(s) to titrate with a loading dose of 0.1 mcg/kg (micrograms/ per kilograms /per hour). over 10 minutes ( optional and not recommended in hypotension). An Initial rate of 0.2 mcg/kg/hr, and then titrate by 0.1 mcg/ kg/ hr every 15 minutes. Maximum rate of 0.7 mcg/kg/hr every 15 minutes. Review of the patient's MAR ( Medication Administration Record) dated 01/16/2014 to 01/17/2014 showed that Precedex 200 mcg/50 ml in NS (normal saline) to titrate IV as directed. The comments noted :4 mcg/ml, do not start if HR (Heart Rate) less than 50 and SBP ( systole blood pressure) less than 90. The order 01/17/2014 at 01/17/2014 showed to titrate the Precedex by 0.1 mcg/kg/hr every 15 minutes to a maximum rate of 0.7 mcg/kg/hr (10.5 ml/hr), and to wean, decreasing by 0.1 mcg/kg/hr every 15 minutes, and that abrupt discontinuation should be avoided. Review of MAR showed that Precedex was given on 01/17/14 at 2:17 AM. Review of 24 Hour Critical Care Flow sheet showed that on 01/17/14 between 1:00 AM and 3:00 AM the patient received 16 ml of Precedex. Review of the 24 hour Critical Care Flow Sheet (Fluid Balance Sheet) dated 01/17/2014 showed that 8 ml of precedex was given at 01:00 and again at 02:00 am. The ( Vital signs on 01/17/14 at 3:08 AM showed the patient ' s BP was 83/38 mmHg and pulse was 59BPM. Review of the MAR dated 01/17/2014, and the 24 hour Critical Care Flow Sheet dated 01/17/2014 revealed that there was no documentation showing that the Precedex was weaned, decreasing by 0.1 mcg/kg/hr every 15 minutes, avoiding an abrupt discontinuation. Further review of the 24 hour Critical Care Flow Sheet dated 01/17/2014 revealed that the precedex was restarted again at 08:00 am until 01/18/2014 at 05:00am. Review of SP#1 vital signs revealed that the patient heart rate decreased to as low as 40 during administration. There is no documentation that the physician was notified and the precedex was discontinued until 5:00 am on 01/18/2014. On 08/20/14 at 11:00 AM, the Director of Intensive Care Unit (ICU) stated that Precedex is a continuous drip that is given up to 24 hours. If the patient has agitation, precedex produces a calming effect. The heart rate can go down. On 08/21/14 at 1:43 PM, the Director of ICU stated that, if the patient is bradycardic then we turn Precedex off. On 08/21/14 at 2:52Pm, Staff F, Registered Nurse (RN), stated that, we use precedex when patients are agitated and uncomfortable. We monitor heart rate, blood pressure, sedation and respiratory rate. We want to keep the heart rate above 60BPM and SBP above 90 to 100. If any of these are below, we stop the drip and call the doctor. We call the doctor if vital signs are jeopardized. 2. SP#1 was admitted to the facility on [DATE] with exacerbation of dementia with violent behavior. Physician Order on 01/12/14 at 10:07 AM showed that Haldol 2 mg IV (intravenous) HS PRN (at sleep as needed for moderate agitation) was ordered. Review of Medication Administration Record (MAR) showed that on 01/12/14 at 2:06 PM, 2 mg (milligrams) Haldol was given.
Based on interview, and record review, it was determined the facility is not in compliance with the medical screening examination requirement to determine if an emergent medical condition exist, the facility failed to provide the necessary stabilizing treatment and failed to ensure an appropriate transfer for 1 out of 22 Sampled Patients (SP), (SP# 1). The facility failed to be in compliance with the Emergency Medical Treatment and Labor Act requirements at 489.24.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, observation and interview the facility failed to ensure that an appropriate medical screening examination (MSE) is provided within the capability of the hospital's emergency department on 1 of 22 Sampled Patients (SP#1). Findings include: Review of the facility ' s Medical Screening Examination shows that an individual requesting medical examination or treatment through the Emergency Department of this hospital has a right to: 1). A medical screening examination, within the capabilities of the Emergency Department and the ancillary services commonly available to the Emergency Department, to determine if an emergency medical condition exist. 2). Medical treatment as necessary to stabilize an emergency medical condition. The Central Log revealed that sampled patient #1 came to the emergency room at hospital #1 on 04/29/2014 at 23:37 pm (first visit). The patient presented with Altered Mental Status and had ingested 24 beers. The patient was seen by the physician and labs were drawn and the serum alcohol level was 293 mg/dl. The patient was ordered sodium chloride and thiamine 100 mg of which he refused. According to the notes the patient was discharged home unaccompanied and walking. Review of the reference provided by the facility, Serum ethanol level of greater than > 300 mg/dl can be potentially fatal. Record Review of sampled patient #1 second visit to hospital #1 reveal that the emergency department (ED#1) Central Log noted that SP#1 arrived at the facility on 04/30/14 at 22:19 pm. The ED#1 log disposition showed that on 04/30/14 at 22:20 pm, SP#1 LPMSE (left prior to Medical Screening Examination). Sample Patient #1 Note showed that he was brought in by two Police officers on 04/30/2014 around 22:19 pm, and a Rapid Initial Assessment/Triage was conducted by the Charge Nurse around 22:20 pm, and it was noted that the patient was brought in by the police for ingestion of ETOH (Ethyl Alcohol) and was on legal hold. Further record review showed a late entry by the Charge Nurse on 05/01/14 at 06:14 am for an incident that occurred at 22:20 pm the night before 04/30/2014 stating, apparently this patient was charged with trespassing the night before per Nursing Supervisor, and confirmed with security and ARNP (Advanced Registered Nurse Practitioner). Police took patient away. Further review of SP#1 ' s reveal the information was entered in the ED Central Log, and an Initial Rapid Assessment was done. There was no evidence that a Medical Screening Examination was provided to SP#1. The ED#1 Nursing Director also stated that all of the ED#1's Staff knew that our policy is not to refuse services to anyone who comes, or brought to the emergency room requesting to be seen regardless of their status or ability to pay. Record review of SP#1's visit at Hospital #2 showed on the Baker Act form Report of Law Enforcement Officer Initiating Involuntary Examination dated 04/30/2014 at 10:00 PM showed that SP#1 called the police because he needed to see a Doctor. Upon making contact with SP#1, he (SP#1) advised he was hearing voices to kill black people and then kill himself. SP#1 then said, If I don't see a Doctor I have to do it. SP#1 was subsequently transported to hospital # 2 and Baker Acted. According to SP #1 admission information, he arrived at hospital #2 at 10: 21 pm. The emergency department psychiatric evaluation states that he is depressed, with suicidal/homicidal ideation. The serum (toxicology) toxi -screen ethanol level was 238.0 mg/DL. He was admitted to the psychiatric unit, treated, and discharged on [DATE]. Interview with the Emergency Department (ED #1's) Nursing Director on June 30,2014 around 11 AM confirmed that SP#1 was brought by two Police#2 to the facility ' s ED on 04/30/2014 around 22:19 pm via the ambulance entrance. The ED#1 Nursing Director stated that there was a lot of confusion that evening. The ED#1 Charge Nurse at that time didn't know SP#1, and didn't know what happened the night before. The ED#1 Charge Nurse received the patient, entered patient information in the ED#1 Central Log, and did a Rapid Initial Assessment while the Nursing Supervisor and the Security Officer who happened to be in the ED were communicating with the police #2. The Nursing Supervisor and the Security Officer apparently recognized SP#1 as the same person who was seen in the ED#1 the night before (04/29/2014) for alcohol intoxication, and was seen, examined, stabilized, and then discharged by the ED#1 physician. Thereafter, Police #1 placed SP#1under police custody for disorderly conduct, and trespassing for refusing to leave the hospital property. The Nursing Supervisor and the security officer were trying to explain the situation with Police#2 who had no idea what happened the previous night since Police#1 was involved. The ED#1 Director stated that the incident happened so fast that by the time the ED#1 Charge Nurse knew it, SP#1 was taken away by the Police#2 and brought to ED#2 at Hospital #2. The police made a quick decision to take the patient to another facility and was not aware of the consequences to our facility. Interview with the ACNO and the Director of ED on 07/01/2014 around 2PM revealed that corrective measures as presented on the Plan of Correction are in place and ongoing. The following corrective measures began and are ongoing: Face to face training on EMTALA/Emergency Access regulations for all active ED Staff took place on June 2-5, 2014. Staff who were on vacation or were on leave will be re-educated upon return. Continue with daily huddles as a constant reinforcement Improve communication with nearby Police Departments, and Fire Rescue Squad regarding taking patients away when patients are already in the facility ' s ED or property. Educate security officers on May 9, 2014, and nursing supervisors on EMTALA/Emergency Access regulations, and to refer to the ED Nurse the responsibility to initiate ED services to patients who come or brought to the ED requesting to be seen. Clarify Trespassing policy and educate appropriate staff. Disciplinary measures on involved staff Quality Assurance monitoring program is ongoing. The facility self-reported a possible violation of the EMTALA (Emergency Medical Treatment & Labor Act) law on May 05, 2014.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, review of policy and procedure, and medical record review, the facility failed to provide the necessary stabilizing treatment that was within the capability and capacity of the hospitals Dedicated Emergency Department (DED) for 1 out of 22 Sample Patients (SP) (SP#1) See tag 2406 for additional information on SP #1. Findings include: Review of the facility ' s Medical Screening Examination shows that an individual requesting medical examination or treatment through the Emergency Department of this hospital has a right to: 1). A medical screening examination, within the capabilities of the Emergency Department and the ancillary services commonly available to the Emergency Department, to determine if an emergency medical condition exist. 2). Medical treatment as necessary to stabilize an emergency medical condition. The Central Log of the first visit revealed that sampled patient #1 came to the emergency room at hospital #1 on 04/29/2014 at 23:37 pm . The patient presented with Altered Mental Status and had ingested 24 beers. The patient was seen by the physician and labs were drawn and the serum alcohol level was 293 mg/dl. The patient was ordered sodium chloride and thiamine 100 mg of which he refused. According to the notes the patient was discharged home unaccompanied and walking. Review of the reference provided by the facility, Serum ethanol level of greater than > 300 mg/dl can be potentially fatal. Record Review of sampled patient #1 second visit to hospital #1 reveal that the emergency department (ED#1) Central Log noted that SP#1 arrived at the facility on 04/30/14 at 22:19 pm. The ED#1 log disposition showed that on 04/30/14 at 22:20 pm, SP#1 LPMSE (left prior to Medical Screening Examination). Sample Patient #1 ED Notes showed that he was brought in by two Police officers on 04/30/2014 around 22:19 pm, and a Rapid Initial Assessment/Triage was conducted by the Charge Nurse around 22:20 pm, and it was noted that the patient was brought in by the police for ingestion of ETOH (Ethyl Alcohol) and was on legal hold. Further record review showed a late entry by the Charge Nurse on 05/01/14 at 06:14 am for an incident that occurred at 22:20 pm the night before 04/30/2014 stating, apparently this patient was charged with trespassing the night before per Nursing Supervisor, and confirmed with security and ARNP (Advanced Registered Nurse Practitioner). Police took patient away. Further review of SP#1 ' s reveal the information was entered in the ED Central Log, and an Initial Rapid Assessment was done. There was no evidence that a Medical Screening Examination was provided to SP#1 nor was the emergent medical condition stablized. Record review of SP#1's visit at Hospital #2 showed on the Baker Act form Report of Law Enforcement Officer Initiating Involuntary Examination dated 04/30/2014 at 10:00 PM showed that SP#1 called the police because he needed to see a Doctor. Upon making contact with SP#1, he (SP#1) advised he was hearing voices to kill black people and then kill himself. SP#1 then said, if I don't see a Doctor I have to do it. SP#1 was subsequently transported to hospital # 2 and Baker Acted. According to SP #1 admission information, he arrived at hospital #2 at 10: 21 pm. The emergency department psychiatric evaluation states that he is depressed, with suicidal/homicidal ideation. The serum (toxicology) toxi -screen ethanol level was 238.0 mg/DL. He was admitted to the psychiatric unit, treated, and discharged on [DATE]. The ED#1 Nursing Director also stated that all of the ED#1's Staff knew that our policy is not to refuse services to anyone who comes, or brought to the emergency room requesting to be seen regardless of their status or ability to pay.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record the facility failed to ensure that the nursing care and interventions were appropriate to meet the needs in 1 of 9 sampled patients (SP#4). Findings include: Clinical record review of SP#4 conducted on 11-06-2013 revealed an admission date of [DATE] due to a PICC (Peripherally Inserted Central Catheter) Dislodgement and the patient has a pertinent medical history for COPD (Chronic Obstructive Pulmonary Disease). Review of SP#4 record conducted on 01-02-14 showed an MD (physician's) order dated 10-04-13 at 19:29 pm which has that the initial order for the medical surgical unit. It was changed on 10-04-13 at 20:38 pm to cardiac monitor. Review of the telemetry alarm record showed that the patient was placed on telemetry box on 10-05-13 at 23:43 pm. Further review of the 8 north telemetry Log dated 10/07/2013 on the 20:00 pm-07:00 am shift revealed that SP#4 was discharged from the (telemetry box) monitor at 20:00 pm. Review of the Nurses notes dated 10/07/2013 at 19: 40 pm the nurse has documented that the Doctor (named) aware of patient HGB (hemoglobin) being 7.7 and HCT (hematocrit) 24.8. But patient is still to be discharged . Review of SP#4 adult Shift Assessment dated 10/07/2013 at 20:00 pm also revealed that in the section for the respiratory assessment has dyspnea (the sensation of difficult or uncomfortable breathing) on exertion. The next entry on the nursing notes at 10/08/2013 at 00:01 am has, found patient unresponsive, sitting on the toilet. Code blue called. Wife at bedside. Interview conducted on 01-03-14 at 4:20pm with RN#3 she stated that the vital signs were taken by the PCA (patient care technician) in her presence and patient had oxygen per nasal cannula. She stated Then I did the discharge papers and after that I went back to let the patient sign the papers but patient was in the bathroom (BR) and so I said, OK, I ' ll give you some privacy and I ' ll come back. After 15 minutes I came back to the room and knocked at the BR door and I said Are you OK (name of SP#4) and he said he was thinking of taking a shower. I explained that he has a dressing on his foot and he could slip with the dressing on and I could not duplicate the dressing done by the podiatrist and he said, OK, I ' ll just freshen up . At the same time I had another admission. I was almost finished when I got called that my patient was unresponsive and code blue was called. He did not sound like he was short of breath when he was talking from inside the Bathroom. Earlier, patient refused respiratory treatment but I insisted and patient took it. Also, earlier I saw the patient sitting at the edge of the bed short of breath and when asked he just went to the Bathroom and I instructed patient to use oxygen and emphasized that it has extension and could reach the BR. Interview with the ACNO (Assistant Chief Nursing Officer) conducted on 01-02-14 at 09:30 am revealed that he also reviewed SP#4 medical records. He stated that this is an isolated case as majority of the patients are discharged within 60 minutes turn around or at reasonable amount of time. That the patients once order a discharge is received that they want to go home right away. But in this case, the wife requested for patient to stay for late pick-up because of her work schedule as she works till 11 pm. Further interview with the ACNO conducted on 01-02-14 revealed that regarding the policy and procedure regarding telemetry removal, there was no change but will continue to re-evaluate based on patient ' s safety. Review of the policy and procedure title: Telemetry transmitter unit count showed: Procedure#3 Once a discharge order is written, transmitter must be removed by the nurse and brought to the monitor technician immediately.
Based on reviews of medical records, incident report, policy and procedure, and Emergency Director report, and interviews, the facility failed to ensure that an appropriate medical screening examination within the capability of the hospital's Emergency Department was provided in 1 out of 22 Sample Patients (SP) (SP#1). Refer to findings at Tag A- 2406. Based on reviews incident report, policy and procedure, Emergency Director report, and interviews, the facility failed to ensure that an individual with an Emergency Medical Condition (EMC) was provided with the necessary stabilizing treatment as required for 1 out of 22 Sample Patients (SP) (SP#1). Refer to findings at Tag A- 2407. Based on reviews of policy and procedure, incident report, and Emergency Director report and interviews, the facility failed to ensure that an appropriate transfer was provided in 1 out of 22 Sample Patients (SP) (SP#1). Refer to findings at Tag A- 2409.
Based on record review and interview, the facility failed to document and maintain medical and other records related to the individuals transferred to and from the hospital for a period of 5 years from the date of the transfer in 1 out of 22 Sampled Patients (SP) (SP#1). The findings include: Review of the Florida Department of Children ' s and Families (DCF) Incident Reporting and Analysis System (Incident Report # 2013-PDSA- ) conducted on 06-18-13 revealed the name of the sample patient (SP) #1 and the brief description of the incident. It showed: Child (SP#1) locked himself in his closet, refused to come out and was cutting himself. Mother called Care Coordinator, who was already en route to home. 911 was called. Child resisted police intervention and was tazered. The cuts on his arms, up to elbows were bleeding heavily. He was transported to this facility (#1) under Baker Act but was not held there since bleeding had been abated by EMS (Emergency Medical Support) and that facility doesn ' t ' treat adolescents. He was taken to Facility #2, who had no beds, then to Facility #3 . Review conducted on 06-18-13 of the ER Director report dated March 28, 2013 regarding DCF request for information confirmed above findings that the patient (SP#1) was brought to Facility #1 ER by police under Baker Act. The report showed: That when the police arrived with the patient (SP#1) and approached the Charge Nurse (CN) desk, someone (unclear who) made a statement something similar to gosh this patient is going to be in the ER all night. At that point the police officer inquired why and was told that we are not a pediatric facility and we would have to transfer the patient out to a pediatric baker act receiving facility. The police officer then said that he would take the patient to Facility #2. The Charge Nurse (CN) then stated we are not refusing the patient, we can transfer him. Based on my report, the police officer said he would just take the patient to Facility #2 since it was nearby and it was the more appropriate facility. A few minutes after the police officer left with the patient (SP#1), the psychiatric intake nurse called the Facility #2 to notify them of what just transpired and asked if they would like us to attempt to retrieve the patient. Their response was that it was fine and they would take care of it. The report further confirmed the findings that the ER should have registered the patient into our system to generate a medical record where we could have documented the occurrences noted above. The report also showed that the CN was asked of the patient ' s name and anything that could be entered into the system but there was none. Review of the Electronic Central log of Facility #1 on date of the incident (02-26-2013) conducted on 06-18-2013 showed no documented name of SP#1 or any information about the patient (SP#1) that was brought to ER by the police under Baker Act. Interview via phone with the Charge Nurse (CN) conducted on 06-18-13 at 10:30 am confirmed above findings. She stated that she worked that night of 02/26/13 at 7pm to 7am when the police came with a minor baker act patient to ER (Facility #1). She stated that, The first thing the police officer asked was if the facility #1 was taking minor baker act patient. The CN responded yes, but we are not admitting but we take them, stabilize and transfer them out to whichever facility is available and can admit minor baker act patient. Then the police said right away, Ok I ' ll take him to facility #2. The CN said, No we are not refusing, we are taking patient but we don ' t admit them here. The police said, No, I'll take him and was leaving and I said wait let me have the psychiatric intake nurse (PIN) talk to you. The CN called the PIN. The PIN talked to the police but still insisted to take the minor baker act patient to facility #2. So, the PIN asked the police Are you willing to take him? and police said, yes, that ' s why I ' m taking him to facility #2. So they left then I called the supervisor right away and told her what happened and police did not even give me the chance to recept (enter in the computer) the patient and did not even know the name and only found out from facility #2. The supervisor asked the PIN to call facility #2 and find out about the baker act minor patient and she did. The PIN called facility #2 and the nurse said, don ' t worry because we ' ll take care of him. When the CN was asked further about the patient ' s physical condition, the CN stated that the patient (SP#1) was very calm and that she did not notice anything unusual. She also stated that she already received the EMTALA training and she should have recept the patient and a medical record was done and that the patient should have the medical screening by the physician. She also stated that she called the ER Director in the morning before she left and reported to her the incident. Interview via phone with the Psychiatric Intake Nurse (PIN) conducted on 06-19-13 at 3:10 pm confirmed above findings that she was called at the desk by the CN on the night of 06-26-13. That it was a rapid sequence of event that they never had the chance to assess the patient. That after the police said that he would take the patient to facility #2 that she asked, Are you willing to do that? and the police said, yes . The PIN further stated that, it was so fast and the intent was not to avoid to take care of the child but the intent was if possible to get the child get care faster but not for any negative reason. She also stated that this was an opportunity to review and learn about EMTALA protocol to increase the safety element in her practice. When asked about the patient ' s condition, she stated that the patient was not in any distress and that the patient was calm and relaxed. Interview via phone with the Medical Director of ER conducted on 06-20-13 at 11:20 am confirmed above findings.
Based on record review and interview, the facility failed to maintain a central log on each individual who comes to the Emergency Department in 1 out of 22 Sample Patients (SP) (SP#1). The findings include: Review of the Florida Department of Children ' s and Families (DCF) Incident Reporting and Analysis System (Incident Report # 2013-PDSA- ) conducted on 06-18-13 revealed the name of the sample patient (SP) #1 and the brief description of the incident. It showed: Child (SP#1) locked himself in his closet, refused to come out and was cutting himself. Mother called Care Coordinator, who was already en route to home. 911 was called. Child resisted police intervention and was tazered. The cuts on his arms, up to elbows were bleeding heavily. He was transported to this facility (#1) under Baker Act but was not held there since bleeding had been abated by EMS (Emergency Medical Support) and that facility doesn ' t treat adolescents. He was taken to Facility #2, who had no beds, then to Facility #3. Review conducted on 06-18-13 of the ER Director report dated March 28, 2013 regarding DCF request for information confirmed above findings that the patient (SP#1) was brought to Facility #1 ER by police under Baker Act. The report showed: That when the police arrived with the patient (SP#1) and approached the Charge Nurse (CN) desk, someone (unclear who) made a statement something similar to gosh this patient is going to be in the ER all night. At that point the police officer inquired why and was told that we are not a pediatric facility and we would have to transfer the patient out to a pediatric baker act receiving facility. The police officer then said that he would take the patient to Facility #2. The Charge Nurse (CN) then stated we are not refusing the patient, we can transfer him. Based on my report, the police officer said he would just take the patient to Facility #2 since it was nearby and it was more appropriate facility. A few minutes after the police officer left with the patient (SP#1), the psychiatric intake nurse called the Facility #2 to notify them of what just transpired and asked if they would like us to attempt to retrieve the patient. Their response was that it was fine and they would take care of it. The report further confirmed the findings that the ER should have registered the patient into our system to generate a medical record where we could have documented the occurrences noted above. The report also showed that the CN was asked of the patient ' s name and anything that could be entered into the system but there was none. Review of the Electronic Central log of Facility #1 on date of the incident (02-26-2013) conducted on 06-18-2013 showed no documented name of SP#1 or any information about the patient (SP#1) that was brought to ER by the police under Baker Act. Interview via phone with the Charge Nurse (CN) conducted on 06-18-13 at 10:30 am confirmed above findings. She stated that she worked that night of 02/26/13 at 7pm to 7am when the police came with a minor baker act patient to ER (Facility #1). She stated that, The first thing the police officer asked was if the facility #1 was taking minor baker act patient. The CN responded yes, but we are not admitting but we take them, stabilize and transfer them out to whichever facility is available and can admit minor baker act patient. Then the police said right away, Ok I ' ll take him to facility #2. The CN said, No we are not refusing, we are taking patient but we don ' t admit them here. The police said, No, I'll take him and was leaving and I said wait let me have the psychiatric intake nurse (PIN) talk to you. The CN called the PIN. The PIN talked to the police but still insisted to take the minor baker act patient to facility #2. So, the PIN asked the police Are you willing to take him? and police said, yes, that ' s why I ' m taking him to facility #2. So they left then I call the supervisor right away and told her what happened and police did not even gave me the chance to recept (enter in the computer) the patient and did not even know the name and only found out from facility #2. The supervisor asked the PIN to call facility #2 and find out about the baker act minor patient and she did. The PIN called facility #2 and the nurse said, don ' t worry because we ' ll take care of him. When the CN was asked further about the patient ' s physical condition, the CN stated that the patient (SP#1) was very calm and that she did not notice anything unusual. She also stated that she already received the EMTALA training and she should have recept the patient and a medical record was done and that the patient should have the medical screening by the physician. She also stated that she called the ER Director in the morning before she left and reported to her the incident. Interview via phone with the Psychiatric Intake Nurse (PIN) conducted on 06-19-13 at 3:10 pm confirmed above findings that she was called at the desk by the CN on the night of 06-26-13. That it was a rapid sequence of event that they never had the chance to assess the patient. That after the police said that he would take the patient to facility #2 that she asked, Are you willing to do that? and the police said, yes . The PIN further stated that, it was so fast and the intent was not to avoid to take care of the child but the intent was if possible to get the child get care faster but not for any negative reason. When asked about the patient ' s condition, she stated that the patient was not in any distress and that the patient was calm and relaxed. Review of the Facility #1 policy and procedure title: Florida EMTALA Central Log Policy confirmed above findings that the facility failed to follow its own policy and procedure regarding maintenance of Central Log for ER. The policy states: The hospital will maintain a Central Log, containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged . Interview with the Associate CNO, Risk Manager and Director of Behavioral Health Unit conducted on 06-19-2013 confirmed above findings that the facility did not follow its own policy and procedure regarding maintenance of Central Log for ER.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of medical records, incident report, policy and procedure, and Emergency Director report, and interviews, the facility failed to ensure that an appropriate medical screening examination within the capability of the hospital's Emergency Department was provided in 1 out of 22 Sample Patients (SP) (SP#1). The findings include: Review of the Florida Department of Children's and Families (DCF) Incident Reporting and Analysis System (Incident Report # 2013-PDSA- ) (incident date 2/26/2013/Time 7:30 P.M ) conducted on 06-18-13 revealed the name of the sample patient (SP) #1 and the brief description of the incident. It showed: Child (SP#1) locked himself in his closet, refused to come out and was cutting himself. Mother called Care Coordinator, who was already en route to home. 911 was called. Child resisted police intervention and was tazered. The cuts on his arms, up to elbows were bleeding heavily. He was transported to this facility (#1) under Baker Act but was not held there since bleeding had been abated by EMS (Emergency Medical Support) and that facility doesn't treat adolescents. He was taken to Facility #2, who had no beds, then to Facility #3. Review conducted on 06-18-13 of the emergency room (ER) Director report dated March 28, 2013 regarding DCF request for information confirmed above findings that the patient (SP#1) was brought to Facility #1 ER by police under Baker Act. The report showed: That when the police arrived with the patient (SP#1) and approached the Charge Nurse (CN) desk, someone (unclear who) made a statement something similar to gosh this patient is going to be in the ER all night. At that point the police officer inquired why and was told that we are not a pediatric facility and we would have to transfer the patient out to a pediatric baker act receiving facility. The police officer then said that he would take the patient to Facility #2. The Charge Nurse (CN) then stated, we are not refusing the patient, we can transfer him. Based on my report, the police officer said he would just take the patient to Facility #2 since it was nearby and it was a more appropriate facility. A few minutes after the police officer left with the patient (SP#1), the psychiatric intake nurse called the Facility #2 to notify them of what just transpired and asked if they would like us to attempt to retrieve the patient. Their response was that it was fine and they would take care of it. The report further confirmed the findings that, the ER should have registered the patient into our system to generate a medical record where we could have documented the occurrences noted above. The report also showed the CN was asked for the patient ' s name and anything that could be entered into the system, but there was no information. Interview via phone with the Charge Nurse (CN) conducted on 06-18-13 at 10:30 am confirmed the above findings. She stated, she worked the night of 02/26/13 at 7pm to 7am when the police came with a minor Baker Act patient to ER (Facility #1). She stated that, The first thing the police officer asked was if the facility #1 was taking minor Baker Act patients. The CN responded, yes, but we are not admitting, but we take them, stabilize and transfer them out to whichever facility is available and can admit minor Baker Act patients. Then the police said right away, Ok I'll take him to facility #2. The CN said, No we are not refusing, we are taking patients but we don ' t admit them here. The police said, No, I'll take him and was leaving and I said wait let me have the psychiatric intake nurse (PIN) talk to you. The CN called the PIN. The PIN talked to the police but still insisted to take the minor baker Act patient to facility #2. So, the PIN asked the police, Are you willing to take him? and police said, yes, that's why I'm taking him to facility #2. So they left, then I called the supervisor right away and told her what happened. The police did not give me the chance to recept (enter in the patient into the computer). They did not know the name of the patient and only found out from facility #2. The supervisor asked the PIN to call facility #2 and find out about the Baker Act minor patient and she did. The PIN called facility #2 and the nurse said, don't worry because we'll take care of him. When the CN was asked further about the patient's physical condition, the CN stated, the patient (SP#1) was very calm and that she did not notice anything unusual. She also stated, she already received the EMTALA training and she should have recept the patient, started a medical record and the patient should've had the medical screening by the physician. She also stated, she called the ER Director in the morning before she left and reported the incident. The medical record from facility #2 (an acute care hospital) was reviewed. The medical record revealed that on 2/26/2013 at 2051 (8:51 p.m.) a [AGE] year old (SP#1) arrived to the emergency department as a Psychiatric emergency. Review of the ED provider note revealed in part, Procedures: wounds cleansed and dressing with topical antibiotic provided ... Clinical impression: The primary encounter diagnosis was Suicide attempt and A diagnosis of Depression was also pertinent to this visit ... ED disposition: Pending admit to psychiatry unit... Condition: Serious. . . Admit 8:56 PM discussed ER (emergency room ) findings, diagnosis and treatment plan for admission for further evaluation and /or treatment ... Pt (patient) received by Aventura Police in Handcuffs and ankle cuffs. Pt appears anxious. States voices are coming back ...Pt arrived with police under a Baker Act after made several self-inflicted lac (lacerations) to L (left) forearm as a suicide attempts. Pt reported he hears voices and today they told him that his life was no long worth living, calling him insane and told him to hurt himself and others. .. pt medically cleared ... Pt received from Peds ED after being seen by an ED psych Liaison RN (Registered Nurse) ...An EKG (measures the electrical activity of your heart) was performed in the Peds ED showing NSR (Normal electrical conduction of the heart). Further record review revealed that SP #1 was appropriately transferred to a psychiatric hospital. Interview via phone with the Psychiatric Intake Nurse (PIN) conducted on 06-19-13 at 3:10 pm confirmed above findings, she was called at the desk by the CN on the night of 06-26-13. She reports, it was a rapid sequence of events and she never had the chance to assess the patient. She reports, after the police said, he would take the patient to facility #2, she asked, Are you willing to do that? The policeman said, yes. The PIN further stated that, it was so fast and the intent was not to avoid to take care of the child, but the intent was, if possible, to get the child care faster but not for any negative reason. Review of Facility #1 ' s policy and procedure title: Florida EMTALA - Medical Screening Examination and Stabilization Policy confirmed the above findings, the facility failed to provide SP#1 a medical screening examination and stabilization. The policy states: If an EMC (Emergency Medical Condition) is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility as defined by and required by EMTALA. Interview with the Associate Chief Nursing Officer (CNO), Risk Manager and Director of Behavioral Health Unit conducted on 06-19-2013 confirmed the above findings, the facility did not follow its own policy and procedure and failed to provide an appropriate medical screening examination.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of the incident report, policy and procedure, Emergency Director report, and interviews, the facility failed to ensure that an individual with an Emergency Medical Condition (EMC) was provided with the necessary stabilizing treatment as required for 1 out of 22 Sample Patients (SP) (SP#1). The findings are: Review of the Florida Department of Children's and Families (DCF) Incident Reporting and Analysis System (Incident Report # 2013-PDSA- ) (incident date 2/26/2013/Time 7:30 P.M ) conducted on 06-18-13 revealed the name of the sample patient (SP) #1 and the brief description of the incident. It showed: Child (SP#1) locked himself in his closet, refused to come out and was cutting himself. Mother called Care Coordinator, who was already en route to home. 911 was called. Child resisted police intervention and was tazered. The cuts on his arms, up to elbows were bleeding heavily. He was transported to this facility (#1) under Baker Act but was not held there since bleeding had been abated by EMS (Emergency Medical Support) and that facility doesn't treat adolescents. He was taken to Facility #2, who had no beds, then to Facility #3. Review conducted on 06-18-13 of the emergency room (ER) Director report dated March 28, 2013 regarding DCF request for information confirmed above findings that the patient (SP#1) was brought to Facility #1 ER by police under Baker Act. The report showed: That when the police arrived with the patient (SP#1) and approached the Charge Nurse (CN) desk, someone (unclear who) made a statement something similar to gosh this patient is going to be in the ER all night. At that point the police officer inquired why and was told that we are not a pediatric facility and we would have to transfer the patient out to a pediatric baker act receiving facility. The police officer then said that he would take the patient to Facility #2. The Charge Nurse (CN) then stated, we are not refusing the patient, we can transfer him. Based on my report, the police officer said he would just take the patient to Facility #2 since it was nearby and it was a more appropriate facility. A few minutes after the police officer left with the patient (SP#1), the psychiatric intake nurse called the Facility #2 to notify them of what just transpired and asked if they would like us to attempt to retrieve the patient. Their response was that it was fine and they would take care of it. The report further confirmed the findings that, the ER should have registered the patient into our system to generate a medical record where we could have documented the occurrences noted above. The report also showed the CN was asked for the patient ' s name and anything that could be entered into the system, but there was no information. Interview via phone with the Charge Nurse (CN) conducted on 06-18-13 at 10:30 am confirmed the above findings. She stated, she worked the night of 02/26/13 at 7pm to 7am when the police came with a minor Baker Act patient to ER (Facility #1). She stated that, The first thing the police officer asked was if the facility #1 was taking minor Baker Act patients. The CN responded, yes, but we are not admitting, but we take them, stabilize and transfer them out to whichever facility is available and can admit minor Baker Act patients. Then the police said right away, Ok I'll take him to facility #2. The CN said, No we are not refusing, we are taking patients but we don't admit them here. The police said, No, I'll take him and was leaving and I said wait let me have the psychiatric intake nurse (PIN) talk to you. The CN called the PIN. The PIN talked to the police but still insisted to take the minor baker Act patient to facility #2. So, the PIN asked the police, Are you willing to take him? and police said, yes, that's why I'm taking him to facility #2. So they left, then I called the supervisor right away and told her what happened. The police did not give me the chance to recept (enter in the patient into the computer). They did not know the name of the patient and only found out from facility #2. The supervisor asked the PIN to call facility #2 and find out about the Baker Act minor patient and she did. The PIN called facility #2 and the nurse said, don't worry because we'll take care of him. When the CN was asked further about the patient's physical condition, the CN stated, the patient (SP#1) was very calm and that she did not notice anything unusual. She also stated, she already received the EMTALA training and she should have recept the patient, started a medical record and the patient should've had the medical screening by the physician. She also stated, she called the ER Director in the morning before she left and reported the incident. Interview via phone with the Psychiatric Intake Nurse (PIN) conducted on 06-19-13 at 3:10 pm confirmed above findings, she was called at the desk by the CN on the night of 06-26-13. She reports, it was a rapid sequence of events and she never had the chance to assess the patient. She reports, after the police said, he would take the patient to facility #2, she asked, Are you willing to do that? The policeman said, yes. The PIN further stated that, it was so fast and the intent was not to avoid to take care of the child, but the intent was, if possible, to get the child care faster but not for any negative reason. The medical record from facility #2 (an acute care hospital) was reviewed. The medical record revealed that on 2/26/2013 at 2051 (8:51 p.m.) a [AGE] year old (SP#1) arrived to the emergency department as a Psychiatric emergency. Review of the ED provider note revealed in part, Procedures: wounds cleansed and dressing with topical antibiotic provided ... Clinical impression: The primary encounter diagnosis was Suicide attempt and A diagnosis of Depression was also pertinent to this visit ... ED disposition: Pending admit to psychiatry unit... Condition: Serious. . . Admit 8:56 PM discussed ER (emergency room ) findings, diagnosis and treatment plan for admission for further evaluation and /or treatment ... Pt (patient) received by Aventura Police in Handcuffs and ankle cuffs. Pt appears anxious. States voices are coming back ...Pt arrived with police under a Baker Act after made several self-inflicted lac (lacerations) to L (left) forearm as a suicide attempts. Pt reported he hears voices and today they told him that his life was no long worth living, calling him insane and told him to hurt himself and others. .. pt medically cleared ... Pt received from Peds ED after being seen by an ED psych Liaison RN (Registered Nurse) ...An EKG (measures the electrical activity of your heart) was performed in the Peds ED showing NSR (Normal electrical conduction of the heart). Further record review revealed that SP #1 was appropriately transferred to a psychiatric hospital. Review of the Facility #1 policy and procedure title: Florida EMTALA - Medical Screening Examination and Stabilization Policy confirmed above findings that the facility failed to provide SP#1 a medical screening examination and stabilization. The policy states: If an EMC (Emergency Medical Condition) is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility as defined by and required by EMTALA. Interview with the Associate CNO, Risk Manager and Director of Behavioral Health Unit conducted on 06-19-2013 confirmed the above findings, the facility failed to provide any necessary stabilizing treatments for sample patient (SP) #1.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of policy and procedure, incident report, and Emergency Director report and interviews, the facility failed to ensure that an appropriate transfer was provided in 1 out of 22 Sample Patients (SP) (SP#1). The findings include: Review of the Florida Department of Children's and Families (DCF) Incident Reporting and Analysis System (Incident Report # 2013-PDSA- ) (incident date 2/26/2013/Time 7:30 P.M.) conducted on 06-18-13 revealed the name of the sample patient (SP) #1 and the brief description of the incident. It showed: Child (SP#1) locked himself in his closet, refused to come out and was cutting himself. Mother called Care Coordinator, who was already en route to home. 911 was called. Child resisted police intervention and was tazered. The cuts on his arms, up to elbows were bleeding heavily. He was transported to this facility (#1) under Baker Act but was not held there since bleeding had been abated by EMS (Emergency Medical Support) and that facility doesn't treat adolescents. He was taken to Facility #2, who had no beds, then to Facility #3. Review conducted on 06-18-13 of the emergency room (ER) Director report dated March 28, 2013 regarding DCF request for information confirmed above findings that the patient (SP#1) was brought to Facility #1 ER by police under Baker Act. The report showed: That when the police arrived with the patient (SP#1) and approached the Charge Nurse (CN) desk, someone (unclear who) made a statement something similar to gosh this patient is going to be in the ER all night. At that point the police officer inquired why and was told that we are not a pediatric facility and we would have to transfer the patient out to a pediatric baker act receiving facility. The police officer then said that he would take the patient to Facility #2. The Charge Nurse (CN) then stated, we are not refusing the patient, we can transfer him. Based on my report, the police officer said he would just take the patient to Facility #2 since it was nearby and it was a more appropriate facility. A few minutes after the police officer left with the patient (SP#1), the psychiatric intake nurse called the Facility #2 to notify them of what just transpired and asked if they would like us to attempt to retrieve the patient. Their response was that it was fine and they would take care of it. The report further confirmed the findings that, the ER should have registered the patient into our system to generate a medical record where we could have documented the occurrences noted above. The report also showed the CN was asked for the patient ' s name and anything that could be entered into the system, but there was no information. Interview via phone with the Charge Nurse (CN) conducted on 06-18-13 at 10:30 am confirmed the above findings. She stated, she worked the night of 02/26/13 at 7pm to 7am when the police came with a minor Baker Act patient to ER (Facility #1). She stated that, The first thing the police officer asked was if the facility #1 was taking minor Baker Act patients. The CN responded, yes, but we are not admitting, but we take them, stabilize and transfer them out to whichever facility is available and can admit minor Baker Act patients. Then the police said right away, Ok I'll take him to facility #2. The CN said, No we are not refusing, we are taking patients but we don ' t admit them here. The police said, No, I'll take him and was leaving and I said wait let me have the psychiatric intake nurse (PIN) talk to you. The CN called the PIN. The PIN talked to the police but still insisted to take the minor baker Act patient to facility #2. So, the PIN asked the police, Are you willing to take him? and police said, yes, that's why I'm taking him to facility #2. So they left, then I called the supervisor right away and told her what happened. The police did not give me the chance to recept (enter in the patient into the computer). They did not know the name of the patient and only found out from facility #2. The supervisor asked the PIN to call facility #2 and find out about the Baker Act minor patient and she did. The PIN called facility #2 and the nurse said, don't worry because we'll take care of him. When the CN was asked further about the patient's physical condition, the CN stated, the patient (SP#1) was very calm and that she did not notice anything unusual. She also stated, she already received the EMTALA training and she should have recept the patient, started a medical record and the patient should ' ve had the medical screening by the physician. She also stated, she called the ER Director in the morning before she left and reported the incident. Interview via phone with the Psychiatric Intake Nurse (PIN) conducted on 06-19-13 at 3:10 pm confirmed above findings, she was called at the desk by the CN on the night of 06-26-13. She reports, it was a rapid sequence of events and she never had the chance to assess the patient. She reports, after the police said, he would take the patient to facility #2, she asked, Are you willing to do that? The policeman said, yes. The PIN further stated that, it was so fast and the intent was not to avoid to take care of the child, but the intent was, if possible, to get the child care faster but not for any negative reason. She also stated, this was an opportunity to review and learn about the EMTALA protocol to increase the safety element in her practice. When asked about the patient's condition, she stated, the patient was not in any distress and the patient was calm and relaxed. The medical record from facility #2 (an acute care hospital) was reviewed. The medical record revealed that on 2/26/2013 at 2051 (8:51 p.m.) a [AGE] year old (SP#1) arrived to the emergency department as a Psychiatric emergency. Review of the ED provider note revealed in part, Procedures: wounds cleansed and dressing with topical antibiotic provided ... Clinical impression: The primary encounter diagnosis was Suicide attempt and A diagnosis of Depression was also pertinent to this visit ... ED disposition: Pending admit to psychiatry unit... Condition: Serious. . . Admit 8:56 PM discussed ER (emergency room ) findings, diagnosis and treatment plan for admission for further evaluation and /or treatment ... Pt (patient) received by Aventura Police in Handcuffs and ankle cuffs. Pt appears anxious. States voices are coming back ...Pt arrived with police under a Baker Act after made several self-inflicted lac (lacerations) to L (left) forearm as a suicide attempts. Pt reported he hears voices and today they told him that his life was no long worth living, calling him insane and told him to hurt himself and others. .. pt medically cleared ... Pt received from Peds ED after being seen by an ED psych Liaison RN (Registered Nurse) ...An EKG (measures the electrical activity of your heart) was performed in the Peds ED showing NSR (Normal electrical conduction of the heart). Further record review revealed that SP #1 was appropriately transferred to a psychiatric hospital. Review of the Facility #1 policy and procedure title: Florida EMTALA Transfer Policy confirmed above findings that the facility failed to follow its own policy and procedure regarding appropriate transfer. The policy states: The hospital shall transfer an individual with an EMC (Emergency Medical Condition) to the closest geographically located hospital with capability and capacity to care for the patient. Any transfer of an individual with an EMC must be initiated either by a written request for a transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician order with appropriate certification as required under EMTALA. Interview with the Associate Chief Nursing Officer (CNO), Risk Manager and Director of Behavioral Health Unit conducted on 06-19-2013 confirmed the above findings, the facility did not follow its own policy and procedure regarding an appropriate transfer for sample patient (SP) #1.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure that the nursing staff keep the wound care assessments and documentation current for 3 of 10 sample patients( SP#1, SP#3, SP#4) needing wound care services . Findings include: 1). Clinical record review of SP#1 conducted from 09-17-2012 to 09-19-2012 revealed that SP#1 came to the hospital complaining of shortness of breathing and was admitted on [DATE]. April 14, 2012, SP#1 had removal of the AICD and leads and the surgery was performed by Surgeon (Surg.) #1 due to an infected AICD. SP#1 went to the Post-Anesthesia Care Unit (PACU) and later was transferred to the Intensive Care Unit (ICU). Review of the clinical record conducted from September 17-19, 2012 failed to show any written post-operative (post-op) orders from the surgeon on April 14, 2012. The Director of Risk Management (Dir. of RM) stated during an interview conducted on September 18, 2012 from 10:15 A.M. to 10:25 A.M. There were no orders written post-op. The Computerized Provider Order Entry (CPOE) was checked for any orders just to be sure but there were no orders. The Director of Stepdown/Telemetry unit (Dir. of Stepdown/Telemetry) stated during an interview conducted on September 17, 2012 from 11:47 a.m. to 12:45 P.M. The staff failed to call the doctor regarding getting an order for the dressing change. The patient stayed on this floor for four (4) weeks. The wound assessment was not done. The Dir. of RM stated during an interview conducted on September 18, 2012 from 10:15 A.M. to 10:25 A.M. I reviewed the nurses' notes and found that the dressing change was done on certain dates only. Some nurses did not describe the incision, others had no documentation at all. The Dir. of Step down/Telemetry unit stated during an interview on September 19, 2012 from 8:50 A.M. to 9:10 A.M. The original dressing was removed by the surgeon. There was another dressing placed. When I asked the nurses who took care of the patient, there were reinforcements of the post-op dressing done but no fresh dressings applied. The above findings were confirmed from the Assistant Chief Nursing Officer, the Vice-President of Quality Management, the Dir. of Step down/ Telemetry unit and the Dir. of RM on September 19, 2012 at 3:20 P.M. that there was failure to ensure that the care and treatment decisions are based on the needs of a post-operative patient. (2). Clinical record review of SP#3 conducted from 09-17-2012 to 09-19-2012 revealed that SP#3 was admitted on [DATE] . Review of the Adult Admission Assessment form showed that SP#3's skin was intact on admission. On 06-27-2012, while the patient was in the Intensive Care Unit (ICU), it was documented that SP#3 had a Stage II pressure ulcer noted on the sacrum. The Wound Care Specialist documentation on July 5, 2012 showed that Santyl ointment was recommended for the sacral ulcer. The WC RN #1 stated during an interview conducted on September 19, 2012 from 11:10 to 11:39 A.M. The presence of fibrin means dead tissue and the Santyl ointment acts as an instant debrider to eat up the dead tissue. Further review of the pressure ulcer documentation as to what type of wound care were provided for the Stage II sacral pressure ulcer during daily wound care were incomplete as to what medication was applied to the pressure ulcer, and descriptions about the pressure ulcer to indicate whether the pressure ulcer showed improving or not on a consistent basis. . The Dir. of WC stated during an interview conducted on September 19, 2012 from 11:10 A.M. to 11:39 A.M. It is possible for a patient who has been turned and repositioned to still develop pressure sores, especially when there is a compromise in nutrition and the presence of other co-morbidities . (3) SP#4 was admitted on [DATE]. Review of the Adult Admission Assessment form showed that SP#4's skin was intact on admission. SP#4 was last seen by the Wound Specialist on 02-08-2012 and it was documented that the patient has a Stage II pressure ulcer on the left buttock with a small satellite wound in the gluteal cleft with measurements taken at both sites. The recommendation is to continue applying the Santyl ointment. Review of the Patient Care Notes revealed that dressing changes were done but failed to show what medication was applied to the pressure ulcer, there and descriptions about the pressure ulcer to indicate whether the pressure ulcer was improving or not and no measurements were documented on a consistent basis. Further record review revealed that 03/29/12 the pressure ulcer had progress to a stage 3 pressure . The Dir. of Stepdown/Telemetry unit stated during an interview conducted on September 17, 2012 from 11:47 A.M. to 12:45 P.M. The Certified Nursing Assistants ' (CNA) reporting are done between CNA to CNA, they also receive report from the nurses. They utilize a worksheet to document information about the patients. I collect these worksheets and I do random checks on documentation like the rounding, turning schedules. I check on the documentation of the nurses, too. If there are any inconsistencies, I address it with the staff. Patients at high risk for skin breakdown are identified on assessments by the nurses, patients who score less than eighteen (18) on the Braden scale will trigger a need to be seen for nutritional support or Wound Care consult, an air mattress may be recommended as part of the treatment. There is a Suggested Reposition Schedule chart posted inside the patient ' s room as a reminder for the staff. The skin care regimen includes use of a spray, a cream/barrier and another thicker cream . Review of the Skin Integrity Risk Assessment/ Pressure Ulcer Wound Prevention policy reveled that 5.1-2 states that the assessment of the skin conditions will be documented in the medical record at least every 12 hours. The presence of pressure ulcers will include location, stage, wound dimensions , characteristics, and the wound care interventions/dressing changes.
Based on reocord review and interview, the faiility failed to ensure staff and practitioners comply with the patients' advance directives in 1 out 10 Sample Patients (SP). (SP#1). The findings include: Record review for sample patient (SP#1) conducted from August 08, 2012 to August 09, 2012 revealed SP#1 was admitted to facility on April 30, 2012 through the Emergency Department (E.D.) accompanied by caretaker after sustaining a fall at the Group home where SP#1 resides. Review of the Conditions of Admission forms dated April 30, 2012 showed the forms were witnessed by 2 staff members of the facility ' s Registration department due to medical condition . The section I have not executed an Advance Directive and do not wish to execute one at this time was checked off. There was no Health Care Surrogate form completed in clinical record at time of record review. Further record review of the clinical record showed that on May 1, 2012 at 18:57 P.M., the Registered Nurse taking care of the patient wrote that she had spoken to the Director of Nursing from the patient ' s group home and was informed that patient had a surrogate and to call the surrogate to see if the surrogate will allow placement of the Nasogastric tube (N.G.T.). On May 1, 2012 at 18:59 P.M., the R.N. documented that patient ' s surrogate was called and plan of care was discussed and surrogate was in agreement with N.G.T. insertion as long as sedation is running. Further record review of the forms Consent for Colonoscopy and Anesthesia Consent dated May 2, 2012 witnessed by 2 Registered Nurses at 17:55 P.M. stated SP#1 ' s surrogate (sister) had agreed to colonoscopy. The form An Important Message from Medicare About Your Rights completed on May 8, 2012 at 2:00 P.M. by facility under the section Signature of Patient or Representative states verbal consent yes but does not show who gave verbal consent on this form. Interview with SE#11, Assistant Director of Case Manager was interviewed on August 9, 2012 from 11:47 A.M. to 12:13 P.M. in the presence of the Director of Risk Management and A.C.N.O. and SE#10 (Case Manager). SE#11 stated that SP#1 belonged to a group home but was not going back due to Insulin management. SP#1 was discharged to a Skilled Nursing Facility. Confirmation that no health care surrogate forms were documented in clinical record at time of review was done at this time.
Based on record review and interview, the facility failed to reassess the discharge plan and coordinate services with the Skilled Nursing Facility to ensure the continuity of patient care needs related to pain management in one (#2) of 12 sample patients. The findings include: Clinical record review of Sample Patient (SP)#2 conducted from 10-31-11 to 11-3-11 revealed an admitting diagnosis of Lumbar Spinal Stenosis. Documentation showed that on the same day, 3-28-11, she had extensive thoraco-lumbo-sacral spine repair. Documentation on the Discharge Summary showed that the patient's condition improved and was transferred to a Skilled Nursing Facility (SNF) on 4-5-2011 in fair condition. The patient is to follow regular diet. No medications prescribed. Physician documentation on the Medical Certification for Nursing Facility/Home Based Services Form conducted on 10-31-11 revealed a form with no date but signed by the discharging physician and showed no medication and treatment orders. Documentation on the Medication Administration Record dated 4-5-11 showed that the last dose of Oxycodone/Apap 5/325 mg [milligrams] was given to SP#2 at 1745 for Pain Level/ Intensity:10 . The 9th Floor Staff RN II's documentation on 4-5-11 at 1806 showed that SP#2's pain level was 0. Documentation on the Discharge Instructions showed discharge instructions for the general patient population but no documented evidence that SP#2 was educated on special instructions after her back surgery and special discharge education on pain relief anticipating SP#2's need for pain medication. The 9th Floor Charge Nurse's documentation dated 4-5-11 at 1905 showed that SP#2's intravenous access was removed per physician's order. Further documentation showed: Medication Education: No. Case Manager I's documentation on 4-5-11 at 1932 showed that SP#2 was transferred to the Skilled Nursing Facility via ambulance. Further documentation showed: Additional Discharge Disposition Notes: No. Review of the facility Policy on Discharge Planning Process conducted on 11-2-11 included but not limited to: Evaluation of patient considering post-hospital needs ; The evaluation will include, but not limited to, information related to ... - medication needs ; The interdisciplinary team will consider the patient needs and abilities when developing the discharge plan and integrate medical, psychological, age-specific needs ...and available resources to ensure essential needs are planned for. ; The case manager/social worker will concurrently evaluate the patient for discharge readiness throughout the hospital stay. Discharge criteria will be applied and ongoing discussions with the attending physician and patient/family should occur. Interview with the Director of Case Management conducted on 11-1-11 at 1115am revealed that an onsite reviewer does the patient discharge assessment. She explained that prior to July 27, 2011, electronic documentation was sent through the Extended Integrated Network. She stated that on the day of discharge, a packet including the Continuity of Care forms completed by the physician and the nurse/social worker are sent with the patient. She added that nurses do not give verbal report to Skilled Nursing Facility staff. Interview with 9th Floor Staff RN II conducted on 11-1-11 at 1120am confirmed that she discharged SP#2 on 4-5-11 as documented in her notes. She stated that she could not recall SP#2. She confirmed that the Discharge Instructions listed were for the general patient population. She confirmed that there were no specific instructions for SP#2 on medications and no special instructions after the type of surgery SP#2 had. Telephone interview with 9th Floor Staff RN III conducted on 11-1-11 at 1125am revealed that he does not remember SP#2. He explained that the transfer forms are prepared by the Case Manager. He stated that the Medication Administration Record, medication reconciliation form and prescriptions, if any, are included in the transfer packet sent with the patient to the other facility. Interview with Case Manager I conducted on 11-1-11 at 2pm revealed that she is the Case Manager for SP#2. She enumerated the documents included in the discharge packet sent with the patient to the Skilled Nursing Facility (SNF). She explained that a prescription for narcotics is needed when patients are transferred to the SNF. Interview with Case Manager II conducted on 11-1-11 at 215pm revealed that she helped out in SP#2's case. She explained that the medication reconciliation form and prescriptions, if any, are considered the responsibility of Nursing. Interview with the Chief Executive Officer conducted on 11-1-11 at 330pm after discussion of SP#2's case concurred that the facility staff could have done better in discharging this patient. Interview with the Director of Case Management conducted on 11-1-11 at 4pm revealed that the medication reconciliation form is not used as a physician order. She stated that a prescription from the physician is needed for pain medications. Interview with the Physician who discharged SP#2 conducted on 11-2-11 at 1110am revealed that he is a critical care medicine physician who evaluated SP#2 after her surgery and who ordered SP#2's discharge. He stated that he intentionally did not order narcotics because of complications with narcotics considering SP#2's age. He added that he should have written to follow MAR [Medication Administration Record]. After reviewing the MAR, he continued to say that he preferred that when the patient reached the SNF, the physician would prescribe what is appropriate. He ended by stating that he will not take responsibility over a patient not under my care. Interview with the Orthopedic & Spine Nurse Navigator conducted on 11-2-11 at 220pm revealed that he does the follow-up of orthopedic and spine patients on the 9th floor. He stated that he keeps a log of patients he contacted after discharge. He recalls SP#2 well. He stated that he spoke with the Director of Nursing (DON) at the SNF where SP#2 was admitted regarding pain management. He concurred he didn't have the date written and could not recall exactly when the follow-up with the DON was. He calculated the conversation could have been a week after SP#2's discharge when he was told that the SNF physician will help with pain management. Interview with Case Manager I and Case Manager II conducted on 11-4-11 at 1035am confirmed that there was lack of continuity of care for SP#2 when it came to pain management. They both concurred that the hospital team should have properly coordinated with the SNF staff regarding SP#2's needs for pain relief.
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