Other·November 22, 2023

Title 22, Division 5, Chapter 3, Article 5, Section 72527. Patients' Rights (a) (6) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22, Division 5, Chapter 3, Article 5, Section 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 42, Code of Federal Regulation 483.15 (c)(7) Admission, transfer, and discharge. (c)Transfer and discharge- (7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. On September 18, 2023, at 12:10 p.m., an unannounced visit was conducted at the facility for an unsafe discharge. It was determined that the facility failed to ensure a safe and orderly discharge for Patients 1 and 2, when the patients were discharged to a hotel with no records of receiving diabetic teaching and had no records of receiving instructions on how to obtain medications for continuity of care and treatment. In addition, the facility failed to ensure the patients received supplies for diabetic care. These failures had the potential to result in Patients 1 and 2 not to receive appropriate medications and treatment increasing the risk for re-hospitalization. On September 18, 2023, Patient 1's medical record was reviewed. Patient 1 was admitted to the facility on July 26, 2022, with diagnoses which included diabetes mellitus (abnormal sugar in the blood), and hypertension (elevated blood pressure). Patient 1's physician history and physical indicated Patient 1 had capacity to make decisions. Patient 1's Physician Order Summary indicated the following: 1. July 8, 2023, "Insulin (diabetic medication used to help the body regulate sugar) Lispro Solution 100 UNIT/ML (milliliter- dosage) Inject 10 units subcutaneously (under the skin) before meals."; 2. August 5, 2023, "Blood Sugar checks three times a day before meals and Notify MD (medical doctor) if BS (blood sugar) less than 60 or greater than 300."; and 3. September 13, 2023, "May go home with meds (medication)." Patient 1's nursing progress notes dated September 13, 2023, at 10 p.m., indicated, "...MD ordered may go home with meds..." Patient 1's "IDT (interdisciplinary team- a group of healthcare professionals who work together to coordinate Patient care) Discharge Summary," dated September 13, 2023, at 10:01 p.m., indicated a list of medication was given to Patient 1. There was no documentation indicating Patient 1 was provided diabetic education, and whether the patient received diabetic supplies. Patient 1's "Notice of Transfer/Discharge" dated September 13, 2023, at 10:07 p.m., indicated Patient 1 discharged to his previous address. On September 18, 2023, the medical record of Patient 2 was reviewed. Patient 2 was admitted on September 16, 2022, with diagnoses which included altered mental status, umbilical hernia (weakening in the abdominal muscle wall), and history of alcohol (ETOH) abuse. Patient 2's physician history and physical indicated Patient 2 had capacity to make decisions. Patient 2's Physician Order Summary dated September 13, 2023, indicated, "...May go home with meds..." Patient 2's "IDT Discharge Summary," dated September 13, 2023, at 7:26 p.m., indicated, "...IF PROBLEMS ARISE DURING DISCHARGE, PLEASE CONTACT THE FOLLOWING INDIVIDUAL(S) AT THE NURSING FACILITY..." The record did not indicate the names or numbers for the patient to contact when in need of assistance. Patient 2's nursing progress note dated September 13, 2023, at 9:28 p.m., indicated, "...Patient left facility at approx. (approximately) 9:15 pm..." On September 18, 2023, at 3:09 p.m., an interview was conducted with the Social Service Assistant (SSA) and the Social Service Director (SSD). The SSA and the SSD stated the facility should ensure the following for a safe discharge: a. Must meet the discharge criteria, b. Must have a discharge plan, c. Assessment of the patient needs and requirements, such as home health and any medical equipment, d. Referrals when needed, e. Education regarding medications, wound care, and any other patient needs, before discharge. The SSD stated patients who were homeless should not be discharged without proper placement. During a concurrent record review of Patient 1's physician order summary, the SSA and the SSD verified Patient 1 required insulin three times a day with fingerstick blood sugar check. The SSA and the SSD acknowledged there was no documentation indicating Patient 1 received discharge education regarding his diabetes, received diabetic supplies, or his insulin and/or a prescription for insulin. On September 18, 2023, at 3:15 p.m., Patient 2's record was reviewed with the SSA and the SSD. The SSA and the SSD stated the Transfer/Discharge notice indicated Patient 2 was discharged "home." The SSA and the SSD stated Patient 2 was homeless, and there was no documentation indicating where Patient 2 was discharged. The SSA and SSD stated Patient 1 and Patient 2 were not discharged safely from the facility. On September 18, 2023, at 4:15 p.m., a telephone interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated patient discharge education began with the charge nurse when the discharge was discussed, usually the day before discharge. The RNS stated he did not provide any discharge education to Patients 1 and 2 on the day of the discharge on September 13, 2023. The RNS stated the charge nurses taking care of the two patients (Patients 1 and 2) provided him with the patients' medications, he reconciled it, and filled out the discharge summaries for Patients 1 and 2. The RNS stated he did not recall giving Patient 1 any insulin or equipment for monitoring his blood sugar, and he did not provide any education to Patient 1 regarding his diabetes. The RNS stated he was not sure where Patients 1 and 2 were discharged. On September 18, 2023, at 5:20 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated he provided care to Patient 2 on September 13, 2023, and he was unaware of the discharge plan for the patient. On September 18, 2023, at 5:45 p.m., an interview was conducted with LVN 2. LVN 2 stated she provided care for Patient 1 on September 13, 2023, until about 8 p.m. LVN 2 stated Patients 1 and 2 were ordered to be discharged, and within 30 minutes were being sent out. LVN 2 stated she asked Patient 1 where he would be going, and Patient 1 stated he was being discharged to a local hotel. LVN 2 stated the discharge did not make sense to her, and she stated it seemed "fishy." On September 19, 2023, at 11:40 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Patient 1's Transfer/Discharge Notice stated Patient 1 was discharged to 'home" on September 13, 2023. However, the DON stated there was no documentation indicating the address of where the patient would be going and whether education regarding his diabetes and insulin use, was provided. The DON stated Patient 1 used insulin three times a day and the patient needed to check his blood sugar three times a day. The DON stated Patient 1 is at risk for hyperglycemia (elevated blood sugar) and/or hypoglycemia (low blood sugar), and either could be very dangerous for Patient 1. On September 19, 2023, at 11:45 a.m., a concurrent interview and record review of Patient 2's record was conducted. The DON stated Patient 2 was homeless and did not have a " home." The DON stated there was no outside referrals made for Patient 2 and she verified the record did not indicate the discharge location for Patient 2. The DON stated the discharge instructions were vague and did not address Patient 2's alcohol and drug addictions need for referrals. On September 19, 2023, at 1:25 p.m., a telephone interview was conducted with the Case Manager (CM). The CM stated the facility must start the discharge planning 72 hours before the discharge date. The CM stated the following should be addressed during discharged planning: outside referrals, medical equipment needs, home health services, and family or patient training on medication administration. The CM further stated discharge planning should also include the notification of the appeals process. The CM stated she was notified around 5 p.m., on September 13, 2023, Patients 1 and 2 were being discharged. The CM stated she asked where the patients were being discharged and was told Patients 1 and 2 would be discharged to home. The CM stated Patient 2 had no funds to provide for himself and was homeless. The CM stated the discharge for Patients 1 and 2 were very "chaotic" and "rushed." The CM stated she was unaware of the location of Patients 1 and 2 and she had not been able to contact them. The CM stated she heard Patients 1 and 2 were sent to a local hotel when she returned to work on September 14, 2023. The CM stated the patients should not have been discharged to a hotel until alternate accommodations were arranged with confirmation of acceptance of the patients. The CM stated Patients 1 and 2 were discharged unsafely. On September 20, 2023, at 11:14 a.m., a telephone interview was conducted with Patient 2. Patient 2 stated he was discharged the night of September 13, 2023, to a hotel. Patient 2 stated he did not receive any referrals for outside counseling for substance use. Patient 2 stated he did not have anywhere to go as soon as he run out of money, and he would be homeless. On September 20, 2023, at 11:20 a.m., During the concurrent telephone interview with Patient 1 and Patient 2. Patient 1 stated on September 13, 2023, he and Patient 2 were discharged to a local hotel with cash provided by the skilled nursing facility. Patient 1 stated he got his medications from the RNS and when he asked about his insulin, he was told by the facility staff, he could not have needles, due to the allegation of drug use. Patient 1 stated he did not get any insulin, medical supplies to monitor his blood sugar, or a prescription for insulin. Patient 1 stated he and Patient 2 would be homeless soon. On September 20. 2023, at 2:20 p.m., a telephone interview was conducted with the owner of the facility provided by the skilled nursing facility as one of the proposed discharged facilities for Patients 1 and 2. The owner stated he had not been contacted by any skilled nursing facility recently for admissions. The owner stated his facility was a room and board and had two beds available, until a few days ago. The owner stated he did receive a call about a potential admission maybe two weeks ago and a name of (Patient 1) was given. The owner stated no paperwork was started, no pricing was discussed, and no contracts were signed. The owner stated he would be the only contact person at his room and board. The owner stated he had one inquiry about a potential need for a bed, but no other information was given, and no further contact was done. Review of the facility policy titled, "Transfer or Discharge Notice" dated January 2018, indicated, "...Our facility shall provide a Patient and/or the Patient's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge...The Patient and/or representative (sponsor) will be notified in writing of the following information...The reason for the transfer or discharge...The effective date of the transfer of discharge...The location to which the Patient is being transferred or discharged...A statement of the Patient's right to appeal the transfer or discharge...The reasons for the transfer or discharge will be documented in the Patient's medical record..." Based on interview and record review the facility failed to ensure a safe and orderly discharge for Patients 1 and 2, when the patients were discharged to a hotel with no records of receiving diabetic teaching and receiving instructions on how to obtain and take medications for continuity of care and treatment. In addition, the facility failed to ensure the patients received supplies for diabetic care. These failures had the potential to result in Patients 1 and 2 not to receive appropriate medications and treatment increasing the risk for re-hospitalization. This violation had a direct or immediate relationship to the health, safety, or security of the patients.