Piedmont Newton Hospital

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 46188 Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to identify patients that were at risk for unsafe discharge for one patient (P) (P1) of four (P1, P2, P3, P4) patients reviewed when P1 was returned to a personal care home (PCH) deemed potentially unsafe and with an active adult protective services case. After returning to the PCH, P1 attempted to elope and sustained an abrasion and contusion to the left eye and was readmitted to the facility. Findings included: Review of medical records revealed that P1 presented to the facility’s emergency department (ED) on 04/10/2026 at 10:48 AM via emergency medical services (EMS). P1 had been found wandering outside, had slurred speech, fell, and had sustained a laceration (cut) to the scalp. A review of a “Clinical Note” dated 04/11/2026 at 14:35 by Case Manager (CM) AA revealed that an initial assessment (IA) was completed of P1 with P1’a family members over the phone. CM AA noted that P1 lives at a personal care home (PCH) and that family did not wish for her to return there due to unsafe conditions. CM AA noted that a tentative discharge plan was to have P1 transition to a new PCH. CM AA provided P1’s family with several PCH options and awaited responses. A review of a “Clinical Note” dated 04/12/2026 at 14:15 by CM AA revealed that P1 was to discharge home (back to the previous PCH) with no required services. CM AA contacted P1’s family but the call was not answered, and CM AA left a voice message including the phone number to appeal discharge if desired. Continued review of the note revealed that CM AA had previously provided the family with a list of PCH’s, and the family declined the list of nursing homes or private pay caregivers. CM AA sent a blank copy of the Important Message from Medicare to the family so that they had the necessary information to appeal P1’s discharge, if desired. A review of a “Clinical Note” dated 04/13/2026 at 08:01 AM, by Social Worker (SW) CC revealed that SW CC spoke to P1’s family about the discharge plan. P1’s (family member) confirmed that she did not want P1 to return to the previous PCH. SW CC reviewed the previous list of PCHs with P1’s (family member) and P1’s (family member) said that many of the PCHs were not available because it was the weekend. SW CC provided another PCH to P1’s (family member) and she agreed to contact them. SW CC spoke to P1’s previous PCH who was not aware that P1’s family did not want her to return and that they would contact P1’s family. Continued review of the note revealed that P1’s Medicare discharge appeal was denied. P1’s (family member) was contacted to discuss P1’s discharge plan or to return P1 to the PCH. P1’s (family member) could not pick up P1 and requested to speak with SW CC’s supervisor. SW CC notified the Director of Case Management (DCM) DD. SW CC noted that P1 was discharged from the facility to the previous PCH. SW CC noted that P1’s family was willing for P1’s return to the same PCH and would transfer P1 to new housing within the next month. SW CC notified the previous PCH of the discharge plan. P1 was discharged from the facility to the previous PCH on 04/13/2026 at 16:45. A review of medical records revealed that P1 presented to the facility’s ED via EMS on 04/15/2026 at 18:20. P1 had attempted to elope and frequently hurts herself at the PCH P1’s family would like P1 placed in a different facility. A review of the “ED Provider Note” dated 04/15/2026 at 19:57 revealed that P1 was alert and oriented to person and place. The physician noted that P1 had an abrasion (skin burn) and contusion (bruise) around the left eye. P1 was admitted to the facility’s medical-surgical unit on 04/16/2026 at 20:00. A review of the facility’s document titled “APS Discharge Complaint 4.2026,” revealed a timeline review and general investigation of P1’s complaint and allegations raised by P1’s family. The facility noted actions taken upon receipt of the complaint and facility leadership debrief. “ A debrief of the event with senior leadership, the Director of Case Management, the Director of Quality and Safety, and the Risk Manager was completed. “ The Chief Nursing Officer disclosed to the family that facility policy was not adhered to by staff. “ The Case Management Manager and the Director of Quality and Safety developed an educational tool and provided education to all Case Management staff with proposed expansion to all clinical staff who are qualified mandated reporters. A review of the facility’s policy titled “Care Management Plan for Discharge Planning and Transitions of Care, “policy #19234400, last revised 11/04/2025, revealed that the purpose of the policy was to define an interdisciplinary approach for identifying and providing for post-discharge needs and continuity of care for the patient and their families after discharge. Continued review revealed, Identification of Patients in Need of Discharge Planning Evaluation, patients in need of discharge planning evaluation will be identified by medical provider referral, patient/family/representative request, or as outlined below: Case Management staff will assess those patients identified as meeting the following high risk criteria: “ Patients admitted from a nursing home, personal care home or assisted living. “ Patients admitted with a diagnosis or suspicion of abuse or neglect. “ Readmissions within 30 days. “ Barriers to compliance with post-acute treatment plan or medication regimen. “ Clinical conditions, such as but not limited to, dementia, psychosis, altered mental status, failure to thrive. A review of the facility’s policy titled “Abuse, Neglect, and Interpersonal (Domestic) Violence Policy,” policy #19290727, last revised 05/26/2022, revealed that the purpose of the policy was to provide a system wide response for managing the care of patients for whom there is suspicion of abuse, neglect, or interpersonal or domestic abuse, violence, or exploitation. 4 Policy It is the policy of the facility that victims of abuse, neglect, and domestic abuse/violence, are identified at the point of entry into the health care systems and that these cases are reported to the appropriate law enforcement agency or referral services in compliance with state and federal laws. 1. Assessment and Reporting 1. Using history and physical and behavioral indicators, assess the patient for possible abuse, neglect, or domestic abuse or violence. 3. Maintain the patient’s safety. 4. Determine the agency that has jurisdiction over the patient. 8. Any child or disabled adult at risk for further immediate danger shall not be released to parents or caretakers until authorized by Child/Adult Protective Services. An interview was conducted on 06/03/2026 at 09:32 AM with Case Manager (CM) AA. CM AA said that she normally works on the weekends and recalls P1. CM AA said that she spoke with P1’s (family member) and learned there were concerns with P1 returning to the PCH where she had previously resided. CM AA provided a list of alternative PCHs. CM AA said that if the family had not made arrangements at an alternative PCH when P1 was ready for discharge, P1 would be discharged to the family member. CM AA recalled a discussion with the family about other PCHs, nursing homes, private paid caregivers, and assisted living facilities and that a list was provided. CM AA explained that it was up to patients and families to contact PCH’s; however, she (CM AA) did assist. She further explained that if the family desired for P1 to be placed in a nursing home, the family would facilitate that process after discharge since P1 did not have any medical needs. CM AA recalled that the anticipated discharge date for P1 was 04/12/2026 and when P1 was ready, CM AA could not get in touch with any family members. CM AA said that P1’s family members called CM AA and requested to file an appeal of discharge. CM AA provided P1’s family with information on the appeal process. CM AA said that she spoke with the Supervisor of Case Management (SCM) EE when she learned that P1 had been readmitted and the circumstances surrounding the readmission. CM AA said that SCM EE provided education about extenuating circumstances that placement into long-term care facilities may occur and how P1’s situation could have been conducted differently. CM AA said that P1’s (family member) never mentioned any illnesses that prevented her (family member) from caring for P1 during their interaction. An interview was conducted on 06/03/2026 at 09:52 AM with the Supervisor of Case Management (SCM) EE. SCM EE said that she began a review of P1’s case after P1’s (family member) submitted a grievance letter. SCM EE said that she potentially saw where and how Adult Protective Services (APS) was involved and that there was a gap identified. SCM EE said that she learned through conversation with P1’s (family member) that she could not care for P1 due to health issues and that she wanted to find another long-term care facility for P1. SCM EE said that the facility identified in a policy where if APS is involved and there is potential for the patient to have an unsafe discharge then the facility will hold the patient until a safe place is identified. SCM EE said that since the incident with P1, a flowsheet has been created as a tool and all staff had been trained in the use of the flowsheet. This occurred prior to the start of this investigation. A follow-up interview was conducted with DCM DD on 06/03/2026 at 10:21 AM. DCM DD said that she was aware of P1 during the initial discharge process. DCM DD said P1’s family appealed P1’s discharge and it was eventually denied. DCM DD said she spoke with P1’s family over the phone and provided them with a list of PCHs as alternatives. DCM DD said that when she followed up with P1’s family they reported that they were considering some PCH options and DCM DD was led to believe that they were going to go that route. DCM DD said that at that time, no request for a nursing home placement was mentioned to her (DCM DD). DCM DD said that when P1 returned to the facility, that was when she received the full details surrounding P1. DCM DD said that prior to this, P1’s family had only provided DCM DD with complaints about the appeal and denial of the discharge. DCM DD said that staff received education on communication and the APS escalation and validation plan. DCM DD said that she has a close relationship with the APS investigator for the facility and she was usually notified of any active investigations. DCM DD said that she learned about the active APS case when P1 returned to the facility. An interview was conducted on 06/03/2026 at 11:00 AM with Social Worker (SW) CC. SW CC recalled P1 and said that P1 came from a PCH. SW CC said that when family got involved, they expressed that they did not want P1 to return to the PCH. SW CC said that P1 did not meet the criteria for a continued inpatient stay and she (SW CC) provided family with a list of alternative PCHs. The family could not come to a decision and said that they had already paid for the full month at the previous PCH. SW CC said that P1’s family appealed the discharge, but it was eventually denied. SW CC recalled that she attempted to contact the family multiple times on the day that P1 was to be discharged from the facility, but they did not answer the phone calls. The only alternative that SW CC could think of doing was to send a text message as P1 was sent back to the same PCH. SW CC said that there was mention by the family of APS involvement There was not a power of attorney (POA) on file and because P1 was able to express their desires, SW CC did what she thought was best given that P1 was to be discharged. SW CC said that she did involve DCM DD. Initially SW CC was told that there was no APS case number or involvement. SW CC received reeducation on the process of handling cases where APS may be involved and this was given to the entire CM staff. An interview was conducted on 06/03/2026 at 11:38 AM with the Chief Nursing Officer (CNO). The CNO said that she later spoke with Case Management, the nursing team, and risk management. The CNO said that after learning that P1 was readmitted to the facility, she made sure she had all the information prior to speaking with P1’s family. The CNO said that the facility staff members did not validate that there was an active APS report prior to discharging P1 back to the PCH. The CNO said that moving forward their goal is to ensure all team members are educated on the process and those allegations involving an unsafe home for discharge, the facility’s responsibility, and how to ensure a safe discharge plan is carried out. The CNO said that she did speak with P1’s family members and provided them with her number but they had not contacted her since then. An interview was conducted on 06/03/2026 at 2:15 PM with the Director of Quality (DOQ) BB. DOQ BB said that P1’s case was reviewed with risk management and case management. DOQ BB said that areas were identified for improvement. DOQ BB said that leadership debriefed, developed an action plan that focused mainly on education of the process to verify patients have no active case with APS prior to sending patients back into an unsafe environment. DOQ BB said that when P1 returned to the facility, staff reached out to APS and the facility was notified that P1 should not have returned to the PCH. DOQ BB said that after investigation, the resolution process was underway for P1 and the family.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42060 Based on a review of medical records, Bylaws, meeting minutes, facility policy and procedures and staff interviews, it was determined that the Governing Body failed to ensure that adequate numbers of staff continuously monitored and changes in condition were immediately conveyed to nursing staff when one (P#1) of five (5) (P#1, P#2, P#3, P#4, P #5) patients sampled experienced bradycardia (low heart rate) on 12/1/25 beginning at 6:38 a.m. P#1 was found unresponsive and pulseless by staff on 12/01/25 at 6:57 a.m. Resuscitation efforts were unsuccessful, and P#1 was pronounced deceased on 12/01/25 at 7:30 a.m. Findings included: A review of the facility ’ s “ Amended and Restated Bylaws “ revealed that the purposes of the corporation included: a) Establishing and maintaining inpatient beds and clinical programs/services to provide diagnosis and treatment for patients, and associated healthcare facilities, programs, and services for inpatients and outpatients; b) Undertaking educational activities related to the provision of health care services; c) Promoting and conducting scientific research related to the provision of health care services; and d) Participating in other activities designed and undertaken to promote the health status and well-being of the community. The Board of Directors obligations and responsibilities was subject to the facility ’ s Bylaws, the corporation policies and the corporation governance protocols. The Corporation Board directs and oversees the affairs of the Corporation. The obligation of the Corporation Board was to ensure that the resources and capacities of the Corporation were deployed in a manner that promoted community benefit and health status. In order to meet this obligation, the Corporation Board fulfilled two responsibilities: 1. Providing general strategic, managerial, operational, financial, and clinical oversight of the Corporation; and 2. Credentialing (appointing, reappointing, and determining clinical privileges of) members of the corporation ’ s medical staff. Such credentialing decisions of the Corporation Board were final and did not require approval of the facility ’ s Board. Quality of Care: The Corporation Board shall, in discharging its ultimate responsibility for the quality of care, assign to the medical staff reasonable authority for ensuring appropriate professional and community standards in the care of patients. Review of the Medical Executive Committee (MEC) meeting minutes from June 2025 through December 2025 indicated the committee met monthly to discuss medical and clinical affairs of the facility per Bylaws regulations. A further review of the MEC meeting minutes dated 12/11/2025 failed to give evidence that the committee discussed the death of P #1 that took place on 12/01/2025. Review of the Telemetry and Nursing staffing at the time P #1 was admitted revealed Telemetry was operating with one Tech. There were no concerns about nursing staffing. Cross refer to A0385 as it relates to the facility’s failure to ensure that nursing staff wre notified of a patient’s change in condition while on continuous telemetry monitoring.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 42060 Based on a review of medical records, facility policy and procedures and staff interviews, it was determined that the facility failed to ensure that patients on cardiac telemetry were continuously monitored and changes in condition were immediately conveyed to nursing staff when one (P#1) of five (5) (P#1, P#2, P#3, P#4, P #5) patients sampled experienced bradycardia (low heart rate) on 12/1/25 beginning at 6:38 a.m. P#1 was found unresponsive and pulseless by staff on 12/01/25 at 6:57 a.m. Resuscitation efforts were unsuccessful and P#1 was pronounced deceased on 12/01/25 at 7:30 a.m. Findings Included: Cross refer to A0144 as it pertains to the facility’s failure to ensure that patients are cared for in a safe environment.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42060 Based on a review of medical records, facility policy and procedures and staff interviews, it was determined that the facility failed to ensure that patients were cared for in a safe environment while on cardiac telemetry when one (P#1) of five (5) (P#1, P#2, P#3, P#4, P #5) patients sampled experienced bradycardia (low heart rate) on 12/1/25 beginning at 6:38 a.m. and nursing staff were not notified. P#1 was found unresponsive and pulseless by nursing staff on 12/01/25 at 6:57 a.m. Resuscitation efforts were unsuccessful and P#1 was pronounced deceased on 12/01/25 at 7:30 a.m. Findings Included: Review of P#1’s medical record revealed she was admitted as an inpatient on 11/30/25 at 8:45 a.m. with a diagnosis of congestive heart failure. Physician orders included telemetry monitoring, heart failure protocol and a cardiology consultation. A review of P #1’s flowsheet revealed that on 12/1/25 at 4:26 a.m., P#1’s heart rate (HR) was 95 beats per minute (bpm) (normal was 60-100 bpm) A review of P#1’s telemetry strips dated 12/1/25 revealed the following: 6:37:05 HR: 105 6:38:09 HR :46 6:39:03 HR: 49 6:42:19 HR: 40 6:43:00 HR:44 6:45:03 HR: 38 6:46:02 HR: 31 6:47:02 HR: 34 6:48:02 HR: 36 6:49:02 HR: 39 6:51:01 HR: 41 6:52:03 HR: 41 6:53:02 HR: 39 6:54:03 HR: 38 6:55:52 HR: 166 6:57:28 HR: 47 A review of ‘Nursing Notes’ revealed that on 12/1/25 at 6:55 a.m., RN LL found P#1 unresponsive with no pulse, CPR was started and a code was called. A review of ‘Code Documentation’ revealed that PA CC responded to a Code Blue for P#1. Continued review revealed that resuscitation efforts following protocol continued for approximately 30 minutes and time of death was called at 7:30 a.m. A review of the ‘Telemetry Surveillance Call Log’ for 11/30/25 beginning at 10:00 p.m. failed to reveal an entry that pertained to P#1. A review of the facility’s policy number 17502401 titled “Scope of Care: Piedmont Newton - House Telemetry,” lasted revised 3/17/25, revealed that the telemetry operated 24 hours a day, seven days a week. The house telemetry unit was equipped to monitor up to 64 patients on telemetry and 12 patients on intermediate intensive care unit (IMCU) at one time and 10 patients in the intensive care unit (ICU). Skill mix included managers, monitor technicians, registered nurses (RN), licensed practical nurses (LPN), and paramedics. Patient assessment consisted of assist nursing staff who provided care by observation of patient rhythms on telemetry and remote bedside monitoring. It also included observing and reporting changes in rhythm per policy and procedure. A review of the facility’s policy titled, “Nursing Procedure - Telemetry Non-ICU Nursing Areas”, no number, effective 9/20/24 revealed the purpose of the procedure was to provide guidelines for telemetry in non-ICU nursing areas. Upon placement of a telemetry order, a requisition was to be printed to notify the monitor tech of a new order. The telemetry box was placed on the patient and the nurse called the monitor tech and verified transmission of the signal, as well as verified and documented the rate, rhythm, and box number in the electronic health record (EHR). The role and responsibility of the Primary Nurse was to check the electrodes and wires once per shift for stability and firm adherence of the electrodes to the skin and to check the batteries daily and as needed. Every shift on cohorted cardiac units the nurse verified and documented rhythm in the EHR upon admission and then every four hours. For rhythm or rate changes, the primary nurse assessed the patient and documented pertinent findings and notified the physician of the change and any pertinent assessment findings. The primary nurse notified the monitor technician of the patient’s transfer to another room, code status changes, removal of telemetry, patient complaints chest discomfort, shortness of breath, palpitations, dizziness, etc., or when the telemetry transmitter dropped on the floor, submerged in water, or was soiled with biohazardous materials. The role and responsibility of the Monitor Technician (MT) was to cross check the list of patients with telemetry orders with the patients being monitored at the beginning of each shift. Ensured that proper alarm limits were set and always audible. Alarm rate limits were to be set to alarm if heart rate was less than 50 or greater than 120 beats per minute. When pulse oximetry was in place, the low limit was 88%. To reduce false alarms, parameters may be individualized and set based on the clinical presentation of the patient. Before customizing any parameters, verification of clinical condition was made with the primary nurse. The monitor tech analyzed telemetry strips upon initiation of telemetry, once per shift and with rhythm changes. Measurements included heart rate, time intervals, and rhythm interpretation. The MT notified the primary nurse of change in the patient’s rhythm, significant change in rate (an increase or decrease of 10% or outside of standard parameters), oxygen saturation less than 90%, or any finding outside of patient-specific alarm settings. The MT notified the primary nurse and STAT Rapid Response Team for lethal and life-threatening arrhythmia. The MT documented each time a nurse was notified. MT logs were reviewed by entity-based process improvement groups on a regular basis. MTs immediately notified the primary nurse or other appropriate staff members of any patient who was unexpectedly not monitored. If the patient remained unmonitored after a maximum of ten minutes the MT notified the nursing supervisor or the unit manager that the patient was not monitored. An interview with Monitor Technician (MT) DD took place on 12/22/25 at 11:30 a.m. in the telemetry room. MT DD explained his role was to keep his eyes on the monitor at all times. MT DD said there were two Techs in the room monitoring the entire facility, ICU, IMCU, and Med-surg. MT DD said he was to call the patient’s primary nurse as soon as something was abnormal with the heart rate. MT DD said he was to call the Charge Nurse within five minutes if the primary nurse did not answer the phone. MT DD explained if the arrythmias was severe enough he was instructed to call a rapid response. An interview with Charge Nurse JJ took place on 12/22/25 at 1:13 p.m. in the Board Room. RN JJ said she was aware of the case with P#1. RN JJ explained that providers entered orders to have patients placed on telemetry; then the nurse was to place the box on the patient to start the monitoring. RN JJ said once the box was in place, the nurse called telemetry and advised them of the patients information. Charge Nurse JJ explained that the monitor technician’s responsibility was to watch everything about the patient’s heart rhythms and always monitor the screens. Charge Nurse JJ explained that if the monitor tech noticed something abnormal, the tech was to call the patient’s primary nurse to report what they had observed. Charge Nurse JJ said the protocol was for the monitor tech to escalate their observations to the Charge Nurse if they could not get in touch with the primary nurse. If the charge nurse could not be contacted, the monitor tech was to notify the house supervisor and rapid response. Charge Nurse JJ explained that rounds were to be done hourly either by the nurse or a patient care tech. Charge Nurse JJ said that the telemetry machine alarm went off every time the heart rate went down or up, if the battery was low, and if the leads came off. An interview with Telemetry Manager HH took place on 12/22/25 at 3:00 p.m. in the Board Room. Manager HH explained that monitor techs monitored all patients that were on telemetry. Manager HH said that techs were to call the patient’s nurse, the Charge Nurse, and if necessary, the House Supervisor if the patient was off telemetry for five minutes. Manager HH said that monitor tech could also call a rapid response. Manager HH explained that she had spoken with MT BB regarding P#1. A phone interview with Monitor Technician (MT) BB took place on 12/23/25 at 12:19 p.m. MT BB said she was the telemetry tech on duty the night P #1 became bradycardiac(low heart rate). MT BB explained that she had been working alone the night of the incident and she was monitoring more than 60 patients that night. . MT BB recalled that were two patients with low heart rate that night, but she said the heart rate was about 50 beats/minute.MT BB said it was towards the end of the shift that P #1’s heart rate started to drop. MT BB said when the morning relief (MT DD) came, she asked him to keep an eye on these two patients because their heart rate was low. MT BB said she called RN LL about P#1’s heart rate but the nurse did not answer the call. A phone interview with Registered Nurse (RN) LL took place on 12/23/25 at 5:01 p.m. RN LL said he was assigned as the primary nurse to P #1 on the morning the patient developed the drop in heart rate. RN LL said there was nothing wrong with the patient during the overnight hours. RN LL said he saw and talked to P #1 around 6:10 a.m.- 6:15 a.m. RN LL recalled that he and the oncoming nurse went into P#1’s room around 6:45 a.m. to 6:50 a.m. for report/shift change. RN LL said he called the patient a couple of times, but she did not respond. RN LL said when he realized P #1 was unresponsive, he called a code, and the response team arrived. RN LL said he did not receive any call from telemetry during the night about P#1. RN LL explained that all nurses carried a hospital issued cell phone with them when they started shift. RN LL said the monitor techs had all the nurses’ numbers and what patients were assigned to a particular nurse.”

“DISCHARGE PLANNING - MD REQUEST FOR PLAN CFR(s): Upon the request of a patient’s physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient. This Standard is not met as evidenced by: 52070 Based on record review, staff interview, and facility policy review, it was determined that the facility failed to develop and arrange a discharge plan per the request of a physician for one patient (P) (P#1) of 4 four patients reviewed for discharge plans. This failure resulted in P#1 being discharged unsafely and inappropriately. Findings included: A facility policy titled “Hospital Wide Discharge Plan,” last revised on 06/04/2024, revealed, “1. Discharge planning begins upon admission with a discharge planning screening by Care Management Staff. All patients that are screened as high risk are referred to a care coordinator for assessment. Any unique patient needs are identified and addressed as part of the D/C [discharge] planning process. 2. Care Management will review the medical record and meet with patients and families as needed to provide appropriate services. The assessment of each patient will involve reviewing the documentation by providers and other disciplines. 3. Patients with identified discharge needs are referred to Case Management through the C.M. [Care Management] screenings and referrals by direct contact with patient/family or by a physician order. See attached table for disposition of patients. 4. Social workers, providers, patient, family, support person and the interdisciplinary team confer regarding the discharge needs of the patient, including: DME [durable medical equipment], Home Health, Rehabilitation Services and Nursing Home Placement. The information is shared through EPIC [electronic health record software] documentation and direct communication to provide timely and appropriate discharge plans. (Refer to Case Management Policy regarding discharge planning) 5. Insurance coverage and demographics are considered within the discharge planning process. Education and supportive services are provided to the patient, family, or support person to assist them in accepting the illness and discharge plan. 6. A provider order is required for certain services such as Home Health, Hospice and DME. 7. Social Workers provide information to patients/families for their use in making informed decisions regarding post-hospital care.” A facility policy titled “Evaluations and Referrals for Discharge Planning Policy,” last revised on 06/20/2023, revealed, “All inpatients of [facility name] shall be evaluated for discharge planning needs. Care Managers and social workers shall conduct the evaluative process. Additionally, the Care Management Department has an open referral policy. Referrals may be accepted from patients, their families, physicians, hospital staff and community agencies and outside agencies as needs are identified. Referrals may be received electronically through EPIC as physician orders, or via interdisciplinary rounds followed by EPIC orders. Identified discharge needs may include: 1. A need for community resources. 2. Orthopedic rehabilitation. 3. Rehabilitation after CVA [cerebrovascular accident] or other debilitating illness. 4. Readmission 5. Patient advocacy, such as in cases of abuse or neglect or patient/family conflict. 6. Patient with little or no support systems. 7. Frequent re-hospitalizations. 8. Significant personal care or nursing care needs identified. 9. Maintenance of a chronic illness. 10. Placement in a skilled nursing facility or rehab placement. 11. End of life needs. 12. NICU [neonatal intensive care unit] admission. 13. DFACS [Division of Family & Children Services/APS [Adult Protective Services] referral.” “ED [Emergency Department] Provider Notes,” dated 02/19/2025 at 12:49 a.m., revealed P#1 presented to the emergency room with a chief complaint of generalized weakness. A “Review of Systems” section revealed the patient was positive for weakness. “ED Notes,” dated 02/19/2025 at 2:37 a.m., and documented by Licensed Practical Nurse (LPN) #3, revealed P#1 ambulated from their bed to the door of their room with assistance from LPN #3. “ED Notes,” dated 02/19/2025 at 3:00 a.m., and documented by LPN #3, revealed P#1 reported having no place to live, including no longer living with their spouse. A “Nursing Note,” dated 02/19/2025 at 3:13 a.m., and documented by Registered Nurse (RN) #13, revealed RN #13 spoke with P#1’s family member, who identified that P#1 could not return to the family member’s home, and the family member could not care for P#1. An order dated 02/19/2025 at 3:28 a.m., revealed Doctor of Osteopathy (DO) #12 placed an order for “Case Management - Referral to post-acute care.” An “ED Re-evaluation Note,” filed on 02/19/2025 at 1:19 p.m., by Medical Doctor (MD) #14, revealed “CM [Case Management] is arranging [a ride-hailing service]” to P#1’s ex-family member’s home. A “Discharge Information” note revealed P#1 was discharged with a disposition of “Home Or Self Care” to a discharge destination of “None” on 02/19/2025 at 1:49 p.m. P#1’s medical record failed to indicate that DO #12’s order for case management was executed. There were no case management notes or evidence of case management assessments conducted prior to the patient’s discharge. During an interview on 05/06/2025 at 2:31 p.m., a Case Manager Director (CMD) stated that, during P#1’s visit on 02/19/2025, a referral was placed by a provider for a case management consultation, but case management never followed up on the consultation. The CMD noted case management was expected to follow up on referrals made by providers first thing in the morning when they arrived to work.”