Maui Memorial Medical Center

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 39853 Based on interview, observation and record review (RR), the facility’s discharge planning process failed to reduce the factors leading to a preventable hospital readmission or negative outcome in two of five patients sampled that were discharged home. P1 was discharged after a two day length of stay for diabetic ketoacidosis and expired five days post discharge. In addition, P2 required 24/7 supervision, but the facility failed to establish a safe discharge plan with her family member (FM), who requested she be sent home, which did not meet P2’s needs. As a result of this deficiency, P2 fell again, and was readmitted. Due to the serious nature of these events, it was determined to be a Condition level deficiency in discharge planning. Findings include: 1) P2 is a 96 year old female with history of chronic back pain, diabetes type 2, gastric and liver mass, chronic anemia and dementia. She had cognitive impairment and was alert and oriented x 2 (aware of their identity and place, but does not know time or situation). P2 lives alone and has a family member (FM) that is actively involved in her care. Her primary language is Japanese, but she can make needs known. P2 had multiple falls, three of which resulted in hospitalizations, 05/12/2024-06/04/2024, 01/20/2025-01/23/2025, and 02/20/2025-current. RR of P2’s 05/12/2024 admission revealed the following entries: Physician Discharge Summary dated 06/04/2024: “She presented after being found in the bathtub. She did not know how long she was in the bathtub or how she got in.” P2 had a subdural hematoma (bleeding near the brain after head injury) and a fracture of lumbar vertebrae (L1). Discharge disposition indicated P2 was to be discharged to a skilled nursing facility. Clinical progress notes by Physical Therapy dated 06/03/2024 at 10:25 AM: “Current recommendations: Discharge Disposition: STR (short term rehabilitation) to LTC (long term care) or setting with 24/7 supervision. Caregiver support at current level of function: Continuous supervision for bed mobility, transfers, and ambulation due to cognition, memory, judgement, insight, impulsivity, fall risk, and safety awareness. Barriers to discharge requires significant assist for ADL’s (activities of daily living), insufficient activity tolerance, cognitive status, and impaired safety awareness with risk of falls. ...” Review of P2’s medical records during hospital admission date 01/20/2025 revealed the following entries: Physical Therapy Evaluation/Discharge dated 01/21/2025 included: “...Pt (P2) is near her functional mobility, however it is unsafe for pt to return to prior living situation as she lives alone with very limited assistance and remains a high fall risk. Recommending home with HHPT (home health physical therapy) and with 24/7 supervision. ...Caregiver support at current level of function: Continuous supervision for bed mobility, transfers, and ambulation due to cognition, memory, judgement, insight, impulsivity, fall risk, and safety awareness. ...” 01/22/2025 at 04:58 PM, Care Coordinator notes: “Chart reviewed and FM/POA (power of attorney) called on 1/21 and 1/22 to discuss discharge planning. FM aware of recommendation for 24/7 assistance/supervision as it was also recommended prior to last discharge. FM reports that she has 2 surveillance cameras in place in patient’s home that she checks regularly and will alert her if there is no movement in a specific amount of time. Aware of the risk of not having someone present 24/7. Patient has declined placement to care home/foster family, assistive living per FM. Patient with private duty caregiver along with caregiver through Office of Aging and home delivered meals. FM regularly sees patient daily in the evening. FM scheduled to return from Las Vegas on 01/26/25. During her absence, she schedule [sic] a private pay caregiver to assist with care. Friend lives on same property. Anticipating DC (discharge) tomorrow 1/23 (Thursday). FM set up for patients friend ...to pick patient up at 2 PM. Private duty caregiver will meet patient and friend at patients home to provide care on arrival. Called Office of Aging to confirm discharge for tomorrow. Home delivered meals to resume on Saturday or Monday. FM aware and states she had prepared meals in patients home for patient that caregiver is able to assist with.” 01/23/2025 at 06:42 AM, Physician (MD)1 Discharge Summary: - “...Pt’s neighbor checked on the patient and found her sitting on the floor. When Pt was asked what happened, she says she simply tripped over. Somewhat unreliable history because she is only A&Ox2 (alert and oriented to) (self, location)). She answers questions better in Japanese. She answers less reliably in English. ...XR (xray) shows no fracture. ...Pt requested to be discharged home but the FM ...requested to get the patient admitted for observation. ...FM is currently on the flight to Las Vegas. - “pt has a caretaker that visits her twice a day, and FM takes care of the mom daily.” - “discussed with pt’s FM, and informed her about the recommendations from therapy which was 24/7 care. FM informed me this was the same recommendation from her mom’s prior hospitalization. FM understands, but wants to respect her mom’s decision of remaining at Hale Mahoulu (living community). Pt has informed FM, that she would rather die and fall at home. If the pt was moved to another facility, the pt will kill her self as per FM. ...The patient was found to have a UTI (urinary tract infection).” RR of 02/20/2025 to current admission revealed the following entries: Medical history and physical dated 02/20/2025: “96 yr old woman ...who presented after an unwitnessed fall with complaint of right hip pain. ...She has had multiple falls over the last year. One occurred while her Family Member (FM) was traveling. While FM enroute to her destination, she was not reachable. This resulted in APS (Adult Protective Services). Today, the patient’s FM was at a meeting with APS when FM’s mother fell again. ...Spoke to APS Case Worker, ...and informed patient needs placement for 24/7 care. ...confirmed that FM is working with ...for LTC Medicaid and plans to apply on March 1st ...” On 02/28/2025 at 10:00 AM, met with P2 at bedside. She was lying in bed, pleasantly confused with calm demeanor. P2 smiled and was able to answer simple yes and no questions, but not interviewable due to her level of cognition. Reviewed the facility policy titled “Discharge Planning” with revised date of 05/2024. The policy included: - Discharge Planning: “A process that is consistent with the patient’s goals for care and treatment preferences, ensures an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable readmission.” - “The process includes the following components: ...4.1.8 Implementation of a safe discharge plan that reduces the likelihood of a hospital readmission.” - “5.2.7 When the patient’s or patient representative’s goals and preferences are unavailable or do not support the care needs, the care management team will work with the patient or patient’s representative to develop a discharge plan that can be implemented.” On 02/27/2025 at 11:00 AM, interviewed Case Manager (CM) in the conference room. She was familiar with P2 and currently working on the discharge plan with FM. She said she knew the FM had put cameras in P2’s home and that she had met with APS. CM agreed that cameras were not an appropriate substitute for 24/7 supervision. CM said they now have a physician statement that P2 was incapacitated and unable to make her own decisions, which may have been seen as a barrier by FM as she wanted to honor P2’s wishes to stay home. The CM agreed that although they did not have a physician statement of competency on the earlier admissions, P2’s cognitive impairment was the same. CM went on to say if FM truly didn’t want to place P2, other options could have been explored to find a safe compromise, such as day care seven days a week with paid caregivers at her home the rest of the time. The CM said P2 is currently waiting to be placed. 2) Cross Reference A802 Discharge Planning Re-Evaluation P1’s condition was not reassessed to ensure his nutritional needs would be met post discharge. It was a priority to ensure P1’s blood pressure was controlled and the nausea/vomiting, so he had adequate nutrition. P1 was treated with intravenous medication for high blood pressure approximately two hours prior to leaving the hospital, but the BP was not rechecked. In addition, he had a critical alert level platelet count that needed timely follow up post discharge and his PCP did not get copies of the medical records. P1’s discharge instructions included “Diabetes and Alcohol: Care Instructions,” but did not include instructions for hypertension, Diabetic Ketoacidosis or thombocytosis. P1 expired four days post discharge.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 39853 Based on interviews, record and document review, the facility failed to reevaluate one patient’s (P)1 condition of a sample size of five to ensure he was stable for discharge. P1’s status at discharge was 1) he had not been adequately monitored to ensure he would have adequate intake to meet his nutritional needs after a change of medication, 2) he was given intravenous medication for high blood pressure (BP), without a recheck approximately two hours before discharge and 3) he had an alert platelet value related to thrombocytosis that was not addressed in his discharge instructions or with a timely referral for follow up. This deficient practice put P1 at high risk of complications, readmission or death. Findings include: A review was conducted of P1’s medical records, which revealed the following: P1 was a 35-year-old male with a history of Diabetes Type 1 (DM1), gastroparesis (condition where stomach empties contents more slowly), alcohol use disorder, essential thrombocytosis (abnormally high platelets, not lifethreatening, but the complications of blood clots or severe bleeding, can be), and hypertension. He had a history of being noncompliant with his medical treatment and was seen in the ED three times in the previous six months. P1 presented to the Emergency Department on 10/09/2024 with nausea/vomiting and high blood sugar. He was admitted with diagnosis of ketoacidosis (life-threatening complication of diabetes) and transferred to the intensive care (ICU) at approximately 07:00 AM on an insulin drip and could have nothing by mouth (NPO). R1 transitioned to subcutaneous (under the skin injection) insulin and transferred out of ICU on 10/10/2024. A new order for cardiac, diabetic consistent carbohydrate diet was entered at 09:29 AM. R1 was discharged home 10/11/2024 and expired four days later. On 10/09/2024 at 06:40 AM, a Clinical Dietician (RD)1 documented: “Current Intake: Inadequate but appropriate: NPO Status.” The goal was to resume oral diet when medically appropriate. On 10/10/2024 at 12:33 PM, Physician (MD)1, documented a discharge summary after examining him in the ICU. The discharge summary included: “Date of Discharge: 10/10/2024. ...Reason for Admission: DM1 DKA (Diabetes Mellitus Type 1, Diabetic ketoacidosis), intractable nausea and vomiting, moderate cannabis use, severe alcohol use, htn (hypertension) essential thrombocytosis. LOS (length of stay) 1 day ...He (P1) was treated in ICU standard protocol. He admits to noncompliance with insulin. No other factor were [sic] identified for trigger of DKA. He improved with hospitalization, was transitioned to subcutaneous insulin. He is being discharged with continued outpatient follow-up.” MD1 wrote a discharge order at 12:25 PM that was later discontinued at 02:56 PM. An order to transfer out of ICU was entered 10/10/2024 at 02:56 PM. On 10/10/2024 at 05:15 PM, Nursing note: “MD1 informed that pt BP 203/166 HR (heart rate/pulse) 105, not yet due for IV prn (intravenous as needed) hydralazine (for high blood pressure) or IV prn labetalol (for high blood pressure). Pt also nauseated and vomiting with no relief from odt Zofran and not due for IV prn Phenergan. MD, okay for RN to place order for 12.5 mg IV x1 and to increase prn IV Phenergan from 12.5 mg to 25 mg; regarding BP he will review pt’s chart and no additional orders at this time.” On 10/11/2024 at 04:59 AM, Nursing note: “..Multiple episodes of vomiting/retching. Minimal relief with Zofran. Felt no relief from Phenergan. Valium given for feelings of agitation due to constant nausea/vomiting. Tolerates only small sips of water. ... cl (clear) liquid as tol (tolerated). ...BS (blood sugar 227, 208. No coverage (insulin) given due to unable to keep food/fluids down. ...” Review of Intake and Output (I&O) documented after transfer to telemetry included: Emesis: 10/10/2024 at 10:00 AM: 60 ml. (milliliters (2 ounces)) 10/10/2024 at 01:00 PM: 1 unmeasured 10/10/2024 at 02:00 PM: 2 unmeasured 10/10/2024 at 03:00 PM: 3 unmeasured 10/10/1014 at 04:00 PM: 3 unmeasured 10/10/2024 at 05:00 PM: 400 ml. (13.6 ounces) 10/10/2024 at 08:05 PM: 200 ml. (6.8 ounces) 10/10/2024 at 09:53 PM: 240 ml. (8 ounces) Stool output: 10/10/2024 at 08:00 AM: “loose liquid.” 10/10/2024 at 02:00 PM: “loose stool small liquid” 10/10/2024 at 09:53 PM: “loose” Urine output and color (urine color changes from clear to orange with hydration level) 10/10/2024 at 05:24 AM: unmeasured 10/10/2024 at 08:00 AM: unmeasured 10/10/2025 at 02:00 PM: 475, yellow 10/10/2024 at 05:00 PM: 175, yellow amber 10/10/2024 at 08:10 PM: unmeasured, yellow amber 10/10/2024 at 10:20 PM: unmeasured, yellow amber 10/11/2024 at 01:00 PM: yellow amber Total Fluid Intake (excluding IV fluids) 10/10/2024: PO fluids, 540 ml 10/11/2024: PO fluids, 480 ml Food intake: 10/10/2024 at 02:00 PM: 25% (first meal since NPO) 10/11/2025 at 08:32 AM: Breakfast refused, 10/11/2024 at 11:15 AM: 50% Weights: 10/09/2024 210 lb. (documented as stated weight) 10/11/2024 191 lb. 9.3 oz On 10/11/2024 at 07:41 AM, MD1 put in a new order for Metoclopramide (Reglan) 10 mg by mouth for nausea and vomiting, three times a day before meals. The first dose was administered on 10/11/2024 at 08:27 AM. R1 refused breakfast, after that dose. The second dose of Reglan was administered at 11:49 AM. R1 ate 50% of lunch prior to being discharged shortly after lunch. On 10/11/2024 at 09:34 AM, MD1 wrote the order to discharge P1. On 10/11/2024 at 09:35 AM, MD1 documented an addendum to the discharge summary written 10/10/2024. The discharge date was changed to 10/11/2024. The addendum added: “Patient stayed overnight for intractable nausea and vomiting and uncontrolled hypertension. This had improved with the resumption of Reglan and low-dose benzodiazepines for anxiety. Prescriptions were given and he is being discharged home today. Patient does have chronic known thrombocytosis. There is no history of thrombotic complications. This needs to be followed as an outpatient. At the time of discharge: Patient’s condition is stable for discharge.” The addendum documented the last BP of 146/106, which was taken before he wrote the discharge order, It also included the last diet intake over the past 24 hrs to be 25% of breakfast (first meal after NPO) on 10/10/24. There was no documentation regarding P1’s nutritional intake after that or the IV hydrolazine at 11:48 AM on 10/11/205 for high blood pressure. On 10/11/2025 at 09:56 AM, nursing note: “...Critical platelets=1042 (high platelet count can cause blood clots/reference range 150-450 10 (9)L). MD (1) notified. 1143 (11:43 AM)-hydralazine IV given; BP 182/107. ...” There was no repeat BP after the IV medication was given or prior to P1’s leaving the hospital at 01:00 PM. It is the standard of nursing practice to monitor response of medication. On 10/11/2024 at 09:56 AM, dietitian note: “Follow up re: nutrition therapy education. N/V noted overnight, Pt sound asleep during time of visit. Healthy Hawaii Daily Food Guide for Diabetes Meal Planning handout left at bedside. RD to follow up with education as able/appropriate.” Reviewed the” After Visit Summary,” discharge instructions, which were documented to be given to P1 at 11:10 AM. The discharge instructions included “Diabetes and Alcohol: Care Instructions,” but did not include any instructions/education related to diabetic ketoacidosis, thrombocytosis or hypertension. In addition, P1’s primary care physician was not notified of the hospitalization as his name had been somehow “unlinked” to P1’s account. The instructions said to “F/u (follow up) PCP (primary care physician) 1-2 weeks.” On 02/27/2025 at 10:13 AM, interviewed RD2. She confirmed there was a consult order for dietician for P1 written on 10/09/2025. She said in general; they need to wait until someone is out of ICU and off the insulin drip. RD2 said many times a DKA patient just needs diet education, but if having cyclic vomiting and not tolerating food, despite noncompliance, would do education, but the priority is to ensure his nutritional needs are met. She went on to say, in this case, he had nausea and vomiting and need to make sure we are “getting enough into him.” RD2 said P1 was sleeping when she went to see him 10/11/2025 and wasn’t going to wake him because he had been throwing up all night. At that time, she was not aware he was being discharged that day. On 02/28/2025 at 09:30 AM, interviewed RD1 in the conference room. She said the consult for P1 was acknowledged and he was NPO and going through insulin therapy. RD1 said with intractable nausea and vomiting, it would be important to make sure he is eating well and gets good nutrition. “At least 50 % of meals on an average, anything less than 50% would be inadequate.” P1 had one meal 10/11/2025 documented at 50% and he went home shortly after. On 2/27/25 at 01:00 PM, interviewed RN1 in the conference room. She confirmed she discharged P1 on 10/11/2024 and said she was only assigned to him one day. RN1 said she recalled he had nausea and got Reglan that morning. She said she reviewed the discharge instructions and medications with him and told him to make an appointment with his PCP. RN1 said P1 had lunch before he left. She confirmed after the discharge order was written, she notified MD1 of the platelet critical value and high blood pressure and received an order to give P1 IV medication for the blood pressure. She acknowledged she should have, but did not check a repeat blood pressure after the administration of the IV medication and prior to his discharge. On 02/28/2025 at 10:30 AM, interviewed MD1 in the conference room. He said from his recall, P1 had recurrent DKA, came into the ER dehydrated and went to ICU on insulin drip. MD1 said “he improved overnight and did well on the floor. He tolerated diet and discharged the following day.” MD1 confirmed his documentation of dates and content of the discharge summary and addendum. He said, “it seemed to be a pretty straight forward case,” as there did not seem to be anything else except the noncompliance with medication that triggered the DKA. When asked MD1 if he had access to view I&O documentation, he responded yes. On 02/27/2025 at 09:10 AM, interviewed the Registration Supervisor (RS) in the conference room. She said she had been made aware there was an issue with P1’s PCP not showing on this admission, and explained someone had “unlinked” the name to the account. She said the PCP was present on the last admission, and looked like someone at the clinic rather than the hospital unlinked it, but was unable to determine specifics. She went on to explain it was importanct so the PCP is notified when a patient is admitted, and has access to the medical records. RS said the PCP can be added to the account at any time when an error is identified. Reviewed the facility policy titled “Discharge Planning” with revised date of 05/2024. The policy included: - Discharge Planning: “A process that is consistent with the patient’s goals for care and treatment preferences, ensures an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable readmission.” - “Reassessment of the patient’s condition to identify changes that require modification of the discharge plan. ...” -“Implementation of a safe discharge plan that reduces the likelihood of a hospital readmission.” - “5.3.3 Hospital records, including but not limited to medical information pertaining to the patient’s current course of illness and treatment, post discharge goals of care and treatment, are transmitted to the PCP upon discharge.””

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 39853 Based on interviews and record review (RR), the facility failed to assess one Patient’s (P)1 ability to care for herself with the resources she had and did not develop a safe discharge plan. The investigation revealed the facility discharge planning process was not effective for P1 in both the inpatient and outpatient (Emergency Department) setting. This deficiency resulted in P1, being discharged on more than one occasion without appropriate discharge planning. As a result of this deficiency, P1 returned to the Emergency Department (ED) several times, readmitted once and discharged and ultimately readmitted on 03/21/2024, after Adult Protective Services (APS) involvement. The cumulative effect resulted in a Condition level deficiency. Findings include: 1) P1 is a 77 year old female with a complex medical history that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, metabolic encephalopathy (disease that affects the brain and causes altered mental state and confusion), past drug abuse, delusions and dementia. She lived alone, had no involved family in the area, and was suppose to be receiving some home health (HH) aide services. P1 used a front wheel walker for short distances and was dependant on supplemental oxygen. She had an Advanced Health-Care Directive (AHCD) designating her sister Power of Attorney (POA). 2) RR reviewed P1’s hospital visits from 12/24/2023 to 03/01/2024 included: 12/24/2023, seen in the ED after a fall, which resulted in lacerations on both legs that required steri-strips and sutures. At that time she had no home health assistance to change the dressings as directed. 12/31/2023, seen in the ED because she could not reach her wounds to change the dressings and did not have help. The dressings were crusted and she required antibiotics. 01/06/2024, seen in the ED, for confusion, and difficulty breathing. Emergency Medical Services (EMS) reported that P1 had issues managing her oxygen equipment, and had contacted them multiple times. The ED progress notes documented “She would likely benefit from additional social work services given her declining baseline health status, advanced age and living alone.” Admitting diagnosis included left leg cellulits (bacterial skin infection). P1 was discharged home on 02/05/2024 with no additional resources. 02/16/2024, seen in the ED for hallucinations and discharged home. 03/12/2024, seen in the ED for shortness of breath and discharged home. EMS reported P1 contacted them four times in the past two days, and she had issues managing her oxygen equipment. 03/21/2024, seen in the ED and admitted. Hospitalist note included “...She (P1) was treated in the ED apparently could not be discharged as she did not have a safe discharge plan. Adult Protective Services apparently involved ...” 2) Cross Reference A-802 The hospital failed to ensure one patient (P)1 had a safe discharge plan. The hospital did not reevaluate the resources needed and capacity for P1 to care for herself safely when discharged from the hospital on 02/05/2024, or from the Emergency Department (ED) on 03/12/2024. She returned to the hospital on 03/21/2024 at which time there was involvement of Adult Protective Services (APS), who deemed it unsafe to discharge P1 home again. The discharges put her at high risk of adverse outcome.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 39853 Based on interviews, document and medical record review (RR), the hospital failed to ensure one patient (P)1 out of a sample size of three had a safe discharge plan. The hospital did not reevaluate the resources needed and capacity for P1 to care for herself safely when discharged from the hospital on 02/05/2024, or from the Emergency Department (ED) on 03/12/2024. As a result of this deficiency, she returned to the hospital on 03/21/2024 at which time there was involvement of Adult Protective Services (APS), who deemed it unsafe to discharge P1 home again. The discharges put her at high risk of adverse outcome. Findings include: 1) P1 is a 77 year old female with a complex medical history that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, metabolic encephalopathy (disease that affects the brain and causes altered mental state and confusion), past drug abuse, delusions and dementia. She lived alone, had no involved family in the area, and was suppose to be receiving 40 hours of home health (HH) aide services. P1 used a front wheel walker for short distances and was dependant on supplemental oxygen. She had an Advanced Health-Care Directive (AHCD) designating her sister Power of Attorney (POA). P1 had multiple ED visits and hospitalizations. 2) Reviewed P1’s ED visits and hospitalizations from 12/24/2023 to 03/01/2024. RR revealed the entries that included, but not limited to following: 12/24/2023: Seen in the ED for skin tear/lacerations sustained when she lost balance after standing and managed to pull over the kitchen table. The lacerations were closed with sutures and steristrips, and she was discharged home with instructions how to care for the wounds and to follow up with primary care provider (PCP). 12/31/2023: Seen in the ED for leg pain. The ED Provider documented “...Patient had stitches done on both legs one week ago. She is unable to change her dressings as she couldn’t get the gauze off without immense pain. Patient does not have a home health nurse and has no one else to help her. ...Her dressings were crusted on arrival. ... I did request case management to make arrangements to have home health see the patient for dressing changes in her home as she has limited mobility and does need dressing changes in [sic] can not reach her legs. 12/31/2023: Case Management (CM) clinical Note: “Chart reviewed for ED consult regarding Home Health needs for BL (bilateral) leg pain and dressing changes needs. Call to F/U (follow up) ED visit and she (P1) will see her PCP tomorrow. She declined CM (case management) needs. ... ED consult closed.” 01/06/2024: Seen in the ED, admitted and discharged on 02/05/2024. 01/06/2024: ED Provider note included: “...presents to the Emergency Department for evaluation of altered mental status. Per ED nurse, patient contacted EMS (emergency medical services) for difficulty breathing. She developed increased lethargy (drowsy) and frequent urination. She has a oxygen compressor at home but had issues with her oxygen tank and today noted low oxygen intake and “hooked the hose directly to her oxygen tank” and experienced minimal relief... She reports that she has a lack of resources at home, she has a sister who lives in the mainland who cares for her and has help aides that shop for her but has not seen them recently. She also states that she has home health aides that are scheduled to come every few days but they have not been visiting often. ...Per ED nurse, patient has contacted EMS frequently for the past several weeks and has been contacting them multiple times in the past few days. ...She was oxygen dependent and case management is not available this weekend to help facilitate obtaining oxygen concentrator. ...consulted medicine for admission. She would likely benefit from additional social work services given her declining baseline health status, advanced age and living alone.” 01/09/2024 Internal Medicine Progress note: “... Patient with history of dementia, very agitated overnight-argumentative with the staff/aggressive, will start Seroquel (antipsychotic).” Nursing Progress notes included: 01/06/2024: “Family Member, sister called, states she is POA, informed RN that her behavior and memory issues has been happening for up to 3 months now and has become progressively worse.” 01/08/2024 08:53 AM: “Pt is AOx2-3 (alert and oriented to person, place and time, not situation) confused and forgetful. Frequent reorientation provided. ...Pt can be impulsive and restless. ...New orders for safety sitter. ...” 01/11/2024 ...Pt was agitated this evening and not directable-removing nasal cannula and getting OOB (out of bed) without assistance. ..1:1 safety sitter at bedside.” 01/30/2024 09:38 AM: “...Unaware of safety limitations although noted to have steady gait when ambulating; refuses to use walker at times and needs reminder to utilize for safety. ... -Pt is unable to safely bathe without minimal assistance and supervision. -Pt can groom/dress self with cueing (can dress, but unable to choose or lay out clothes. -pt is disoriented (partially or intermittently)...” 01/30/2024 10:56 PM: “On ICF level of care (Intermediate Care Facility level of care- Criteria includes functional limitations to include self-care rather than acute medical needs) uncooperative, anxious, angry, refuses due medications to take. Came in to the next patient’s bed, trying to hit CNA (certified nurse assistant) staff with call bell, patient said: “I go pee on the floor I don’t care to all of you” and “where is the man with a kid with bubbles on his mouth. ...transferred to other room...due to unacceptable behavior. ...” 01/31/2024 01:58 AM: “...Confused- “there were 2 men right outside my window” re-oriented patient. ...” 02/02/2024 06:09 PM: “..A&x2. ...Constant redirection required. Patient with increased somnolence. ...” 02/04/2024 02:59 PM: “...Constant redirection required...Mental/Behavior: -pt is disoriented (partially or intermittently)...” 02/04/2024 11:08 PM: “...still wakes up at night saying “there’s a man inside the room with a boy, they are sitting on the second chair. ...” 02/05/2024 09:02 AM: “...Refused labs this morning despite education. ...forgetful/confused and irritable at times. ...Plan: return home today with HH for PT/OT (physical/occupational)...” 02/05/2024 10:04 AM, Hospitalist Discharge Summary: “...Dementia with behavioral issues-now improved, f/u with PCP...” 01/29/2024 Case Manager note: “ICF waitlist since 1/19/24. ...Pt is in the acute hospital, waiting for CG (caregiver/HH aide) to return from vacation, supposedly to return on 02/04/2024. ...No identified social support resources and other: no available caregivers to provide approved...services and pt not safe to live alone. Spoke to Home Health, who confirmed CG will return on the 4th. ...also mentioned she is the only CG that can handle P1. Plan: Return home when services are available. Pt does not meet ICF NF pts (points to meet level of care)...” The day before discharge, although P1 was assessed to be forgetful, needed redirection and continued to have delusions at night, she was discharged home to the same environment, living alone with the same resources. 02/16/2024 11:50 AM: Seen in ED and discharged. ED provider notes: “.... brought in by medics to the Emergency Department for evaluation of hallucinations. She states she went to a clinic ...but is unable to recall why she went there. Per medic report, patient was at Dr. ...office where patient reported visual hallucinations of children crawling on the roof. She states she has been sober from methamphetamines “for at least a month now. ... 02:53 PM: Patient well, no acute distress, awake and alert, clear headed. Unclear why she had any altered mental status ... stable for discharge at this time. Prior to leaving the department, the patient has a plan for discharge, has decision making capacity, and acknowledges an understanding of the verbal and written discharge instructions.” 03/12/2024 Seen in ED and discharged. ED provider notes: “...Per EMS (emergency medical services), patient has activated EMS 4 times in the past 2 days due to shortness of breath. Upon arrival to the patient’s home, they have found her nasal cannula cut, then taped and tied together and is unable to remember how to hook it up to oxygen tank. ... Consults: 03/12/2024 08:56 PM Spoke to Hospitalist about the case at length. Will review chart. 03/12/2024 09:12 PM. Spoke to Hospitalist. Updated on patient’s next course of action as she will be able to be discharged home via transport from Medic 10. ...Through shared decision making it was decided by the patient of [sic] myself that she could be safely discharged home. We arranged for the patient to be transported by ambulance with oxygen. I also put in for social work consult to evaluate her at her home for difficulties with her oxygen tank. ...” ED Nursing Notes: 07:43 PM: “Medics report multiple 911 phone calls from pt because pt can’t remember how to operate her home oxygen and she requires home O2 ... Medics reports pt seems to be having cognitive decline. Pt lives at home alone. She reports that she does have family on island but they are not involved in her life and the only family that she has that is involved with her life live on the mainland. ...Pt reports she can never remember how to take off the oxygen or hook it up to the new oxygen tank. ...” 08:47 PM: “Attempted to trial pt on room air. Pt desatted (oxygen level dropped) to 88%. MD aware, Pt put back on 2LNC (2 liters nasal cannula).” Social Services Note: “Reason for Referral ...Pt needing help learning how to use home O2. Has made frequent calls to paramedics for assistance with oxygen. Needs assistance with getting meals and ADL’s (activities of daily living). ...” Social Work Involvement: “Pt was discharged. SW (Social Worker) call to HH service coordinator ...requesting follow up with pt in the community and to call SW if further questions.” 03/21/2024 Seen in the ED and admitted. Provider notes: “...Medical Decision Making: ... presents to the Emergency Department for evaluation of dyspnea (Shortness of breath) ... she is on home oxygen and has breathing treatments available at home however she has dementia lives alone and has had poor compliance with treatment. On her home oxygen her oxygen levels are at baseline, she is not in respiratory distress, chest xray does not show signs of pneumonia or significant pulmonary edema. She was observed in the ER did not have additional findings. I discussed findings with the patients sister who reports that she is the POA. The patient’s sister insists that the patient needs to be admitted to the hospital that she is unsafe discharge and that Adult Protective Services had advised to seek admission in the hospital until she can be placed on April 5. I discussed with Hospitalist who declined admission at this time requesting instead social work and case management in the morning. ...” Hospitalist Admission History and Physical: “ ...COPD oxygen dependent and dementia who lives alone and was in the process of being placed at a facility due to her inability to live on her own. ...She was treated in the ED apparently could not be discharged as she did not have a safe discharge plan. Adult Protective Services (APS) apparently was involved and confirmed that the patient would not have placement until April 5th. Medicine Service asked to admit.” At the time of survey, P1 remained hospitalized waiting for placement. 3) On 06/12/2024 at 04:10 PM, interviewed the ED Provider (MD)1 for ED visit 03/12/2024. He explained the ED does not have Social Services (SS) available at night, so the provider will often order a consult and SS will follow up with the patient after discharge. MD1 said from his recall, P1 had been to the ED several times, had dementia, lived alone and used oxygen at home. Discussed the provider notes, and MD1 said the hospitalist didn’t want to admit her because she didn’t meet criteria, so he made a referral to Social Services. On 06/12/2024 at 04:30 PM, during an interview with the discharge ED RN (Registered Nurse) on 03/12/2024. She recalled the ED visit and said P1 “had trouble connecting the cannula (nasal tubing) to the tank (oxygen) and called the paramedics to the house multiple times and they showed her how to connect it. The fourth time they brought her to the ED because they felt she may need more resources at home to manage.” RN1 said she left at 10:00 PM that day and did not know if the Social Worker had seen P1 in the ED or not. She went on to say when she left, the plan was to send her home. When asked how she felt about that, she said “we could of maybe acknowledged the issue more.” RN1 said she did not know the conversation between the MD and the hospitalist. She said if patients don’t meet admission criteria, we can get Social Services involved to assist with outside resources. RN1 said it is a problem when the hospitalists don’t want to admit and often disagree on the level of care the patient needs. On 06/13/24 at 11:30 AM, interviewed Social Worker (SW)1 who responded to the ED consult for P1 on 03/12/2024. She said the ED has SS coverage till 04:30 PM, and it is “Consult based.” She went on to say if a consult is requested and they in the hospital, they will see the patient at that time. Otherwise, when they come in the morning they check for consults requested off hours, follow up and document a note in the medical record. She explained they “connect with community resources” after the patient is discharged. SW1 said for P1’s consult, she identified who her service coordinator was and called her. SW1 said she did not have a conversation with the service coordinator, but “left a message.” Asked specifically what the message was, and she replied “just informed her that P1 had been in the Emergency Room.” Inquired further if SW1 provided the service coordinator any specifics or that the follow up needed to be a priority because P1 was dependant on oxygen and couldn’t figure out her equipment, and she replied “no.” SW1 said SS is not involved in discharge planning, but focus on “connecting with community resources.” Discussed P1’s next visit to the ED and admission on 03/21/2024. SW1 said she had been told APS spoke with the Case Manager and said it was not safe to discharge P1 home. 4) Review of P1’s AHCD signed by her on 01/22/2022. In Part 1 of the AHCD, P1 identified her daughter as primary agent “to make health care decisions authorized in this document.” P1 checked the box that read: “If I mark this box my Agent’s and/or my alternate agent’s authority to make healthcare decisions for me takes effect immediately. I retain the authority to make my own decisions while I have capacity. P1 also checked the box in the AHCD that said “ If I mark this box, I do not want to be hospitalized or put in a convalescent or similar home as long as it is reasonable to maintain me in my personal residence.” 5) Reviewed the policy titled “Discharge Planning” last revised 7/2020. The policy included: “Policy Statement: A discharge plan for post-hospital or Emergency Department follow-up care is addressed by the interdisciplinary team. ...” Purpose: “2.1 To outline a process ..., to identify patients, with potential discharge planning needs, conduct discharge planning assessments, facilitate safe transitions in care, prevent avoidable readmissions ...” Provisions/Procedures: “Scope/Coverage: “5.1 Discharge Planning (DCP) begins on admission and identification of a hospitalized patient with care transition needs. ...” “5.3 The Case Manager and/or Social Worker performs an initial discharge planning assessment for patients who are likely to have discharge planning needs, with high risk for readmission, or other circumstances that increase the risk of an unsuccessful transition from the hospital setting. ...Triggers for DCP may include: ...” “5.3.3. Unscheduled readmission within 30 days of last discharge. ...” “5.3.7 Age >75.” “5.3.8 Diagnosis Specific ...g. Congestive Heart Failure h. Chronic Obstructive Pulmonary Disease ...” “5.3.9 Psych/Social ...c. Patients with significant self-care deficit related to chronic condition. ...” “5.4 The Discharge Plan will be reassessed throughout the patient’s stay... Factors that may trigger a reassessment include ...changes, in medical condition or function, or requests by any member of the clinical team, by the patient or by a person acting on the patient’s behalf. The plan may be modified based on the patient’s clinical status and as needed ...””