Larabida Childrens Hospital I

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 40079 Based on document review and interview, the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to conduct an appropriate medical screening examination, including a complete triage assessment, and examination by a qualified medical practitioner (QMP) determined by the hospitals’ medical Staff by-Laws to determine whether or not an emergency medical condition existed.See A-2406. 2. The hospital failed to ensure that an appropriate transfer was performed. See A-2409.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 9 of 20 records (Pt. #1, #3, #4, #5, #6, #7, #9, #10, & #20) reviewed for individuals who presented to the Emergency Department (ED), the hospital failed to ensure that the correct disposition was documented on the ED Centralized Log, as required. Findings include: 1. The hospital’s policy titled, “EMTALA: Emergency Medical Treatment and Labor Act” (Last Approved 4/2021) was reviewed and included, “Central Log 1. Hospital shall maintain a Central Log of all individuals who come to the ACC (Acute Care Clinic) or are transferred to Hospital for a potential emergency medical condition. The log shall identify the individual by name and other identifying information as well as whether the individual ... was transferred, admitted and treated, stabilized and transferred, or discharged from Hospital.” 2. The clinical record of Pt. 1 was reviewed. Pt. #1 presented to the ED, on 03/11/2025 at 1:53 PM, with a chief complaint of constipation/abdominal pain. The clinical record lacked documentation of the patient’s disposition. 3. The clinical record of Pt. #3 was reviewed. Pt. #3 presented to the ED, on 03/21/2025 at 10:00 PM, with a chief complaint of wound on hand. The clinical record did not include the patient’s disposition. 4. The clinical record of Pt. #4 was reviewed. Pt. #4 presented to the ED, on 04/20/2025 at 7:36 PM, with a chief complaint of emesis (vomiting) and diarrhea. The clinical record indicated that the patient was referred to higher level of care, however the patient was discharged to home and instructed to follow up with their primary physician. 5. The clinical record of Pt. #5 was reviewed. Pt. #5 presented to the ED, on 05/10/2025 at 10:44 AM, with a chief complaint of skin abrasion. The clinical record lacked documentation of the patient’s disposition. 6. The clinical record of Pt. #6 was reviewed. Pt. #6 presented to the ED on 6/2/2025 at 12:48 AM, with a chief complaint of right flank pain. The clinical record did not have documentation of patient disposition. 7. The clinical record of Pt. #7 was reviewed. Pt. #7 presented to the ED on 6/19/25 at 2:20 PM, with a chief complaint of earache. The clinical record did not have documentation of the patient’s disposition. 8. The clinical record of Pt. #9 was reviewed. Pt. #9 presented to the ED on 7/9/25 at 8:00 pm, with a chief complaint muscle pain and sore legs. For Pt. #9, the clinical record did not have documentation of patient disposition. 9. The clinical record of Pt. #10 was reviewed. Pt. #10 presented to the ED on 8/10/25 at 7:45 pm with a chief complaint constipation and inability to pass bowels. The clinical record did not have documentation of a patient disposition. 10. The clinical record of Pt. #20 was reviewed. Pt. #20 presented to the ED on 5/10/25 at 1:37 PM with a chief finger pain. The clinical record indicated that Pt. #20 was categorized as non-emergent condition and was referred to a higher level of care, however the record did not indicate where Pt. #20 was referred to. 11. The hospital’s ED Logs dated 02/19/2025 through 08/16/2025 was reviewed. The log did not indicate a disposition for Pt. #1, #3 - #7, #9, #10, & #20. 12. An interview with the Chief Medical Officer (MD#1) was conducted on 8/21/2025 at approximately 12:20 PM. MD#1 stated that the ED Log and clinical records should include the disposition of patients, whether transferred for higher level of care or discharged to home.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50411 Based on document review and interview, of 10 (Pt. #1, #2, #3, #5, #6, #7, #8, #9, #10, and #20) of 20 clinical records reviewed for patients seeking emergency medical services, the hospital failed to conduct an appropriate medical screening examination, including a complete triage assessment, and examination by a qualified medical practitioner (QMP) determined by the hospitals’ medical Staff by-Laws to determine whether or not an emergency medical condition existed. Findings include: 1. The hospital’s policy titled “EMTALA: Emergency Medical Treatment and Labor Act” (Last Approved 4/2021) was reviewed and included, “ ...”Medical Screening Examination” or “MSE” - The process required to reach, with reasonable certainty, the point at which it can be determined whether the individual has an emergency medical condition, including the use of necessary available testing resources ... [In general, a proper MSE should generally include: log entry with disposition, triage record, recording of vital signs, oral history, physical examination, use of on-call physicians as needed, discharge or transfer vital signs, and adequate documentation ...” 2. On 8/22/2025, the hospital’s Medical Staff By-Laws (Approved 11/9/2015) did not indicate who can perform a medical screening examination. 3. On 8/22/2025, the hospital’s Medical Staff By-Laws (Approved 07/29/2025) included, “Section 8 - Medical Screening Exams. Qualified medical personnel performing medical screening exams in the Acute Care Clinic may include registered nurses and APNs (Advance Practice Nurse) ...” 4. The clinical record of Pt. #1 was reviewed. Pt. #1 presented to the Emergency Department (ED), on 02/20/2025 at 5:07 PM, with a chief complaint of fever. The clinical record lacked documentation of a complete MSE (Medical Screening Examination). The medical record did not include documentation of a vital signs, such as respirations, oxygen saturation level, temperature, or a review of systems. 5. The clinical record of Pt. #2 was reviewed. Pt. #2 presented to the ED, on 03/11/2025 at 1:53 PM, with a chief complaint of constipation/abdominal pain. The clinical record lacked documentation of a complete MSE. The record did not include documentation of vital signs such as respirations, blood pressure, oxygen saturation, temperature, and review of systems. 6. The clinical record of Pt. #3 was reviewed. Pt. #3 presented to the ED, on 03/21/2025 at 10:00 PM, with a chief complaint of wound on hand. The clinical record lacked documentation of a complete MSE, vital signs or a pain assessment. 7. The clinical record of Pt. #5 was reviewed. Pt. #5 presented to the ED, on 05/10/2025 at 10:44 AM, with a chief complaint of skin abrasion. The clinical record lack documentation of a complete MSE, vital signs, pain assessments and review of systems. 8. The clinical record of Pt. #6 was reviewed. Pt. #6 presented to the ED on 6/2/2025 at 12:48 AM, with a chief complaint of right flank pain. There was no documentation of vital signs or a pain assessment. 9. The clinical record of Pt. #7 was reviewed. Pt. #7 presented to the ED on 6/19/25 at 2:20 PM, with a chief complaint of earache. The clinical record lacked a complete medical screening examination (MSE). The only vital sign documented was a temperature of 98.6 F (Fahrenheit) (normal temperature 97 F to 99 F). There were no other vital signs nor pain assessment documented. 10. The clinical record of Pt. #8 was reviewed. Pt. #8 presented to the ED on 6/21/25 at 7:35 PM, with a chief complaint of a rash. The clinical record lacked a complete medical screening examination (MSE). The only vital sign documented was a temperature of 37.1 C. There were no other vital signs nor pain assessment documented. 11. The clinical record of Pt. #9 was reviewed. Pt. #9 presented to the ED on 7/9/25 at 8:00 PM, with a chief complaint muscle pain and sore legs. The clinical record lacked documentation of a complete MSE. The only vital signs documented were oxygen saturation of 99.1% (reference range (95% to 100%) on room air and temperature of 36.6 C (Celsius) (reference range 36.5 C to 37.5 C). There was no documentation of a pain assessment documented. 12. The clinical record of Pt. #10 was reviewed. Pt. #10 presented to the ED on 8/10/25 at 7:45 PM with a chief complaint constipation and inability to pass bowels. The clinical record lacked a complete medical screening examination (MSE). The record only included a temperature of 37.3 C. No other vital signs nor pain assessment were documented. 13. The clinical record of Pt. #20 was reviewed. Pt. #20 presented to the ED on 5/10/25 at 1:37 PM with a chief complaint of finger pain. The clinical record lacked a complete medical screening examination (MSE). The record did not include vital signs, pain assessment or review of systems. 14. On 8/20/2025 at approximately 12:00 PM, an interview was conducted with the Pediatric Hospitalist (MD#3). MD#3 stated that for all patients who present to the Hospital for medical assistance, an MSE should be completed. The MSE should include at least the vital signs (blood pressure, temperature, respiratory rate, pulse rate), a complete physical assessment (head to toe examination). 15. On 8/20/2025 at approximately 1:52 PM, an interview was conducted with the Chief Medical Officer (MD#1). MD#1 stated that during change of leadership of the hospital sometime in May 2025, MD#1 performed audits of charts involving EMTALA compliance and identified issues with Medical Screening Examination. MD#1 stated that for all patients presenting in the ED requesting for medical assistance, an MSE should be performed. 16. On 08/21/2025 at approximately 2:30 PM, an interview was conducted with the Chief Executive Officer (E #2). E #2 stated that the hospital’s Medical Staff By-Laws approved 11/9/2015, did not include who can perform medical screening examinations in the ED. The current By-Laws approved 07/29/2025, were updated to include who can perform MSE, which includes RNs, APNs, and Physicians.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 50411 Based on document review and interview, for 1 (Pt. #13) of 3 patients seeking medical evaluation and transferred, the Hospital failed to ensure that an appropriate transfer was performed. Findings include: 1. The hospital’s policy titled “EMTALA: Emergency Medical Treatment and Labor Act” (Last Approved 4/2021) included: “...Appropriate Transfer - A transfer is appropriate if: Hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; The transferring physician or designee has contacted the receiving facility and documented that the receiving facility has available space and qualified personnel for treatment of the individual and has agreed to accept the individual and to provide appropriate medical treatment; Hospital provides copies of all medical records related to the emergency medical condition that the individual has presented that are available at the time of the transfer...; The transfer is carried out by qualified personnel and transportation equipment, including necessary and medically appropriate life support measures...” 2. The clinical record of Pt. #13 was reviewed. Pt. #13 presented to the Emergency Department (ED) on 4/07/2025 at 2150 (9:20 PM), with a chief complaint of breathing difficulty. The clinical record included: -ACC (Acute Care Coordinator) documentation dated 4/7/2025 at 10:11PM included Chief Complaint Difficulty breathing ...Brief History and focused exam ...in no apparent distress. Mom stated wants (Pt. #13) checked out ...Mom wants 911 called, (physician) assessed the child, called 911 they arrived at 2220 (10:30 PM) taken to (Outside hospital/OSH) for further evaluation ...Triaged and transferred to high level of care ...” - The “Non Patient Documentation Tool” completed on 4/7/2025 at 10:28 PM, by the physician indicated “Pt. #13 (pediatric) observed ambulating, running, laughing in no distress ...lungs clear ...due to reported respiratory event, unresponsive event, called 9111 for evaluation. Handoff completed with EMS (ambulance)” The clinical record did not indicate that the receiving facility was contacted to ensure they had available space, qualified personnel to provide appropriate medical treatment and that they could accept the patient. 3. On 8/20/2025 at approximately 9:47 AM, an interview was conducted with the Administrative Nurse Coordinator (E#6). E#6 stated that when a patient needs to be transferred, the hospital will utilize the service of an ambulance provider. For patients with conditions beyond the capability of the hospital, E#6 stated that they will call 911. E#6 stated that for transfers, transfer documentation is completed and a physician-to-physician report or nurse to nurse report is done. E#6 stated that the transfer documentation includes a certification by the physician of the need for transfer. E#6 added that their process to comply with EMTALA was changed about a week before July 4 of this year. 4. On 8/21/2025 at approximately 12:20 PM, an interview was conducted with the Chief Medical Officer (MD#1). MD#1 stated that minor patients that present to the hospital with request for medical assistance and needs a higher level of care will be transferred in accordance with their transfer protocol and agreement. MD#1 stated that these patients should be transferred following their transfer protocol (utilize an ambulance provider, providing report to receiving hospital, completion of transfer documentation). MD#1 stated that for adult non-patients who present for medical assistance, these cases would not be within their scope of practice so these patients would be stabilized based on their capability and 911 called to transport the patient to a facility capable of caring for the patient.”

“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: 36774 Based on document review and interview, it was determined that for 1 of 5 patients’ (Pt. #1) clinical records reviewed regarding discharge planning, the hospital failed to ensure that the plan was updated. Findings include: 1. On 11/25/2024, the hospital’s document titled, “Inpatient Case Management Discharge Planning” (8/2023) included, “ ... To provide guidance to the inpatient case management staff on discharge planning ... Procedure ... III. The discharge plan will be noted in the EMR (electronic medical record) ... The discharge plan is a fluid plan and will be updated when there are changes or additions to the plan based upon the patients’ needs ...” 2. On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. On 7/25/2024, Pt. #1 was discharged to (Name of Skilled Nursing Facility). There was no documentation regarding re-evaluation of Pt. #1’s mode of transportation upon discharge to (Name of Skilled Facility). 3. On 11/25/2024, the multidisciplinary discharge plan meeting notes on 7/24/2024 for Pt. #1 was reviewed and indicated, “ ... (Case Manager) discharge plan: Tentative Discharge Date: 7/25/2024 ... Transitional Care ... (Pt. #1) will transfer from (Name of Skilled Facility) to (Name of Transitional Home A) once they open ...” The note did not include Pt. #1’s mode of transportation. 4. On 11/25/2024 at approximately 2:09 PM, and on 11/26/2024 at approximately 9:30 AM, interviews were conducted with E #3 (Social Worker). Regarding the mode of transportation, E #3 stated, “the options were to: 1) send (Pt. #1) through ambulance, but (Pt. #1) was not approved (by the insurance); 2) (Z1/Pt. #1 DCFS Foster Parent) will go with (Pt. #1), but (Z1) lives 3 hours away; and 3) (Pt. #1’s) insurance will make the arrangement and our employee will go with the patient. However, the transportation arranged by the insurance was too small, and was not wheelchair accessible. So, we call an Uber that was wheelchair accessible and have a staff accompanied (Pt. #1). 5. On 11/25/2024 at approximately 10:30 AM, an interview was conducted with E #8 (Pt. #1’s Advance Practice Provider). E #8 stated that Pt. #1 was appropriate for discharge on 7/25/2024. However, E #8 stated that E #8 was not aware that there was an issue with Pt. #1’s mode of transportation. E #8 stated that to ensure appropriateness of discharge planning, e.g., transportation issue, E #8 expects to be contacted.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 5 patients’ (Pt. #1) clinical records reviewed for discharge planning, the hospital failed to ensure that Pt. #1’s placement was discussed/approved by Pt. #1’s legal guardian. Findings include: 1. On 11/25/2024, the hospital’s policy titled, “Discharge Procedures” (5/2023) included, “ ... to establish standards to inform and instruct the patient and caregiver of medical care related to health needs prior to discharge, to promote safe transition of patient to home or long-term care unit ...” 2. On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. The clinical record included: - The face sheet indicating Z1 as Pt. #1’s DCFS (Department of Childrens and Family Services) foster parent, case worker, and person to notify regarding Pt. #1’s care. - On 7/16/2024 at 3:19 PM, E #3 documented, “ ... Discharge Planning. (E #3) spoke with DCFS worker (Z1) about (Name of Skilled Nursing Facility) transitional care. Per (Z1), (Pt. #1) was referred in the past and (was) denied. (Z1) will investigate again and update (E #3) to submit a referral, if needed.” - On 7/22/2024 at 8:43 AM, E #3 documented, “(Name of Skilled Nursing Facility) accepted (Pt. #1). Awaiting admission date.” - On 7/23/2024 at 8:28 AM, the covering case manager documented, “ ... Discussed during (Discharge Plan Meeting) plan to transfer (Pt #1) to (Name of Skilled Nursing Facility) transitional care this week ...” There was no documentation that Pt. #1’s placement was discussed/approved by Z1. 3. On 11/25/2024 at approximately 2:09 PM, and on 11/26/2024 at approximately 9:30 AM, interviews were conducted with E #3 (Social Worker).” E #3 stated that there was no documentation in the clinical record to indicate that Z1 agreed with the plan to transfer Pt. #1 to (Name of Skilled Facility).”

“DISCHARGE PLANNING-QUALIFIED PERSONNEL CFR(s): Any discharge planning evaluation or discharge plan under this paragraph must be developed by or under the supervision of a registered nurse, social worker, or other appropriately qualified personnel. This Standard is not met as evidenced by: 36774 A. Based on document review and interview, it was determined that for 1 of 5 patients’ (Pt. #1) clinical records reviewed regarding discharge planning, the hospital failed to ensure that the personnel responsible for discharge confirmed that Pt. #1’s urologic, wound, and bathing supplies were authorized/provided at (Skilled Nursing Facility) prior to Pt. #1’s discharge. Findings include: 1. On 11/25/2024, the hospital’s policy titled, “Inpatient Case Management Discharge Planning” (8/2023) included, “ ... To provide guidance to the inpatient case management staff on discharge planning ... Procedure ... III. The discharge plan will be noted in the EMR (electronic medical record) ... The discharge plan is a fluid plan and will be updated when there are changes or additions to the plan based upon the patients’ needs ... g ... medical supplies are to be provided ...” 2. On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. The clinical record included: - On 7/23/2024 at 5:15 PM, E #2 (Case Manager) documented, “ ... Presenting Problem... DME (Durable Medical Equipment), Discharge Planning ... Notified this morning that (Pt. #1) was going to transfer to (Name of Skilled Nursing Facility) on Thursday (July 25, 2024) ... Reached out to (Name of Insurance Case Worker), asking for approved DME companies that can provide (Pt. #1’s) wound care and urological needs ... I completed the orders and faxed them to (Name of DME Company). Will follow-up ... I also received an email from (Pt #1’s) OT (Occupational Therapist) who requested that I order a tub transfer bench and over the toilet commode ... (Name of DME Company) cannot provide the supplies. I emailed (Name of Insurance Case Worker) asking what company they use ... currently awaiting a response...” - On 7/25/2024 at approximately 8:30 AM, E #8’s (Pt. #1’s Advance Practice Provider) discharge plan, instructions, and summary, indicated, “ ... Discharge Diagnosis: Muscle Weakness ... Discharge to: (Name of Skilled Nursing Facility) ... DME Company ... Bath Equipment Supplier ... Neurogenic Bladder: Continue (every 4 hours clean intermittent catheterization, allowing an 8-hour break overnight from 12 AM to 8:00 AM to promote sleep hygiene) ... Sacral Pressure Injury ... Remove old dressing. Cleanse wound with Vashe Wound Cleanser by saturating 4 x 4 gauze and placing in wound bed (for) 5-10 minutes ... Apply Sureprep (type of wound dressing) ... to protect the skin. Pack Calcicare Silver dressing to wound bed ... Cut rectangular piece of Hydrofera Blue (type of wound dressing) ... Change every three days or as needed for drainage or stool soilage...” - The clinical record lacked documentation ensuring that the personnel responsible for discharge confirmed that the urologic, wound, and bathing supplies were authorized/provided to (Skilled Nursing Facility). 3. On 11/25/2024 at approximately 9:15 AM, an interview was conducted with E #2 (Case Manager). E #2 stated that E #2 handled arrangement of Pt. #1’s urological, wound, and bathing needs. E #2 stated that there should be documentation that the urological and wound supplies were provided and authorized. E #2 could not provide documentation that urological, wound, and bathing supplies were provided to Pt. #1, along with confirmation that the supplies were authorized to be delivered to the facility. B. Based on document review and interview, it was determined that for 1 of 5 patients’ (Pt. #1) clinical records reviewed, it was determined that the hospital failed to document that Pt. #1’s legal guardian understood the discharge instructions: Pt. #1’s time of discharge, mode of transportation, and condition of Pt. #1. Findings include: 1. On 11/25/2024, the hospital’s policy titled, “Discharge Procedures” (5/2023) included, “ ... The purpose of this policy is to establish standards to inform and instruct the patient and caregiver of medical care related to health needs prior to discharge ... Policy... B. The nurse is responsible for the discharge process...” 2. On 11/25/2024, the hospital’s document titled, “Discharge Procedure” (undated) included, “ ... 6. Document the discharge in the electronic medical record to include: A. The ... legal guardian’s understanding of the discharge instructions ... C. Time Discharged. D. Mode of transportation ... E. Condition of patient. F. Person to whom the patient was discharged ...” 3.On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. On 7/25/2024, Pt. #1 was discharged to (Name of Skilled Nursing Facility). The clinical record lacked documentation of Pt. #1’s legal guardian’s understanding the discharge instructions, Pt. #1’s time of discharge, mode of transportation, and condition of Pt. #1. 4. On 11/26/2024 at approximately 9:47 AM, a telephone interview was conducted with E #1 (Pt. #1’s Registered Nurse on 7/25/2024). E #1 stated that there should be discharge documentation in Pt. #1’s clinical record.”