Aeries Healthcare of Illinois, Inc. DBA Riveredge Hospital

“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: 32741 Based on record review and interview, it was determined that for 1 of 11 (Pt. #3) closed clinical records reviewed for discharge planning, the Hospital failed to ensure that the patient’s family was notified of the time and mode of transportation on day of discharge. Findings include: 1. On 10/22/2024, the Hospital’s policy titled, “Patient/Family Discharge and Aftercare Plan” (dated 8/2023) was reviewed and required, “Discharge and aftercare planning is an important aspect of the patient’s treatment beginning at admission and continuing through the patient’s stay...RN completes discharge note, including date, time, type of discharge, manner in which patient left, destination, patient’s status and who accompanied patient...” 2. On 10/22/2024, Pt. #3’s clinical record (dated 8/20/2024 thru 8/30/2024) was reviewed and indicated: -Pt. 3’s initial psychiatric evaluation & treatment plan written by MD #2 dated 8/21/2024 noted, “Pt. #3 with a long history of psychiatric illness and extensive psychiatric hospitalizations, carries diagnosis of schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior), admitted due to increased aggression at home, shouting, seeing vampires not sleeping for the past several nights. Evidence of failure at or inability to benefit from a less intensive outpatient setting. Pt. #3 is oriented to person and place.” - Pt. #3’s discharge order written by MD #2 dated 8/30/2024 noted “Discharge Pt. #3.” Pt. #3’s nursing discharge instructions written by the Registered Nurse (E #7) dated 8/30/2024 noted, “List of medications reviewed with Pt. #3. Copy of Crisis Safety Plan reviewed and given to Pt. #3. All belongings sent with Pt. #3 and Pt. #3 signed inventory form. Suicide prevention materials provided. Aftercare Plan reviewed with Pt. #3. Pt. #3 able to verbalize discharge instructions. Pt. #3 verbalize understanding of when/how to seek further treatment.” -Pt. #3’s clinical record noted that on 8/29/2024, “E #6 attempted to contact Pt. #3’s mother and sister to inform them of scheduled discharge for Pt. #3 tomorrow. There was no answer and E #6 was unable to leave VM (voice message) due to mailbox being full. Writer will attempt to contact family tomorrow prior to Pt. #3 discharging.” -Social service discharge note written by E #6 dated 8/30/2024 noted Pt. #3 was discharged back to Pt. #3’s mother and sister’s home. Method of transportation will be used to transport Pt. #3 at discharge - cab. The note did not include an attempt to contact Pt #3’s family on 8/30/2024 prior to discharge. 3. On 10/23/2024 at 9:15 AM, an interview was conducted with the Registered Nurse (E #7). E #7 stated that E #7 discharged Pt. #3 on 8/30/2024. E #7 stated that E #7 did not know if Pt. #3’s mother was notified regarding Pt. #3’s discharge. E #7 stated that E #7 walked Pt. #3 down to the hospital lobby and gave Pt. #3 a bus card (that was provided by the social worker - E #6). E #7 stated that E #7 asked Pt. #3 if Pt. #3 knew what bus to take. E #7 stated that Pt. #3 refused assistance and walked out the hospital door. 4. On 10/22/2024 at 11:00 AM, an interview was conducted with the Director of Social Service (E #4) regarding the process for discharge planning. E #4 stated that this facility has an arrangement with the cab company that the cab company will transport patients “door to door.” E #4 stated that if any problems arise during the transport to the discharge location, the cab company will notify E #4. E #4 stated that E #4 told E #6 that Pt. #3 was ok to take a cab. E #4 stated that E #4 talked to Pt. #3 about taking a cab, and Pt. #3 agreed to take a cab. E #4 stated that E #4 is not sure what happened on the day of Pt. #3’s discharge. E #4 stated that Pt. #3 must have refused the cab and agreed to a bus pass.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 5 patient (Pt. #1) clinical record reviewed for care planning, the hospital failed to ensure that Pt. #1’s representative participated in the development of the care plan. Findings include: 1. The hospital provided a document titled, “Rights of Individuals Receiving Mental Health and Developmental Disabilities Services” (undated) was reviewed and included, “Medical/Dental Services: Except in emergencies, no medical or dental services will be provided to you without informed consent.” 2. On 07/17/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 06/15/2024 due to increasing aggression. The clinical record included the following: -Medicine Progress Notes (MD #2) dated 07/07/24, included, “I was called to evaluate (Pt. #1) complaining of toothache. Patient is pointing to right upper molar tooth. Problem/Assessment: Toothache” The clinical record did not include documentation that (MD #2) or nursing staff contacted (Pt. #1’s) mother regarding tooth infection and treatment with oral antibiotics. -Physicians’ orders, dated 07/07/24, “Acetaminophen (pain medication) 500 mg (milligrams) by mouth every 6 hours as needed for pain. Amoxicillin (antibiotic) 500 mg oral every 8 hours by mouth for tooth infection for 7 days.” 3. An interview was conducted with the Attending Physician (MD #2) on 07/18/24 at 9:20 AM. MD #2 stated that MD #2 was called to evaluate (Pt. #1) several times for different reasons including a toothache. MD #2 stated that it is protocol to contact the parent or guardian to inform of any change in condition and treatment plan including tooth infection with plan to treat with antibiotics. MD #2 stated that MD #2 did not call the parent, and assumed that the nursing staff would call to update (Pt. #1’s) mother.”

“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: 39802 Based on document review and interview, it was determined that for 3 of 7 records (Pts. #4, #5, and #7) reviewed for safety precautions, the Hospital failed to ensure that safety precautions were documented on the observational rounding records to ensure that staff were aware of what behaviors to monitor for during rounding. Findings include: 1. The Hospital’s policy titled, “Patient Observations” (revised 8/2020), was reviewed and required, “...The RN [registered nurse] ensures that the patient observation/precaution status is reviewed daily... Documents the patient observation/precaution level on the Patient Observation/Precaution Form... MHA [mental health associate]: ... Review and update patient observation forms. Reflect changes in individual patient precaution levels...” 2. The clinical record of Pt. #4 was reviewed on 4/17/2024. Pt. #4 was admitted on 4/14/2024, with a diagnosis of schizoaffective disorder (mental health disorder). Physician orders for aggression/homicide precautions, elopement risk, sexual victimization risk, and fire starting risk were placed on 4/14/2024 at 7:00 PM. Patient Observation Records from 4/14/2024 and 4/15/2024 lacked any precautions marked for Pt. #4 on these dates. 3. The clinical record of Pt. #5 was reviewed on 4/17/2024. Pt. #5 was admitted on 4/13/2024, with a diagnosis of schizoaffective disorder. Physician orders for aggression/homicide precautions, elopement risk, sexual aggression risk, suicide precaution, and self-harm risk were placed on 4/13/2024 at 7:00 AM. Patient Observation Records from 4/13/2024 to 4/16/2024 did not include homicide/assault precautions and/or self-harm risk. 4. The clinical record of Pt. #7 was reviewed on 4/17/2024. Pt. #7 was admitted on 4/11/2024, with a diagnosis of bipolar disorder (mood disorder). Physician orders for aggression/homicide precautions and suicide precaution were placed on 4/11/2024 at 7:00 PM. Fire starting risk orders were placed on 4/12/2024 at 12:00 PM. Patient Observation Records from 4/11/2024 to 4/14/2024 lacked any precautions marked for Pt. #7 on these dates. 5. An interview was conducted with MHA (E#11) on 4/17/2024, at approximately 12:00 PM. E#11 stated that rounding staff know what precautions a patient is on by looking at what’s marked on the observation sheets. E#11 stated that these sheets are reviewed at the beginning of the shift by the nurse and updated throughout the shift if a precaution is added or removed. E#11 stated that it’s important to mark the sheets so that staff know what behaviors and risks to monitor for each patient.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 4 clinical records (Pt #1) reviewed for medications prescribed following discharge, the Hospital failed to ensure that the discharge medication list was accurate. Findings include: 1. The Hospital’s policy titled “Patient/Family Discharge and Aftercare Plan” (dated 8/2023) was reviewed and required, “The Physician completes the discharge order: Provides prescriptions for current psychotropic medications...RN (Registered Nurse) checks chart for prescriptions and gives to patient/family...RN completes discharge note, including date, time, type of discharge, manner in which patient left, destination, patient’s status and who accompanied patient. Note if prescriptions were given to patient/family and that family/patient was instructed about how to administer medication at home. Document education provided for appropriate medical care/follow-up as needed.” 2. Pt #1’s clinical record dated 11/20/2023 thru 11/27/2023 was reviewed and indicated: -Pt #1 was admitted to inpatient behavioral health unit on 11/20/2023 with the diagnosis of paranoid schizophrenia. -Pt #1’s discharge medication summary report, completed on 11/24/2023, noted, “these discharge prescriptions ePrescribed to local pharmacy” included “Remeron [antidepressant] 45 mg at bedtime, Cogentin [anti-tremor] 2 mg twice a day and Zyprexa [antipsychotic]10 mg at bedtime.” The discharge medication summary was signed by Registered Nurse (no longer employed at the Hospital) and Pt #1 on 11/27/2023. -Pt #1’s discharge medication summary dated 11/27/2023, and signed by MD #1, for Pt #1 noted the following medications: -Cogentin 2 mg twice a day for eps (extrapyramidal side effects - drug induced movements disorders), Remeron 45 mg at bedtime for sleeplessness, Zyprexa 10 mg at bedtime for major depressive disorder, and Risperdal [antipsychotic] 2 mg twice a day for mood/psychosis. 3. On 2/13/2024 at 2:30 PM, an interview was conducted with MD #1. MD #1 stated that Pt #1’s Zyprexa was discontinued on 11/24/2023, and Pt #1 was started on Risperdal 2 mg twice a day (beginning 11/24/2023). MD #1 stated that Pt #1 was supposed to be discharged with a prescription medication order for Risperdal not Zyprexa. MD #1 stated that it may have been his error that Pt #1 signed a discharge medication summary (discharge prescriptions sent to pharmacy) for Zyprexa instead of Risperdal. MD #1 stated that MD #1 cancelled the Zyprexa with the pharmacy prior to Pt #1’s discharge, and the pharmacy did not dispense Zyprexa. MD #1 stated that the pharmacy dispensed Risperdal, not Zyprexa. [This was confirmed through review of report which had been obtained from pharmacy where ePrescription had been sent.] However, MD #1 did not ensure that the discharge paperwork had been updated before Pt #1 signed and was discharged.”