Menorah 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: 47233 Based on policy review, record review, and interview, the hospital failed to ensure the discharge planning process effectively assessed and evaluated the respiratory needs for 1 of 9 (Patient 1) patients upon discharge. The failure to assess and evaluate patient care needs at discharge places patients at risk for poor outcomes and/or hospital readmissions. Findings Include: The hospital failed to ensure the discharge planning process identified a patient likely to suffer adverse health consequences at the time of discharge for 1 of 9 (Patient 1) patients reviewed. (Refer to Tag A-0800)”

“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: 47233 Based on record review, document review, policy review, and interview, the hospital failed to ensure the discharge planning process identified a patient likely to suffer adverse health consequences at the time of discharge for 1 of 9 (Patient 1) patients reviewed. This deficient practice has the potential to negatively impact the health and well-being of patients and result in rehospitalizations. Findings Include: Review of a hospital policy titled, “Discharge Planning Policy,” dated October 2024, showed “ ... To identify a process that ensures patients are screened using appropriate criteria, and discharge needs are identified ...The discharge planning process will support patient care across the continuum ... Patients will be screened who may have discharge needs based on such factors such as but not limited to ... diagnosis ... or other high-risk indicators ... Case Management ensures that there is a safe discharge plan in place for the patient ... prior to the patient physically leaving the acute care setting ...” Patient 1 Review of Patient 1’s discharged medical record showed a 67-year-old admitted on 02/01/25 for respiratory failure. Medical history showed chronic obstructive pulmonary disease (COPD) (a progressive lung condition that causes breathing difficulties due to airflow limitation), obstructive sleep apnea (OSA) (sleep-related breathing disorder), chronic hypoxic respiratory failure (an ongoing condition where body tissues do not receive enough oxygen to properly function), and hypercapnic respiratory failure (condition where the body’s ability to eliminate carbon dioxide is impaired) with dependence on 4 liters (L) of oxygen (O2) via nasal canula (NC). Review of a document titled, “History of Present Illness,” dated 02/01/25 at 9:57 PM, showed “ ... COPD on 4L/NC at home ...” Review an order dated 02/01/25 at 10:12 PM, showed Patient 1 had an order for oxygen therapy via nasal canula. Review of a document titled, “Coding Summary” dated 02/01/25 (date of admission) at 4:21 PM through 02/19/25 (date of discharge) at 6:42 PM showed, “ ...DEPENDENCE ON SUPPLEMENTAL OXYGEN ...” Review of a “Physician Attestation,” dated 02/14/25 at 4:22 PM, showed that Patient 1 had a diagnosis of “severe oxygen-dependent COPD with hypercapnic respiratory failure.” Review of a document titled, “Hospitalist Discharge Summary,” dated 02/19/2025 at 10:17 AM, showed “ ... Assessment Acute on Chronic Hypoxic and Hypercarbic [sic] Respiratory Failure (4L NC at baseline) ...” Review of Patient 1’s “Discharge Report,” dated 02/19/25 at 10:17 AM, showed that Staff J, MD, documented, “I certify this patient requires post-hospital: ... respiratory therapy ... oxygen ...” Review of Patient 1’s discharge medical record failed to show documented evidence that a discharge order was placed for supplemental oxygen. Review of a document titled, “Nurses Notes,” dated 02/19/25 at 6:42 PM, showed, “ ... [the Hospital] used our [non-medical taxi service that utilizes independent drivers that use their personal vehicles] account and set up a ride to [Hospital 2] ...” Dunring an interview on 03/05/25 at 2:55 PM, Staff K, Registered Nurse (RN), stated that Patient 1 was to be discharged home, but the patient had requested transportation service to take her to [Hospital 2]. Staff K stated that Patient 1 was receiving oxygen when she was wheeled down to the discharge exit and the oxygen was removed prior to Patient 1 leaving with the non-medical taxi service. The hospital did not provide oxygen or ensure that Patient 1 had access to oxygen during transport. Review of a Hospital 2 document titled, “ED [Emergency Department] to Hosp [Hospital 2]-Admission,” dated 02/19/25 at 7:05 PM, showed, “ ...· Shortness of Breath ... Pt [Patient 1] states she was discharged in an [non-medical taxi service that utilizes independent drivers that use their personal vehicles] from [Above Named Hospital] and told to come to [Hospital 2] ED. Pt [Patient 1] states she is normally on [oxygen] 4LPM [liters per minute] via NC [nasal canula] for COPD and CHF [congestive heart failure]. Pt [Patient1] was discharged from [Above Named Hospital] without oxygen and oxygen saturation was 50 percent on arrival which was increased to 99 percent on her normal oxygen.) ...” The hospital’s failure to ensure that supplemental oxygen was provided during transport resulted in Patient 1 becoming hypoxic and required admission to Hospital 2 for further evaluation and stabilization treatment.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 45841 Based on interview, document review, email correspondence, and policy review, the facility failed to follow their policy for the provision of a response to a grievance for 1 (Patient 4) of 3 sampled patients reviewed for grievances. Findings Include: Review of a facility policy titled, “Patient Grievance and Complaint Management Policy,” with an effective date of May 2020, revealed, “2. Upon receipt of a grievance, the Patient Advocate (or designee of the organization) shall confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient. These grievances should be reviewed immediately by Risk Management given the seriousness of the allegations and the potential for harm to the patient. A representative of the administrative staff will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve physician delivery of care issues. 3. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days.” Review of the hospital grievance log, revealed Patient 4 called on an unknown date to report a grievance that they had obtained a healthcare associated infection, been accosted, and received poor quality care during their stay. During an interview on 04/10/24 at 2:50 PM, the Vice President of Quality and Risk acknowledged Patient 4 called and spoke with the Manager of Quality on 01/19/24 and sent a letter that was received on 02/07/24. Per the Vice President of Quality and Risk, Patient 4’s concerns should have added as a grievance. The Vice President of Quality and Risk confirmed a seven-day, and 30-day response letter was not sent to the patient. Review of an email correspondence to the surveyor from the Vice President of Quality and Risk dated 04/10/24 at 3:49 PM, revealed on 01/19/24, Patient 4 called to report their grievance and sent a letter the hospital on 02/07/24. The Vice President of Quality and Risk stated she did not find the 7-daty acknowledgment letter and staff missed the 30-day window to submit the resolution letter to the patient.”

“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: 45841 Based on policy review, record review, and interview, the facility failed to ensure their policy for vital signs was followed for 1 (Patient 1) of 1 sampled patients reviewed for vital signs. Findings Include: A review of the facility policy titled, “Provision of Care Evidence Based Clinical Documentation,” with a replaced/revised date of September 2023, revealed, “d. Medical Telemetry/4 North Med [medical] Surg [surgical] Tele [telemetry] i) Routine Care: (1) Vital signs (including but not limited to BP [blood pressure], HR [heart rate], O2 [oxygen] Saturation, RR [respiratory rate], Temperature and pain) unless otherwise ordered by physician, or patient’s condition warrants more frequent assessment (a) On admission within 15 minutes (b) Level of Care: Medical or Surgical, every 8 hours.” Review of Patient 1’s clinical record documentation, with an admission date of 01/30/24 for abdominal pain and surgical intervention for multiple anterior abdominal wall hernias, revealed that, on 02/11/24 at 7:58 AM, a complete set of vital signs were recorded for Patient 1. Review of Vital Signs dated 02/11/24 at 6:28 AM showed, Temperature (T) 37.7 (normal 37), HR 101 (normal 60-100), RR 18 (normal 12-20), Oxygen Saturation (SP02) 86% (normal 95-100 %) on room air. Documentation dated 02/11/24 at 8:18 AM, revealed, “Other notification comments: BP this moring is 77/49. Patient denies paine. Not Symptomatic. Alert and oriented. Rest of vitals are within normal limits. Notified [Nurse Practioner 1]. Order for 500 NS bolus given. After completion of bous. BP is 94/57 with MAP of 69. Patient is stable.” Documentation dated 02/11/24 at 7:58 AM showed, T 37.0, BP 94/57, HR 64, RR 18, SPO2 76% on room air. Documentation dated 02/11/24 at 12:30 PM, showed, Patient 1’s BP was 95/67. Further review of the medical record showed that on 02/11/24 at 5:05 PM, a “Code Blue” (need for CPR) was responded to and Patient 1 was found sitting in the recliner, unresponsive, with emesis (vomit) coming out of his mouth. The emesis had the appearance and smell of stool. Patient 1 was coded for about 30 minutes. CPR was stopped at 7:45 PM and Patient 1 was deceased. There was no evidence in the medical record to indicate staff obtained another complete set of vital signs for Patient 1 after 7:58 AM on 02/11/24. During an interview on 04/10/24 at 2:34 PM, the Director of Clinical Operations confirmed Patient 1’s vital signs were not checked every eight hours on 02/11/24.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f) Restraint or Seclusion: Staff Training Requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 45841 Based on email correspondence and policy review, the facility failed to ensure there was evidence to indicate 1 (Medical Doctor 3) of 1 physician reviewed had training on restraints. Findings Include: Review of the facility policy titled, “Patient Restraint/Seclusion,” with an effective date of 02/20/20, revealed, “Physicians and other LIPs [licensed independent practitioner] authorized to order restraint will have a working knowledge of this policy on the use of restraint and seclusion.” Review of email correspondence to the surveyor from the Vice President of Quality and Risk dated 04/10/24 at 11:28 AM, revealed facility staff had been unable to locate Medical Doctor 3’s training on restraints.”