Christus Southern New Mexico

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 46375 Based on record review, interviews and observations, the facility failed to maintain patients’ Protected Health Information (PHI) for 42 (P (Patient) 11 - P52) of 42 (P11 - P52) patients. This failed practice can lead to direct inappropriate disclosure and an increased risk of misuse and breach of PHI. The findings are: A. Record review of facility’s policy titled “HIPPA [Health Insurance Portability and Accountability Act] Security Program” dated 01/30/2023 revealed: “POLICY: 2. Organizational Management of Security Program: Clean Desk and Screen Policy - All workstation screens must be clear of Confidential Information from their desks when unattended to prevent inadvertent or deliberate viewing by unauthorized individuals.” B. Record review of facility’s policy titled “Workstation Use & Security” dated 11/27/2023 stated, “Policy: Acceptable Use: “1. All personnel are responsible for protecting the information resources at their individual workstations and abiding by all Information Security Policies and Procedures that apply to their individual environment.” Workstation Security “3. Sensitive, confidential or critical electronic business information or data, including ePHI [electronic protected health information], used or generate at the workstation will be secured.” C. During an observation on 01/29/2024 at 2:52 pm of emergency department nursing station 1 the following PHI was visible on computer workstations: 1) Computer 1 revealed the following PHI list: patient name, age, sex, location, patient details (complaints, reason for visit), temperature, heart rate, oxygen level, weight, status, and length of stay for P11 through P24 2) Computer 2 revealed the following single patient PHI: patient name, age, sex, complaint, blood glucose level, medications, and labs for P19. 3. Computer 3 revealed the following PHI list: location, patient name, age, sex, patient details (patient complaint), medical history, temperature, blood pressure, respiratory rate, oxygen level, weight, status, and length of stay for P12 - P18 and P25 - P35. 4. Computer 4 revealed the following single patient PHI: patient name, allergies, age, sex, height, weight, medical record number, date of birth, financial number, location, reason for admission, patient phone number, and activity view for PHI for P24. 5. Computer 5 had an Electrocardiogram ((EKG) a test that measures the electrical activity of the heartbeat) revealed the following PHI: patient name, identification number, date of birth, age, sex, and EKG results for P19. D. During an observation on 01/30/2024 at 2:40 pm of nursing station 2 the following PHI was visible on computer workstations: 1. Computer 1 revealed the following PHI list: location, patient name, age, sex, patient details (complaint), temperature, blood pressure, heart rate, respiratory rate, oxygen level, weight, status, and length of stay for P36 - P51. 2. Computer 2 showed the following PHI list: location, patient name, age, sex, patient details (complaint), temperature, blood pressure, heart rate, respiratory rate, oxygen level, weight, status, and length of stay for P36 - P49. 3. Computer 3 showed the following single patient PHI: patient name, allergies, medication administration record summary, age, sex, height, weight, medical record number, date of birth, financial number, location, code status, COVID - 19 test results, admitting diagnosis, and patient phone number for P52. E. During an interview on 01/30/2024 at 2:45 pm with Staff (S) 3 Charge Nurse, confirmed when staff walk away the from the computer the screen should be locked and should never be open with patient information.”

“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: 47480 Based on record review and interview the facility failed to provide a safe discharge for 1 (P (patient) 1) of 10 (P1-P10) patients leading to multiple readmissions to this facility. This deficient practice could likely result in serious injury, harm or death for all patients discharged from this facility. Refer to A-0808 and A-0813”

“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: 47480 Based on record review and interview the facility failed to conduct a discharge planning evaluation to establish an appropriate discharge plan to discuss with the patient or patient’s representative to arrange for post-hospital care for 1 (P (patient) 1) of 10 (P1-P10) patients reviewed. This deficient practice could likely result in serious injury, harm or death for all patients discharged from this facility. The findings are: A. Record review of the facility policy “Utilization Management Plan [a process that evaluates the efficiency, appropriateness and medical necessity of treatments, services, medical care to reduce costs]” “Last Review/Revision Date: November 2022” stated: 1. “The Care Coordination staff have responsibility to form the complex discharge planning of patients ... needs include but are not necessarily limited to the following: -Initial placements for patients unable to return to home environment at time of discharge. -Placements resulting from a patient not being able to return to his/her previous living situation. -Out of area placements. -Psychosocial [pertaining to how social issues affect an individual’s mind or behavior] issues that impact the patient’s ability to maintain his/her health.” 2. “7. Discharge Planning: In order to safely return a patient to the community, the necessary post-discharge services, equipment, transportation, and medications must be arranged prior to the patient leaving the facility ...A risk assessment is conducted on each patient to identify those patients who may need post-hospitalization services.” B. Record review of P1’s medical record revealed a discharge planning evaluation was not completed for inpatient admission on 06/24/23 at 5:29 PM through discharge on 09/25/23 at 6:11 PM. C. During an interview on 12/06/23 at 3:45 PM with Staff (S) 12 Medical Doctor confirmed P1 was discharged without a plan for follow up care. D. During an interview on 12/07/23 at 9:40 AM with P1’s treatment guardian [a court appointed individual given authority to make decisions for a patient’s mental health care], the treatment guardian confirmed the facility did not discuss or evaluate P1 for services or equipment needed post discharge.”

“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: 47480 Based on record review and interview the facility failed to discharge 1 (P (patient) 1) of 10 (P1-P10) patients to the appropriate post-acute care facility (Skilled Nursing Facility) based on the extent of care P1 required to prevent readmission. This deficient practice likely resulted in P1’s readmission to the hospital and lack of appropriate outpatient medical care; which can result in serious injury, harm or death for all patients discharged from this facility. The findings are: A. Record review of the facility’s policy “Discharge Planning” “Approval Date: November 6, 2023” stated: 1. “3. While the physician is the leader of the treatment team in formulating the discharge plan, the therapist/case manager is responsible for ensuring it is appropriate to the needs of the patient and all related activities (releases, appointments, transportation, etc.) are in place prior to discharge.” 2. “7. Prior to discharge, the therapist and/or nurse will set up appointments for medical and psychiatric appointments. The appointments will be documented on the discharge instructions and in the patient’s medical record.” B. Record review of P1’s medical record for inpatient admission on 06/24/23 at 5:29 pm through discharge on 09/25/23 at 6:11 pm [date and time of discharge order] revealed: 1. “Miscellaneous Patient Care Documents” “Service Date/Time: 6/27/2023 16:03 MDT (4:03 pm] “coccyx [base of spine] dimensions area 32.97 cm2 [centimeter squared], length 7.41 cm, width 6.27 cm” 2. “Physician Progress Note” “[Physician name] (9/13/2023 14:03 MDT [2:03 pm] [in reference to P1:] “MoCA [Montreal Cognitive Assessment-a rapid screening tool assesses for mental impairments] score 10 out of 30 [moderate to severe cognitive impairment, this is P1’s score] is under the guardianship [treatment guardianship-a court appointed individual given authority to make decisions for a patient’s mental health care] of his niece.” 3. Revealed “Progress Note-Physician” “Service Date/Time: 9/19/2023 00:00 MDT [midnight]”. “It would appear that there will be ethics committee meeting later today to consider his status and the options available in echo [sic] debility meeting the patient’s medical requirements and concomitantly (at the same time) the extended hospitalization concerns.” a. Document “Name of Committee: Ethics Committee” “Date: 9/19/2023” “Place and Time: Board Room at 4:30 pm” revealed: b. “-bed sores on body-how going to treat; send c [with] home health”. “-cannot take care of self on DC [discharge]”. “-incapable of doing self care.” “Plan ...move to Nursing home ...” c. “Behavioral Health Notes” “Service Date/Time: 9/21/2023 19:10 MDT [7:10 pm]. “A 1 hour meeting was held today to discuss the patient’s case, including some of the behaviors that have been noted. This case discussion included Christus ethicist, nursing director, executive director of behavioral health, patient advocate, risk management, director of case management, patient’s case manager, VP [Vice President] of Physician services. I reiterated to the team in the meeting today that the disinhibited social behaviors [inability to stop inappropriate behavior] we are seeing are related to his underlying dementia [loss of cognitive abilities] diagnosis, I continue to clinically suspect that we are seeing a frontotemporal dementia behavioral [variant] [a brain disorder that can cause problems with memory, thinking, language, changes in mood, emotions and behavior], which can have trying behaviors due to the patient’s lack of executive function [capacity for planning, self-control, thinking] and subsequent social disinhibition ....he would likely do poorly in an independent living setting, and he needs long-term care. We will continue to seek these services out for the patient.” 4. “Miscellaneous Patient Care Documents” “Service Date/Time: 9/21/2023 16:42 MDT [4:42 pm]” “coccyx dimensions area 8.04 cm2 (-78% [decrease of 78 percent]), length 10.93cm (-12%), width 1.93 cm (-64%)”. “sacral [base of spine] DTI [deep tissue injury], site evolved into 4x [times] wounds, 1x has since healed over, 2x that are proximal [near] to rectum [end of large intestine] noted to have tunneling [extension of wound below skin surface], inferior of the wounds tunnel depth noted to be 0.7 cm [centimeter] and the superior wound noted to be 2.4 cm which is increase from last visit ...there is also 1x wound superior [above] to these two that is unchanged since last visit, dressing changed following orders ...” 5. “Behavioral Health Notes” “[Physician Name] (9/21/2023 19:38 MDT [7:38 pm]) “ ...frontotemporal dementia behavioral variant ....and he needs long-term care.” 6. “CM [Case Management] Discharge Planning Ongoing Assessment” “Discharge Plan/Needs: Discharge To...Other: Pt [patient] presently requires care for everything but eating - [name of case manager] S16 - 09/22/23 14:57:00 [2:47 pm].” 7. Revealed “Discharge Documentation” “Document Name: Inpatient Clinical Summary” “Service Date/Time: 9/22/2023 15:17 MDT [3:17 pm]” “Clinical Discharge Summary ...Discharge Information”: a. “Discharge Disposition: [blank]” There was no entry for Discharge Disposition. b. “Discharge Location: [blank]” There was no entry for Discharge Location. c. “Discharge Summary”: entry was dated 7/13/2023. There was no entry for discharge date 9/25/2023. 8. “Physician Progress Note” “[Physician name] (9/24/2023 10:24 MDT [10:24 am])”: “1. Major neurocognitive disorder [significant decrease in mental function] ...4. Decubital ulcer [bedsore] with tunneling interconnection is stable and managed by the wound service ...5. Impaired mobility ...Case management continue to work on his placement.” 9. Revealed 07/19/23 through 09/18/23, case management exclusively sought placement to long term care and skilled nursing facilities. There were no referrals for home health care, wound care, or other home health services. 10. “Revealed on 09/25/23 DC [discharge] instructions stated, “Home treatments that have been arranged for you: NONE....Discharge documentation; Pt [patient] refused to sign” 11. Emergency department admission 09/27/23 at 12:05 pm through discharge 09/27/2023 at 5:56 pm revealed P1 transported by ambulance to the emergency department from the [Address]. An internet search found this address is a hotel. ED (emergency department) Physician note 9/27/2023 13:49 MDT (1:49 pm) “He [P1] was brought in because he had a bowel movement [stool] and was unable to clean his backside family is also not able to help him.” Per “Emergency Documentation ...Physical Exam: Musculoskeletal [muscle and bones]: Multiple blisters on the lower extremities [legs].” These “blisters” were not noted on Physician Progress Notes prior to 9/25/2023 discharge. 12. Revealed a letter on [Facility] letterhead dated September 27, 2023, “[Facility] is requesting [name of ambulance company], ambulance transport, for [P1 name], From [Facility] to [name of hotel] at [address of hotel]. On Wednesday, September 27, 2023, [Facility] will accept full financial responsibility for this transport. Respectfully [name] Vice President of Finance.” 13. Emergency department admission 10/05/2023 1:52 pm through discharge 10/30/2023 8:30 am: “Admission Reason: Bilateral Infection-Legs”. P1 was transported by ambulance to the emergency department from the address “[address of hotel]”. There was a concern from EMS that he cannot care for himself. DX Failure to thrive. a. “Progress Note-Nurse” “Service Date/Time: 10/05/2023 15:40 MDT [3:40 pm]”: “wounds to ...bilateral legs ...wounds to ...buttocks and coccyx ...new wound in ...rectal area ...” b. “Emergency Documentation [Physician]” “10/05/2023” “0510 pm: ...patient needs to be admitted due to not being able to take care of him a he [sic] is not a safe discharge ...pt is pending placement or safe discharge.” c. “Wound Care Note” “Service Date/Time: 10/26/2023 15:24 MDT [3:24 pm]”: “ ...noted improvement to sacrum ...” C. During an interview on 11/30/23 at 3:50 PM with the treatment guardian [appointed by the court with the authority to make decisions regarding mental health treatment including mental medication] for P1, the treatment guardian reported on 09/25/23 the staff would not give her any information about P1 that day. Finally the treatment guardian received a call to come and pick him up. The facility was discharging P1 without setting up any services, no wound care, no oxygen, no home care, only a few meds and no psych meds. They told her that her uncle was trespassing on the facility and they would call the police. She told them that she was unable to care for him. She called Adult Protective Services (APS) and she also called the police on the hospital. A crisis team was convened. Finally, the hospital agreed to place P1 in the ED, but no one assumed care and he was not given any medications and was not cleaned. She was told that if she did not come and get him they would take him to his house. She tried to get some supplies for his house. She stated that staff took P1 to his home in a personal or hospital vehicle (not an ambulance). His trailer was uninhabitable, so they offered to pay for him to stay in a hotel for a week. He was unable to care for himself, so he was covered in urine and feces the next day, he did not have any medications or services set up for him by the hospital. Treatment guardian called APS and he was taken back to ED on 09/27/23. He was not admitted. D. During an interview on 12/07/23 at 9:40 AM with the treatment guardian for P1, the treatment guardian reported on September 26th hospital staff transported P1 to his home, found his home unlivable [not fit to live in], then transported him to a hotel. The guardian stated the hospital paid for the hotel. The treatment guardian stated P1 was discharged without referrals for outpatient care, home health, or wound care. The treatment guardian stated they were unable to secure home health services due to P1’s extensive needs and hired [untrained] hotel staff out of pocket to care for P1. E. During an interview on 12/07/23 at 12:30 PM with Staff (S) 16 RN (Registered Nurse) CM (Case Manager), S16 confirmed when a patient requires “care for everything,” the appropriate discharge is placement in a skilled nursing facility or rehabilitation hospital [a specialty hospital that can provide physical therapy and other therapies]. Regarding P1, S16 stated case management was “strictly working on finding skilled nursing placement. The only option was long term care ...” S16 RN Case Manager confirmed P1 was discharged to a hotel. S16 confirmed P1 was discharged without referrals for outpatient care, wound care, or home health. F. Record review of P1’s medical record stated, P1 was boarded (admitted) in the emergency department from 10/05/2023 through 10/30/2023. On 10/30/23 placement was found and patient was transferred to a skilled nursing facility . “EMTALA [Emergency Medical Treatment and Labor Act-this form was used because P1 was transferred from the emergency department] Form Entered On: 10/30/2023 13:24 MDT [1:24 pm]” “Receiving Facility Accepting [Name of facility]”.”