Unity Hospital

“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: 49205 Based on policy review, medical record review, and interview, in one of 20 medical records reviewed, the hospital medicine team failed to provide the necessary medical information related to current clinical presentation at the time of discharge to the inpatient chemical dependency team and provide an effective transition from hospital to post-discharge care (Patient #2). Reference: §482.43(c): Transfer protocols”

“TRANSFER PROTOCOLS CFR(s): Effective July 1, 2025, the hospital must have written policies and procedures for transferring patients under its care (inclusive of inpatient services) to the appropriate level of care (including to another hospital) as needed to meet the needs of the patient. The hospital must also provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care. This Standard is not met as evidenced by: 49205 Based on policy review, medical record review, and interview, in one of 20 medical records reviewed, the hospital failed to follow written policies and procedures for the transfer of patients to the appropriate level of care to meet patient needs (Patient #2). Specifically: 1.Patient #2 was discharged from the medical inpatient unit to an inappropriate level of care as needed to meet the needs of the patient. Patient #2 was denied admission to the inpatient chemical dependency program due to altered mental status and required re-admission to another hospital for treatment of focal seizures, and stabilization of hyponatremia (low sodium), anxiety, hypothyroidism (abnormally low activity of the thyroid gland), and alcohol cravings. 2.Care Management and clinical staff did not know the policies and procedures for transferring a patient to the inpatient chemical dependency unit. Findings include: Review of the policy “Discharge Planning (Screening- High Risk) Policy,” effective January 2025, revealed the Care Management Team (Registered Nurse (RN) Care Managers and Social Workers) evaluate new patients assigned to each nursing unit for risk factors that may influence discharge planning or increased risk for hospital readmission. Collaborative care planning is initiated to determine discharge planning needs. Identified post hospital care needs are used to determine appropriate discharge planning including the discharge disposition. The Care Management Team will make other referrals based on patient/caregiver goals appropriate to facilitate a discharge plan, to reduce factors that can lead to preventable readmissions, and ensure an effective transition of the patient to post discharge care for Hospice, homecare, post-acute care, community-based care providers, and non-healthcare services. Social Work and Care Management can assist patients, their families, and/or their representative in choosing a post-acute care provider by providing data on quality measures and resource use measures. Findings #1: Review of the inpatient Medical Unit medical record for Patient #2 revealed the following: -On 07/25/25, Patient #2 presented to the Emergency Department due to a history of heavy alcohol use and an evaluation of altered mental status. Patient #2 was admitted to a medical unit for alcohol abuse/withdrawal, severe hyponatremia, severe hypothyroidism, and acute metabolic encephalopathy (sudden onset of brain dysfunction). -On 07/28/25, Patient #2 was alert, oriented to situation, had poor judgement, poor safety awareness, poor attention/concentration, clear speech, and vital signs stable in the morning. An assessment was conducted for placement in the inpatient chemical dependency program, and a referral was made. At 02:38 PM, Patient #2 was confused, not oriented to place or time, only oriented to person, did recognize their family member in the room, reported having auditory hallucinations (a type of sensory perception where a person hears sounds, such as voices, music, or noises, without any external stimulus), could not answer any other questions about their condition, and reported being anxious and scared. At 04:14 PM, a progress note by Staff (T), Physician, indicated Patient #2 remained ill, continued to need inpatient level of care, and close monitoring. -From 07/29/25 to 07/30/25, vital signs remained stable, however, Patient #2 experienced delusions/confusion at nighttime, was alert, disoriented to situation, had poor judgement, poor safety awareness, poor attention/concentration, speech appropriate for development age, and displaying anxiety symptoms. -On 07/30/25, Patient #2 was accepted into the inpatient chemical dependency program with a bed offer for the following morning. At 08:57 PM, Staff (PP), Physician was called to see Patient #2 for confusion and pacing in and out of their room repeatedly according to nursing staff. Staff (PP) felt Patient #2 was displaying signs of delirium and prescribed 0.5 milligrams of haloperidol (antipsychotic medication) for agitation. -On 07/31/25 at 06:43 AM, Staff (KK), RN documented Patient #2 was alert and oriented to person and place, but had experienced confusion, anxiousness, and repeatedly asked the same questions the previous night. Patient #2’s only complaint was dizziness which resolved after receiving Zofran (medication used to prevent nausea and vomiting). At 07:52 AM, vital signs were stable. At 10:08 AM, Staff (AA), Licensed Practical Nurse (LPN), called report to the inpatient chemical dependency program. Review of the “Secure Chat Messages,” dated 07/31/25 revealed from 10:36 AM to 10:56 AM, Staff (U), Physician Assistant (PA) at the Chemical Dependency Unit sent messages to the inpatient medical unit team questioning the nursing documentation related to Patient #2’s mental status, if they were actively in alcohol withdrawal, and if further testing was needed. Staff (AA), LPN at the Medical Unit responded Patient #2 was alert and oriented, answered everything correctly, had some confusion overnight, and was an alcohol/benzo withdraw patient. Staff (PP), Physician at the Medical Unit, responded Patient #2 was to have thyroid testing (gland that controls your metabolism, growth & development, body temperature, heart rate, and calcium regulation) in 4 to 6 weeks. Staff (U), PA at the Chemical Dependency Unit, asked if the hyponatremia (low sodium) could be the cause of Patient #2’s mental status fluctuation. Staff (U), PA at the Chemical Dependency Unit, documented the chemical dependency unit had to ensure Patient #2 was independent and ambulatory. The unit only has three nurses for 38 patients and cannot provide intravenous (IV) medications. The unit would not be able to support Patient #2 if they were experiencing confusion like what was documented in their medical record overnight. At 10:56 AM, Staff (OO), RN at the Medical Unit responded Patient #2 was not in active withdrawal. The last phenobarbital (medication used to treat seizures and cause sedation) dose was on 07/29/25. Patient #2 was independent and ambulatory. Staff (OO) watched Patient #2 get dressed and walk around all morning. Patient #2 was a little anxious, but their orientation was fine. Review of the inpatient medical record for Patient #2 revealed on 7/31/25 at approximately 10:45 AM, Patient #2 was discharged and transferred to the inpatient Chemical Dependency Unit with security and a RN despite Staff (U), PA at the Chemical Dependency Unit, indicating messaging the inpatient Medical Unit staff that Patient #2 would not be candidate for admission based on the overnight clinical presentation. Review of the inpatient Chemical Dependency Unit medical record for Patient #2 revealed on 7/31/25 at 10:51 AM, a note by Staff (U), PA, revealed they were contacted by the nursing staff who requested a medical evaluation of Patient #2, who appeared to be disoriented. Patient #2 was oriented to themselves and why they were there, had extensive thought blocking (a sudden and involuntary interruption of thoughts or speech) and was unable to say the date. Patient #2 kept perseverating over “a shot” that they were given at the hospital. Staff (U), PA reached out to the attending physician related to Patient #2’s current mentation did not seem appropriate for admission to the inpatient chemical dependency unit. Patient #2 was joined by a family member, who stating this level of confusion was not baseline for Patient #2, and Patient #2 was not ready to be discharged from the hospital. This prompted a discussion between Staff (U), PA, the attending physician, Patient #2, the family member, and nursing staff regarding next steps. Patient #2 continued to present as altered, talking at inappropriate times with bizarre word content. Patient #2 had been medically discharged from the hospital, the only way to become re-admitted was for Patient #2 to present to the ED. The family member verbalized understanding but expressed frustration of how the discharge had been handled, and agreed Patient #2 needed a higher level of care. Patient #2 was considered a non-admit to the inpatient chemical dependency unit due to not being medically qualified. The family member agreed to take Patient #2 to the ED for evaluation. Review of the “Secure Chat Messages,” dated 07/31/25 from 12:20 PM to 03:08 PM, revealed Staff (U), PA at the Chemical Dependency unit, had some questions for the attending physician that discharged Patient #2 from the medical unit. Staff (SS), Physician at the Chemical Dependency Unit documented Patient #2 was not oriented and appeared confused. Patient #2 also had some minor gait instability requiring assistance and recommended to Patient #2 and their family member that Patient #2 should return to the ED for further evaluation. Staff (T), Physician at the Medical Unit, inquired if the Chemical Dependency Unit would be interested in Patient #2 if they progressed in terms of mobility and mentation in the next couple of days. Staff (U), PA, documented that they would re-evaluate Patient #2 for admission once they were fully oriented times three consistently and their gait was stable. The intake would have to be re-submitted by social work. Staff (SS), Physician, agreed with Staff (U), PA and indicated it would be helpful if Patient #2 had a documented normal mental status for greater than 34 hours. Staff (T), Physician at the Medical Unit, documented that Patient #2’s family member may take Patient #2 home and re-submit a referral through Patient #2’s primary care provider social worker for inpatient rehab, anticipating Patient #2’s mental status will improve at home with 24/7 family supervision. Interview on 08/19/25 at 01:03 PM Staff (T), Physician at the inpatient Medical Unit, revealed Patient #2 was fully discharged from the hospital when they left for the Chemical Dependency Program and was not confused. When Patient #2 was refused admission by the chemical dependency program and returned, Patient #2 presented much different than when they were discharged. Patient #2 was confused and did not have any sort of coherent thought process. Interview on 08/19/25 at 02:33 PM, Staff (U), PA at the inpatient Chemical Dependency Unit, revealed nursing staff had requested an assessment of Patient #2 due to confusion. Patient #2 was not oriented. Staff (U) was concerned because of the documentation from the previous night indicating Patient #2 had an episode of confusion and it appeared Patient #2 had an unsteady gait. The inpatient Chemical Dependency Program operates with three nurses and 38 patient beds; therefore, patients must be ambulatory and independent to be accepted into the program. Based on the presentation assessment of Patient #2, the facility could not proceed with admission if medical appropriateness was not met. There had been communication between nurses prior to the Patient #2’s arrival, and the attending chemical dependence physician was called to assess Patient #2. After discussing Patient #2 with the attending physician, Staff (U) recommended to the family member take Patient #2 to the ED for a full evaluation. Findings #2: Review of the policy “Admissions Procedures for Substance Use Disorder Treatment” for use in both inpatient and outpatient programs, effective September 2024, revealed in order to be admitted, the individual (referred) will not need acute hospital care, acute psychiatric care, or other intensive services which cannot be provided. The decision to admit an individual is made by a clinical staff member who is a qualified healthcare provider, documented with a dated signature, and includes the basis for admitting the patient. Review of the inpatient medical unit medical record for Patient #2 revealed on 07/28/25, an assessment and referral were made to the inpatient chemical dependency program. On 07/30/25, Patient #2 was accepted into the inpatient chemical dependency program with a bed offer for the following morning. On 07/31/25 at 10:45 AM, Patient #2 was discharged and transferred to the inpatient Chemical Dependency Unit with security and a RN. Review of the inpatient chemical dependency unit medical record for Patient #2, revealed on 07/31/25 at 10:51 AM, Patient #2 was disoriented upon arrival, a medical evaluation was initiated. Patient #2 required a higher level of care and was considered a non-admit to the inpatient chemical dependency unit due to not being medically qualified. Interview on 08/19/25 at 01:03 PM Staff (T), Physician at the inpatient medical unit, revealed there is currently no system in place for direct physician-to-physician communication for discharges to the chemical dependency program. Staff (T) was unaware a patient could be refused admission. Interview on 08/19/25 at 02:33 PM, Staff (U), PA at the inpatient chemical dependency unit, revealed the health information specialist (HIS) officer coordinates with the medical staff of the hospital to ensure a patient is appropriate for admission to the inpatient chemical dependency program, but a patient can still be refused admission if the chemical dependency medical staff determine a patient is not independent or ambulatory. Staff (U) stated there is typically no direct communication between providers to discuss the readiness of a patient for admission to the program. Interview on 08/20/25 at 09:30 AM with Staff (K) and Staff (L), Social Workers at the inpatient medical unit, revealed when a consult is placed by a provider for chemical dependency, an evaluation will be performed by the HIS officer and reviewed by the chemical dependency team. It can take several days to receive acceptance or denial for the program. When a patient is accepted, the HIS officer will communicate with social work the date of bed availability. The social worker is the liaison between the hospital medical team (physician and nurses) and the chemical dependency program team. It is the understanding of Staff (K) and Staff (L) that when a bed availability date and time is given to the patient, that indicates that the patient is accepted into the program. Interview on 08/20/25 at 10:30 AM with Staff (R), Psychiatric Assignment Officer, revealed they completed the assessment of Patient #2, and the referral was sent to the chemical dependency intake team. The intake review takes approximately two to three days. During the times that Patient #2 was assessed, they were oriented and forward thinking. Staff (R) was not aware that after a bed, date and time was offered, the patient would still require an additional assessment to determine eligibility for acceptance into the program.”