Carolinas Continuecare Hospital at Pineville

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 39307 Based on observation, hospital policy, medical record review and staff interviews, the hospital staff failed to identify and track an Adverse Event 1 of 4 patients(Patient #2). The findings included: Observation during Interdisciplinary Meeting on 07/09/2026 at 1000 with participants of CEO, Nursing Leadership, Respiratory Therapy staff member, Physical Therapy staff member, several Case Management staff members, and Medical Provider staff members who provided discussion of the plan of care for each patient. Observation revealed the staff failed to discuss the identified difference for transition needs of the cuffed versus cuffless care needs of the patient due to not all facilities accepted patients with cuffed tracheostomies. Hospital policy Event Reporting, Definitions, Types of Occurrences last reviewed/revised date 05/2024 revealed “Purpose: To delineate what constitutes an incident or occurrence. To outline the purpose for hospital occurrence or incident reporting. Policy: All patient, visitor, property, and employee occurrences will be reported per definition and types of occurrences to be reported ...Procedure: 1. Definitions A. Incident or Occurrence: A hospital incident or occurrence is any happening to patient, visitor, employee or property which is not consistent with the desired operation of the hospital or the routine care or the desired routine care and which may have potentially harmful medical/legal significance ...” Closed medical record review on 07/07/2026 revealed that Patient #2 was a 74-year-old female admitted on 05/01/2026 to the facility for Ventilator Support Weaning from an outside Hospital facility. Review of the Mechanical Ventilator Log revealed on 05/01/2026 Patient #2 had been documented to have “ ...Trach tube 7XLTCD ...” (number 7 Extra-Long Trach Cuffed Distal) in place. On 05/05/2026 at 1430 the Case Management (CM) Admission Statement was completed by CM#1. Review of the Interdisciplinary Plan of Care documentation on 05/07/2026 signed by the Medical Provider failed to include evidence of cuffed Tracheostomy. On 05/08/2026 the CM Progress Notes revealed CM documented “IDT (Interdisciplinary Discharge Team) held with team and providers ...Goals for the week include discharge planning ...CM met with patient at the bedside along with MD (Medical Doctor) to update about the plan of care ...” Review of the CM Progress Notes revealed on 05/13/2026 a Choice List was presented to the patient which included the option of the “Named” Skilled Nursing Facility option of choice by the patient. Care Management Team members were the staff to communicate with the facility for the awareness of a facility’s acceptance of cuffed versus cuffless tracheostomy patient needs for continued care. Review of the Interdisciplinary Plan of Care documentation signed by the Medical Provider failed to include evidence of cuffed tracheostomy. Review of the CM Progress Notes revealed on 05/14/2026 at 1500 the CM documented “Patient discharged to ‘Named’ for long term care per her choice ...Patient is back to baseline on trach collar and appropriate for a lower level of care. Patient, providers, and family are aware and in agreement with discharge ...” Record review failed to reveal a physician order to change to a cuffless tracheostomy prior to the discharge to the Skilled Nursing Facility of choice. Review revealed the hospital transferred Patient #2 on 05/14/2026 to a facility that did not have capability to care for Patient #2 with a cuffed tracheostomy. Interview requested on 07/07/2026 for the Discharging Medical Provider, PAC (Physician Assistant Certified) #2 revealed the PAC was unavailable for interview. Interview requested on 07/07/2026 for the Case Management staff (CM#1) who planned the discharge plan for Patient #2 revealed CM#1 was unavailable for interview. Interview on 07/07/2026 with the Case Management (CM) Leader CM #3 revealed the CM had been employed at the facility for approximately 10 years. Interview during the review of Patient #2’s medical record revealed after 05/06/2026 there was no further documentation of the patient having had a cuffed or cuffless tracheostomy. Review of the Discharge Summary revealed no evidence of tracheostomy as cuffed or cuffless. Interview on 07/07/2026 at 1035 with the Respiratory Therapist (RT) RT #4 who provided care to Patient #2 on 05/13/2026 (the day before discharge) and on 05/14/2026 (the day of discharge) revealed it is possible for a patient to have a Trach #7XLT (extra-long trach) cuffed or cuffless. The RT revealed on 05/14/2026 the RT did not know Patient #2 was being discharged and it would be up to the Medical Provider to decide which patient could change out to cuffless trach or remain cuffed. The RT revealed patients have been discharged to other facilities with cuffed as well as cuffless tracheostomies to various types of facilities. Interview on 07/07/2026 at 1100 with a Registered Nurse Supervisor RN #5 who had been employed at the facility for approximately 14 years revealed the Supervisor would not have conversation with the MD related to the plan for discharge. Interview revealed it would typically be CM that would send an email to the Supervisor and other staff including the Physician that the patient was able to discharge on the next day. A sheet of paper with patient name would be printed and placed in a central location to inform all staff of the planned discharge. Interview revealed the RN Supervisor was aware of the Incident that occurred on 05/14/2026, whereby Patient #2 was discharged to a outside facility with a cuffed tracheostomy that did not accept cuffed patients for admission to that facility, but did not create an Incident Report nor report to Nursing Leadership. Interview revealed it was the expectation of staff to complete an Incident Report when an issue, error or event occurred that was unintended. Interview on 07/07/2026 at 1120 with the assigned RN #6 who discharged Patient #2 on 05/14/2026 with a cuffed tracheostomy revealed the RN was unaware of the inability of the receiving facility. The RN was unaware that the receiving facility for Patient #2 was a facility that did not accept cuffed tracheostomies nor did the RN document the notification to the facility of Patient #2 who had a cuffed tracheostomy. The RN made documentation of the size of the tracheostomy and included XLT (extra-long trach) without notation of cuffed or cuffless. Interview on 07/08/2026 at 1650 with the Corporate Executive Officer (CEO) CEO #7 revealed the CEO was made aware on 05/15/2026 (the following day) of the Incident that occurred on 05/14/2026 whereby Patient #2 was discharged to the outside facility with a cuffed tracheostomy in error. Interview confirmed that no Incident Report was created prior to survey. The CEO did not create an Incident Report which would allow a process of investigation, education and tracking for unintentional Incident Report procedures.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 39307 Based on observation, hospital policy, medical record review and staff interviews, the hospital failed to provide a discharge planning evaluation of a patient’s likely need for appropriate post-hospital services, the availability of the appropriate services as well as of the patient’s access to those services for 1 of 4 patients with a cuffed tracheostomy (Patient #2). The findings included: Observation during Interdisciplinary (IDT) Meeting on 07/09/2026 at 1000 with participants of CEO, Nursing Leadership, Respiratory Therapy staff member, Physical Therapy staff member, several Case Management staff members, and Medical Provider staff members who provided discussion of the plan of care for each patient. Observation revealed the staff failed to discuss the identified difference for transition needs of the cuffed versus cuffless care needs of the patient due to not all facilities accepted patients with cuffed tracheostomies. Hospital policy Patient Discharge Planning Multidisciplinary Patient Care Conferences last reviewed/revised date 05/2024 revealed “Purpose: To ensure that all patients are provided with a safe and effective discharge plan ...Procedure: ...10. IDT meeting updates will be filed in the patient record for access to the health care team ...12. Once the health care team, along with the patient and/or their surrogates establishes the safest possible discharge plan for the patient, the Case Manager or Discharge Planner will provide the patient and/or their surrogate with information on facilities that will best fit the need of the patient ...” Closed medical record review on 07/07/2026 revealed that Patient #2 was a 74-year-old female admitted on 05/01/2026 to the facility for Ventilator Support Weaning from an outside Hospital facility. Review of the Mechanical Ventilator Log revealed on 05/01/2026 Patient #2 had been documented to have “ ...Trach tube 7XLTCD ...” (number 7 Extra-Long Trach Cuffed Distal) in place. On 05/05/2026 at 1430 the Case Management (CM) Admission Statement was completed by CM #1. Review of the Interdisciplinary Plan of Care documentation on 05/07/2026 signed by the Medical Provider failed to include evidence of cuffed tracheostomy. On 05/08/2026 CM Progress Notes revealed the CM documented “IDT (Interdisciplinary Discharge Team) held with team and providers ...Goals for the week include discharge planning ...CM met with patient at the bedside along with MD (Medical Doctor) to update about the plan of care ...” Review of the CM Progress Notes revealed on 05/13/2026 a Choice List was presented to the patient which included the option of the “Named” Skilled Nursing Facility option of choice by the patient that did not accept cuffed tracheostomy devices. Review of the Interdisciplinary Plan of Care documentation signed by the Medical Provider failed to include evidence of cuffed tracheostomy. Review of the CM Progress Notes revealed on 05/14/2026 at 1500 the CM documented “Patient discharged to ‘Named’ for long term care per her choice ...Patient is back to baseline on trach collar and appropriate for a lower level of Care. Patient, providers, and family are aware and in agreement with discharge ...” Record review failed to reveal a physician order to change to a cuffless tracheostomy prior to the discharge to the Skilled Nursing Facility of choice. Review revealed the hospital transferred Patient #2 to a facility that did not have capability on 05/14/2026 to care for Patient #2 with a cuffed tracheostomy. Interview requested on 07/07/2026 for the Discharging Medical Provider PAC #2 was unavailable for interview. Interview requested on 07/07/2026 for the Case Management staff (CM#1) who planned the discharge plan for Patient #2 was unavailable for interview. Interview on 07/07/2026 with the Case Management (CM) Leader CM #3 revealed the CM had been employed at the facility for approximately 10 years. Interview revealed during the review of Patient #2 record review revealed after 05/06/2026 there was no further documentation of the patient having had a cuffed or cuffless tracheostomy. Review revealed the Discharge Summary revealed no evidence of tracheostomy as cuffed or cuffless. Interview on 07/07/2026 at 1035 with the Respiratory Therapist (RT) RT #4who provided care to Patient #2 on 05/13/2026 (the day before discharge) and on 05/14/2026 (the day of discharge). The RT revealed it is possible for a patient to have a Trach #7XLT (extra-long trach) cuffed or cuffless. The RT revealed on 05/14/2026 the RT did not know Patient #2 was being discharged and it would be up to the Medical Provider to decide which patient could change out to cuffless trach or remain cuffed. RT revealed patients have been discharged to other facilities with cuffed as well as cuffless tracheostomies. Interview on 07/07/2026 at 1100 with a Registered Nurse Supervisor RN #5 who had been employed at the facility for approximately 14 years revealed the Supervisor would not have conversation with the MD related to the plan for discharge. Interview revealed it would typically be CM that would send an email to the Supervisor and other staff including the Physician that the patient was able to discharge on the next day. A sheet of paper with patient name would be printed and placed in a central location to inform all staff of the planned discharge. Interview revealed the RN Supervisor was aware of the Incident that occurred on 05/14/2026, whereby Patient #2 was discharged to an outside facility with a cuffed tracheostomy that did not accept cuffed patients for admission to that facility, but did not create an Incident Report nor report to Nursing Leadership. Interview on 07/07/2026 at 1120 with the assigned Registered Nurse RN #6 who discharged Patient #2 on 05/14/2026 with a cuffed tracheostomy revealed the RN was unaware of the inability of the receiving facility. The RN was unaware that the receiving facility for Patient #2 was a facility that did not accept cuffed tracheostomies nor did the RN document the notification to the facility of Patient #2 who had a cuffed tracheostomy. The RN made documentation of the size of the tracheostomy and included XLT (extra-long trach). Interview on 07/08/2026 at 1650 with the Corporate Executive Officer (CEO) CEO #7 revealed the CEO was made aware on 05/15/2026 (the following day) of the Incident that occurred on 05/14/2026 whereby Patient #2 was discharged to the outside facility with a cuffed tracheostomy in error. The CEO did not feel the need to create an Incident Report which would allow a process of investigation, education and tracking for unintentional Incident Report procedures. During the survey the CEO began to create an Action Plan for the Corrective Actions needed. NC00237797 and NC00236033”