Regency Hospital of Greenville

“CARE OF PATIENTS - PRACTITIONERS CFR(s): 482.12(c)(1) [ ...the governing body must ensure that the following requirements are met:] Every Medicare patient is under the care of: (i) A doctor of medicine or osteopathy (This provision is not to be construed to limit the authority of a doctor of medicine or osteopathy to delegate tasks to other qualified health care personnel to the extent recognized under State law or a State’s regulatory mechanism); (ii) A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State and who is acting within the scope of his or her license; (iii) A doctor of podiatric medicine, but only with respect to functions which he or she is legally authorized by the State to perform; (iv) A doctor of optometry who is legally authorized to practice optometry by the State in which he or she practices; (v) A chiropractor who is licensed by the State or legally authorized to perform the services of a chiropractor, but only with respect to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated on x-ray to exist; or (vi) A clinical psychologist as defined in §410.71 of this chapter, but only with respect to clinical psychologist services as defined in §410.71 of this chapter and only to the extent permitted by State law. This Standard is not met as evidenced by: 41743 Based on interview and record review, the hospital’s Governing Body failed to ensure that 2 of 2 in-patients transferred to another hospital were under the care of a qualified licensed practitioner who agreed to accept the patients upon transfer. (Patient #1 and #7). Findings include: 1. On 08/14/24 at 9:00 AM, review of Patient #1’s medical record revealed Patient #1 was a 55 year old patient admitted to Hospital #1 on 12/07/21 with a diagnosis of acute respiratory failure. Patient #1’s insurance information is listed as “Medicare” on admission. Paperwork for Durable Power of Attorney and Healthcare Power of Attorney was signed on 08/17/21 by Patient #1’s mother. Patient #1’s history includes Cerebral Vascular Accident (CVA), seizure disorder, hypertension, respiratory failure acute and chronic, sepsis, Deep Vein Thrombosis (DVT) left upper arm, Diabetes Mellitus type 2, tracheostomy, sacral wound, hypothyroidism, encephalopathy, sepsis and kidney failure. Review of the Case Management Progress Note dated 04/05/22 revealed, “ ...trach will be permanent. Stable to discharge ...submitted updated clinical to (name of healthcare facility) ...patient is clinically accepted. Facility attempted to speak to (patient’s family member/POA) about admission and financial information but (family member/POA) hung up ...” Review of the Case Management Progress Note dated 04/07/22 revealed, “ ...Spoke with (name of family member/POA) informing her of patient’s Medicare exhaust date of 3/10/22 ...(Family member/POA) kept stating, “You will not send her out of state. I’ve already told you that. She will not go ...(Family member/POA) hung up ...”. Review of the Case Management Progress Note dated 08/11/2023 revealed, “Patient admitted for acute and chronic respiratory failure wit (with) hypoxia. (Patient) is ventilator and dialysis dependent. She has been stable for discharge to long term ventilator facility with on site dialysis. Barrier to discharge to long term ventilator facility is family who does not agree with discharging patient. There are no facilities locally that can provide the patient needs. Nearest facility is (name of facility in another state) which has offered a bed but mother refuses ...”. Review of Case Management Progress Note dated 08/18/2023 revealed, “Patient admitted for acute on chronic respiratory failure and now ESRD (End Stage Renal Disease) since admission in 2021. Patient remains table on the ventilator and requires HD (Hemodialysis) MWF (Monday, Wednesday, Friday). Unable to transfer patient to long term ventilator facility per mom. Patient does have several options to discharge with onsite HD as patient is a high risk dislodgement and does not need to transport 3 days a week to OPHD (Outpatient Hemodialysis)...Multiple conversations with mom that there are no facilities in the state of South Carolina to accommodate her daughters needs.” Case Management Progress Note dated 08/25/2023 revealed, “Patient remains stable for discharge to long term ventilator facility..Mom has refused for her to transfer. Patient is ESRD and ventilator dependent. She requires on site HD as she is a high risk dislodgement and cannot transfer 3 days a week to an OPHD with ventilator.” Continued review of Patient #1’s record on 08/14/24 at 9:00 AM revealed the History and Physical dated 08/16/2022 indicated, “ ...PRIMARY CARE PHYSICIAN ...No primary care provider on file ...ATTENDING PHYSICIAN ...[Medical Director] ...REFERRING PHYSICIAN ...[MD #3] ...REASON FOR ADMISSION ...Tracheal stenosis s/p (status-post) tracheostomy revision ...seen by bronchoscopy in February of 2022 for anatomic reasons, will require permanent tracheostomy ...” . Continued review of Patient #’1 record on 08/14/24 at 9:00 AM revealed the Case Management Progress Note dated 10/13/23 indicated, “ ...Reassessment of Discharge Plan with ...Interdisciplinary Team Conference, Patient, Physician and POA (power of attorney)/Family/Concerned Adult ...Patient remains ventilator and dialysis dependent. Family refuses (patient) to transfer to LTVF (long term ventilator facility) with on site HD (hemodialysis) due to location. There are no locations in South Carolina..” Case Management Progress Note dated 11/3/2023 indicates, “Pt (patient) Medically stable. Continues to be vent and HD dependent. Bed offer from (out of state) Co (county) vent facility. Family continues to refuse discharge ...” Review of the Case Management Progress Note dated 11/10/2023 revealed, “Patient remains ventilator and dialysis dependent. She is stable for discharge to long term ventilator facility. Bed offer from (out of state facility) but barrier is mother who refuses to allow patient to transfer to (out of state facility). There are no facilities closer than (out of state facility)...”. Review of the Case Management Progress Note dated 12/8/2023 indicates, “ ...Family aware of upcoming move to (Hospital #1’s new location). Continue to refuse DC (discharge) to vent facility ...”. Patient remains stable for discharge to long term acute care that provides on site hemodialysis. (Hospital #1) unable to discharge patient even though a bed is available in (another state) as mom will not agree to discharge plans ...” Reassessment of Discharge Plan with the “Team Conference Note” dated 12/29/2023 indicated, “ ...Discharge Plan ...SNF (Skilled Nursing Facility) ...Barriers to Discharge ...Limited Post-Acute (PAC) service within patient/family preferred location ...Clinical needs exceed caregiver capacity, Dialysis, Trach (tracheostomy), Vent (Ventilator) ...”. Review of MD (Medical Doctor) Progress Note dated 01/02/24 at 10:16 AM revealed, “Called both the (family member) as well as the (other family member) today to inform them of plans of care. Phone call was witnessed by both (names of two Hospital #1 staff members) were present for and witnessed that call. The family agrees with the assessment and understands plans will be for discharge disposition to local emergency department on Wednesday 1/3/2024 following hemodialysis. All questions were answered and all needs were met ...”. Review of the Discharge Summary dated 01/03/2024 revealed the primary diagnosis of end stage renal failure on dialysis. The document indicated the name of a primary care provider and a follow-up physicians name for nephrology. The Discharge Disposition indicated, “ ...patient is being discharged from (Hospital #1) to (Hospital #2’s) Emergency Department due to inability to provide hemodialysis services at our facility in (Hospital #3). The move to that facility on January 4th has been discussed with administrative staff, case management as well as family understanding that we can not continue to provide hemodialysis as well as vent management in the same facility where we are going. The patient has been offered and has been accepted at a vent dialysis center in (another state). We have made attempts to send him/her to a LTAC (Long-term acute care) . He/She can not be managed at a lower level of care due to the refusal of the patient’s family. Because dialysis is not available at the facility where we will be treating patient’s subsequently, his/her only other option was to discharge him/her to the nearest emergency department from which he/she came, which was here at (Hospital #2) prior to him/her transferred to (Hospital #1). His/Her primary care physician is (name of physician). His/Her Pulmonary Medicine physicians have been (Palmetto Pulmonary. Family was informed of his/her discharge to (Hospital #2’s) Emergency Department today. Multiple conversations took place prior to this discharge and planning has been under way with family involved in detail ...”. Review of Nursing Notes dated 01/03/2024 at 12:58 PM revealed, “Report called to [name of Registered Nurse] at [Hospital #2’s] ER (emergency room). [Patient #1’s family member name] at bs (bedside), and aware of transfer. Pt’s (patient’s) (family member) ask pt if he/she wants to go to (Hospital #1’s new location), pt nods no. All belongings sent with family, awaiting ...Ambulance service for transport.” 2. On 08/15/24 at 10:00 AM, review of Patient #7’s medical record revealed Patient #7 is a 57 year old patient, full code status, with Humana insurance coverage. Patient #7 was previously a resident of Facility A (a skilled nursing facility) and was transferred to the Emergency Room at Hospital #4 on 11/20/23 with a diagnosis of hypoxemic episode with a blood glucose level of 7 (normal glucose range 70-110) and was admitted at Hospital #4 until 12/13/23 and then discharged to Hospital #1. Record review revealed Patient #7 was admitted on 12/13/23 to Hospital #1 for acute respiratory failure with hypoxia including other diagnoses of chronic kidney disease stage 3, acute kidney infection, tracheostomy in place, unresponsive, ventilator, MRSA (Methicillin-resistant Staphylococcus aureus) bacteremia, Diabetes mellitus, alcoholic cirrhosis, Stage IV pressure ulcer of sacrum, tube feeding via Dobhoff tube, hypertensive heart disease, and metabolic encephalopathy. Continued review revealed an Operative note on 12/19/23 at 11:36 AM documents “Insertion via left internal jugular vein of Trialysis catheter (for temporary hemodialysis)...Patient tolerated the procedure well”. Review of the chart further revealed Patient #7 received hemodialysis treatments on 12/20/23, 12/21/23, 12/22/23, 12/23/23, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/29/23,12/31/23, 01/01/24, 01/02/24 and 01/03/24. Review of Hospital #1’s Team conference dated 12/19/23 at 2:13 PM, with Case Manager #2, Chief Nursing Officer (CNO), Pharmacy Director, Wound Care Registered Nurse (WCRN), Medical Social Worker (MSW), Speech Therapist (ST), Respiratory Director, Registered Dietician (RD) and Rehab Director, reports “Anticipated Discharge to Skilled Nursing Facility (SNF) on 01/12/24. Barriers to discharge include “Limited Post Acute (PAC) service within patient/family preferred location”. Continued review revealed Team conference on 12/27/23 at 4:10 PM, with Case Manager #2, Pharmacy Director, WCN, Medical Social Worker (MSW), Respiratory Director, RD and Rehab Director, reports anticipated discharge to Skilled Nursing Facility (SNF) on 01/15/24. Barriers to discharge include “Limited Post Acute (PAC) service within patient/family preferred location. Review of Team conference on 01/02/24 at 1:41 PM, with Registered Nurse (RN) #1, WCN, MSW, Respiratory Director, RD, CNO, Pharmacy Director and Rehab Director, reports anticipated discharge to Skilled Nursing Facility (SNF) on 01/15/24. Barriers to discharge include “Limited Post Acute (PAC) service within patient/family preferred location. Review of Case Manager Note dated 12/21/23 at 8:39 AM reports Case Manager #2 met with Patient #7’s spouse/POA (Power of Attorney) states “the current discharge plan is skilled nursing facility”. Review of Case Manager note dated 12/28/23 at 8:52 AM states “Current discharge plan is Skilled Nursing Facility”. Review of Case Manager Discharge prep on 01/02/24 at 4:14 PM documents: Planned Transfer/Discharge: Yes; Discharge Destination/Patient Discharge Location: Short term General Hospital; Discharge Destination: Short Term General Hospital; Acceptance of Discharge Plan: Caregiver/Primary contact verbalizes acceptance; Functional and Clinical status has been reassessed and the discharge plan meets patient needs: Yes; Rehab choices obtained by patient and/or family: Yes; Referrals made 3-5 days prior to anticipated discharge: Yes; Obtain orders from MD: Yes; Arranged transportation: Yes; Inform family of room number and transportation arrangements: Yes. Review of MD progress note dated 12/28/23 at 11:30 AM revealed the Medical Director reports “Plan: remains vent dependent and dialysis dependent. Overall decline in demise is imminent...spouse persists in his/her request for full resuscitation status”. Review of Hospitalist progress note dated 01/02/24 at 1:41 PM revealed “Prognosis: extraordinary poor ...(spouse) is insistent on pursuing current course ....”. Review of the Discharge Summary dated 01/03/2024 revealed the primary diagnosis of acute hypoxic respiratory failure. The Discharge Prognosis note states “ ...Extraordinary poor ... Prognosis for meaningful recovery is not expected. This has been reiterated to the family multiple times but (spouse) is insistent on pursuing current course of care ...The pt (sic) will require continued HD and vent support. Her/his case was d/w (discussed with) pt’s (spouse) by Medical Director in detail. Unfortunately, (Hospital #1) is moving to (Hospital #3) and the new facility will not be able to provide HD. As such, the pt will be sent back to Hospital #4 for continue medical care including HD. The case was d/w pt’s (spouse) and he/she is in agreement per d/w Medical Director”. Final Nursing note dated 01/03/24 at 3:25 PM reports Medication reconciliation to Patient /family at time of discharge. Patient #7 was transferred to Hospital #4’s Emergency Department room via ambulance. Interviews An interview was conducted on 08/14/2024 at 1:00 PM in the office of the Chief Executive Officer (CEO) with CEO #1 (the current CEO of Hospital #1 as of 01/05/24), Director of Quality Management (DQM) and CEO #2, (the previous CEO prior to moving from Hospital #2 to Hospital #3 on 01/04/2024). During the interview CEO #2 stated that Hospital #1 was first aware that Hospital #2 would require Hospital #1 to vacate in 2022. CEO #2 states that in 2023, talks and legal discussions were held and by mid 2023, the move was finalized with Hospital #3. CEO #2 reports application for Certificate of Need (CON) on 08/01/23 but final approval was not received until 11/15/23. CEO #2 stated that Hospital #2 was not willing to extend Hospital #1’s lease which ended on 11/30/23. CEO #2 reports he/she toured the new location at Hospital #3 with the biomedical engineer from the dialysis facility and the dialysis Inpatient Program Manager to discuss room construction needs to be able to provide bedside dialysis in the rooms. CEO #2 stated that the engineer gave feedback that the water pressure in rooms was adequate but the threading on the water faucets was not. CEO #2 stated that approval was needed from Hospital #3 for any construction type work and for state agency also to approve work when finished. CEO #2 reports that work was completed, and state agency cleared the work on 12/28/23. CEO #2 stated that Hospital #1 had stopped admitting patients requiring dialysis earlier as they knew they would not have the ability to perform bedside dialysis and were not sure when it would be available after the move. CEO #2 stated that 2 patients required dialysis but did not have appropriate discharge locations and were sent back to their referring hospital. Lead surveyor asked who made the decision to send Patient #1 and Patient #7 back to their referring hospital and CEO #2 stated the Regional Director for Hospital #1, the legal team and CEO #2 made the decision as “the best course of action, best for the patients”. Lead surveyor asked CEO #1 and #2 why Patient #7 was sent back to the referring hospital. CEO #2 stated that Patient #7 required acute care and the family wanted to continue with all care Patient #7 was receiving. Lead surveyor asked why Patient #7 was not transferred to facility in Georgia and CEO #2 stated that the (out of state) a facility is not licensed for acute care, it is a long term/chronic care facility and was unable to meet Patient #7’s needs; no acute care facilities in South Carolina that could manage bedside dialysis and ventilator. CEO #2 stated “we tried to be good stewards of his/her (Patient #1’s) benefits ...we were declining patients because we did not have the bed (due to Patient #1). ...we transferred (Patient’s #1 and #7) the day before we moved”. During an interview on 08/15/24 at 2:50 PM in the second floor conference area, Lead Surveyor asked CEO #1 if Hospital #1 staff had contacted Patient #1 to discuss re-admittance now that bedside dialysis was offered, CEO #1 stated that Patient #1 wouldn’t meet criteria being chronic/long term care and not acute care. CEO #1 stated that Hospital #1 was no longer receiving referrals from Hospital #2 and they were not sure where Patient #1 was located at this time. During an interview on 08/15/23 at 2:31 PM in the second-floor conference room, Chief Nursing Officer (CNO) and the Director of Quality Management (DQM) met with the survey team. CNO stated he/she has been the CNO for less than 6 months and was the house supervisor at Hospital #1 and the CNO at Hospital #3 during the hospital transfer of patients on 01/04/24. The CNO states that he/she was aware of the lack of bedside dialysis in the new location and had no part of any conversations with leadership about the situation. DQM stated that the situation with lack of bedside dialysis was known and not covered up. DQM reports patients requiring bedside dialysis were transferred the day before the actual move date of 01/04/24. DQM reports 9 patients were moved from Hospital #2 to Hospital #3 and 1 patient admitted at Hospital #3 that day and the transition went “smoothly”.”