Pennsylvania Department of Health
EINSTEIN MEDICAL CENTER MONTGOMERY
Patient Care Inspection Results

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EINSTEIN MEDICAL CENTER MONTGOMERY
Inspection Results For:

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EINSTEIN MEDICAL CENTER MONTGOMERY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of an unannounced complaint investigation (LHV24C003V) initiated offsite on March 13, 2024, and completed offsite on April 10, 2024, at Einstein Medical Center Montgomery. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.









 Plan of Correction:


105.22 (a) LICENSURE DISCHARGE PLANNING:State only Deficiency.
105.22 Discharge planning
(a) Discharge planning shall be an integral part of the hospitalization of each patient and shall commence as soon as possible after admission. When the hospital determines no discharge planning is necessary in a particular case, that conclusion shall be noted on the medical record of the patient.
Observations:

Based on review of facility policy and procedures, review of the medical record (MR1, and interview with staff (EMP), it was determined the facility failed to follow their approved policies and procedures to identify the need for appropriate post hospital discharge planning and failed to communicate with the medical staff provider and an external caseworker to protect a nonverbal, bedbound adult patient from suspected abuse, neglect or exploitation in one of one medical records reviewed (MR1).

Findings include:

Review on March 13, 2024, of the facility policy "Discharge Planning," reviewed/revised October 2, 2021, revealed, " ... III. B. Identification of hospital and post-hospital needs is made via pre-admission testing, admission assessment ... emergency department treatment, patient/family identification of a need for service, at service re-assessment, or through daily communication with nursing and medical staff ... F. The Case Manager establishes with the patient/family, appropriate discharge care plans by assisting them in planning for a supportive environment necessary to provide the for the patient's post hospital care while considering the medical, social, education, and financial needs/status of the patient ... ".

Review on March 19, 2024, of facility policy, "Adult Abuse Identification and Reporting,"
effective November 1, 2019, revealed, " ... I. PURPOSE Einstein Healthcare Network ("Einstein") recognizes the need to protect Adults from abuse, neglect, exploitation or abandonment. Einstein acknowledges the responsibilities of its staff in complying with the Adult Protective Services Act ("APS") (Act 70 of 2010) by ensuring appropriate procedures exist to identify and report or cause to report suspicion of abuse, neglect, exploitation or abandonment (hereafter referred to as "abuse") of Adults ... II. POLICY ... D. Clinical and Discharge Considerations 1. All necessary treatment shall be promptly initiated. 2. If hospital admission is required, the Adult should be admitted. 3. The Social Services Department should be notified for assistance and/or followup. 4. If no medical reasons for admission exist and the treatment team feels there is no danger in the patient returning to his home environment, the patient may be discharged after the report is made to the Protective Services hotline and appropriate follow-up is arranged. Note that Adult patients with capacity are allowed to decide to return to an abusive environment. ... VI. PROCEDURE A. Identification 1. While sometimes an Adult patient or accompanying Caregiver may volunteer a history of abusive events, often s/he presents only with complaint of injury or even seemingly unrelated medical conditions. Therefore, an appropriate review and consideration of abuse must occur when: ... e. there is any evidence of poor personal hygiene, malnutrition, dehydration, decubitus ulcers in the absence of obvious precipitating causes f. the Adult is extremely anxious, withdrawn, agitated, depressed or exhibiting infantile behavior. 2. Other considerations include, but are not limited to: a. Adult presenting multiple times with a variety of medical complaints that may or may not have obvious organic causes ... d. Signs of psychological, emotional, verbal or financial abuse or neglect ... 4. Information from the exam, including the history and physical will be evaluated to determine if there is reasonable cause to suspect Adult abuse and the need to file a mandated report as set forth in Section VI. B of this Policy. 3. The Social Services Department should be notified for assistance and/or followup ... ".

1) Review on March 12, 2024, of MR1 revealed an admission to the facility dated November 25, 2023, through December 1, 2023. Review of provider documentation for MR1 dated November 25, 2023, revealed the assessment for MR1 included acute hypoxic respiratory failure, acute chronic respiratory failure with hypoxia, pneumonia, sepsis, COPD with lower respiratory infection, hyponatremia, type 2 DM, hyperglycemia, acute anemia, history of CVA with residual effect, PEG tube placement, chronic indwelling Foley catheter, chronic systolic and diastolic CHF, anxiety, depression and sacral ulcer.

Review on March 12, 2024, Social Worker (SW) documentation for MR1 dated November 29, 2023, revealed that an order placed on November 28, 2023, requesting home-term placement for patient due to the RN staff concerns with care at home. Further review of CM (Care Management) documentation for MR1 revealed the RN concerns were discussed with the SW on November 27, 2023, and it was determined that no intervention from SW was needed at that time. The family requested MR1 to return home once medically stable and the patient was discharged to home with a family paid caregiver and home care services on December 1, 2023.

2) Review on March 19, 2024, of MR1 revealed an admission to the facility on December 9, 2023, through December 20, 2023, for respiratory failure requiring intubation. The patient continued to be at non verbal, bedbound baseline.

Review of facility document for MR1 revealed Department (ED) nursing documentation in a abuse/neglect report dated December 9, 2023, at 2:39 PM, revealed the patient appeared neglected at home, with a description that included the patient was unkempt, had matted hair, appeared unwashed, had multiple large wounds throughout body, urinary catheter was old, filled with foul-smelling urine and pus, malnourished, severely dehydrated, feeding tube is crusted and had discharge around it and appeared the patient had aspirated and now has sepsis. Continued review of this report for MR1 revealed Emergency Medical Services reported to the ED nurse that the home where the patient resided was full of garbage and unlivable, with about 20 other people living in the home. Further review of the ED nursing docmentation in the facility document for MR1 revealed the patient was recommended for hospice on a previous admission, but the family refused and requested discharge to home.

Review on March 19, 2024, of provider documentation for MR1 dated December 12, 2023, revealed the patient was not getting turned enough with several decubitus ulcerations, with one of the decubitus is a stage IV which extended distally down the lateral aspect of the thigh which was not present on the patient's previous admission. Further review of provider documentation for MR1 revealed it was futile to continue to debride these decubitus ulcerations if the patient is not going to be properly cared for when the patient left the hospital.

Review on March 19, 2024, of Care Management/Social Work (CM/SW) Documentation for MR1 for the December 9, 2023, through December 20, 2023, admission, revealed no documentation the medical provider was notified that an abuse/neglect report was submitted for MR1 on December 9, 2023.

Further review on March 19, 2023, for MR1 revealed the patient's family refused hospice or long term care, and the patient was discharged back to home on December 20, 2023, with a paid family caregiver through county waiver program and previous home health services.

3) Review on March 21, 2024, of MR1 revealed an admission to the facility dated December 23, 3023, through January 2, 2024, for presenting from home due to difficulty breathing and concern for aspiration by family. Patient was tachycardic, hypoxic, and in respiratory distress on arrival with a high probability of imminent or life-threatening deterioration due to sepsis.

Review on March 21, 2024, of nursing documentation for MR1 dated December 29, 2023, revealed an assessment that included the patient appeared disheveled, hair extremely matted, malodorous, multiple DTI's [Deep Tissue Injuries], many of which are at least stage 4 all over the buttock area, B/L heels, hips, and posterior upper thigh. The patient grips RN during nursing tasks and looks fearful, diaphoretic at times, especially during DTI dressing changes. Patient was given a good bed bath, all fresh dressings, a new 16 F foley catheter, the current one clogged and cloudy, pain medication ... an offloading wedge, and a new gown. Z-flex boots remain in place.

Review on March 19, 2024, CM/SW documentation for MR1 dated December 29, 2023, revealed the SW spoke with an external caseworker who wanted to confirm whether the patient had been discharged since the December 9th admission and the reason for the readmit. The external caseworker requested a call from the facility's SW/CM when the patient in MR1 was cleared for discharge for this admission, including emailing the information to the external caseworker.

Review on March 20, 2024, of provider documentation in the "Discharge Summary" for MR1 dated January 2, 2024, imaging of chest showed evidence of pneumonia, most likely due to aspiration, blood culture was positive for bacteria. Further review of the "Discharge Summary" for MR1 revealed the patient was medically stable for discharge, and the family decided on full code status and transition back to home care.

Review on March 20, 2024, of CM/SW documentation for MR1 for the December 23, 2023, through January 2, 2024, admission revealed the patient was discharged back to the home with a paid family member providing care through a county waiver program and home health care services. Continued review of SW/CM documentation for MR1 for this admission revealed no documentation the external caseworker was contacted as requested for notification of the clearance for the patient's discharge, or that information was emailed to the external caseworker when the patient was cleared for discharge.

4) Review on March 22, 2024, of the admission to the facility for MR1 dated January 24, 2024, through February 7, 2024, revealed the patient presented to the ED unresponsive with a notable large necrotic wound at the left hip and had purulent sputum.

Review on March 22, 2024, of CM/SW documentation for MR1 dated January 25, 2024, noted an RN assessment of suspicion for abuse/neglect/exploitation under the psychosocial assessment, with documentation of the patient was not able to respond at the time.

Review on March 20, 2024, of CM/SW documentation dated January 31, 2024, at 3:11 PM, revealed, the SW spoke with the external caseworker about the patient's discharge plan, and that the patient could not be discharged to home with the only option for MR1 would be hospice at the hospital or in a nursing care facility. Further review of CM/SW documentation for MR1 revealed the family was not in agreement with the discharge plan for nursing care facility placement or hospice care. The patient in MR1 was transferred to a long term nursing care facility on February 7, 2024, with a plan to transition to hospice care.

5) Email interview with EMP1 on March 27, 2024, at 2:41 PM, confirmed there was no documentation in MR1 that the CM/SW contacted or emailed the external caseworker, as requested, and failed to notify them of the patient being cleared for discharge to home with a paid family caregiver and home health services for the December 23, 2023, through January 2, 2024 admission.

Email interview with EMP1 on April 8, 2024, at 11:53 AM confirmed there was no documentation the hospital's CM/SW communicated with the patient's medical staff provider and failed to notify them that an abuse/neglect report was filed for the patient in MR1 on December 9, 2023, and the patient was subsequently discharged after medical clearance back to home with a paid family caregiver and home health care services on January 2, 2024.
















 Plan of Correction - To be completed: 06/03/2024

1. The manager of Case Management will meet with all social workers and case managers involved in the patient's care planning to understand where the communication breakdown occurred to prevent it from happening in the future.

2. The manager of Case Management will review Policy A0300.1: Adult Abuse Identification & Reporting with all social work and case management staff.

3. The manager of Case Management will meet with the social work and case management staff to review policy AD-001.03: Discharge Planning.

4. At monthly team meetings, the manager of Case Management will review and discuss ongoing compliance with the above noted policies.

The manager of Case Management will perform a monthly audit of twenty (20) charts beginning on 05/20/2024. The audit will assess adherence to policy as it relates to proper follow-up/communication and documentation. The results of the audit will be reported monthly to the Regional Director of Case Management and to Quality Council until there is a compliance rate of 100% for 3 consecutive months.

The Regional Director of Case Management has overall responsibility for these actions.

Completion Date
6/3/2024


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