Table 2.

Themes Perceived by Consumers as Contributing to Preventable Readmissions (N = 49)

Site of concern	Preventability themea and consumers’ representative quotations	Endorsement n (%)
Hospital	Problem never resolved at hospital	7 (14.3%)
	Nobody knew about the GI bleed.
	They never found the cause of her pain.
	Discharged too soon from hospital	8 (16.3%)
	They could have kept me longer in the hospital. I feel safer at the hospital; you can take better care of me here.
	The stay here last time could have been extended to be sure she was over the illness last time.
	Poor hospital discharge planning/ lack of communication	8 (16.3%)
	[I] wished they had told me and my wife about the medication before they took me off it.
	They should have made sure that where they sent my mother they knew about the TEP, and how to clean it and what to do for it.
SNF	Improper medication management at SNF	10 (20.4%)
	When I asked about my water pill and informed them I had not had it for 13–18 days, I felt like I was being blown off.
	As soon as the Butrans patch arrived they were supposed to discontinue the hydrocodone, but they kept giving it even after I questioned it.
	Inadequate treatment, responsiveness, or monitoring at SNF	34 (69.4%)
	They didn’t know what to do with my drain and feeding tube. They started up the feeding “in” and never connected the “out” to a bag like I told them.
	She was neglected. No one went in to check on her and her health declined to the point she had to come back to the hospital.
	Poor decision-making by SNF regarding transfer for readmission	7 (14.3%)
	They told me I needed to go back to the hospital and I begged them not to send me. I had stopped bleeding by then but the nurse said I scare them out there.
	They could have trusted me when I told them it was bad. I had to call my own doctor and he told me to get to the ER.

Notes: ER = emergency room; GI = lower gastrointestinal; SNF = skilled nursing facility; TEP = tracheoesophageal puncture.

^aThemes were not mutually exclusive in that one consumer comment could be coded as pertaining to more than one theme.