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Based on interviews and document reviews, the facility failed to establish an appropriate discharge plan in one of four medical records reviewed (Patient #2).

Findings Include:

Facility Policies:

The Discharge Planning and Referrals of Patients to Post Discharge Providers policy read, the purpose is to ensure a discharge planning process that focuses on the patient's goals and include the patient and his or her caregivers as active participants in the discharge planning for post-discharge care.

The Discharge Planning and Continuing Care Overview policy read, the social worker will coordinate with family and community resources. The discharge continuing care plan is reviewed with the patient and the family.

The Discharge Planning and Referrals for Patients to Post Discharge Providers policy read, discussion with the patient/caregiver about discharge evaluation results, the patient/caregiver agreed upon discharge plan and any followup notes will be placed in the medical record. The hospital will arrange for implementation of the discharge plan including in-hospital training to patient and family/caregiver.

1. The facility failed to establish an appropriate discharge plan which included the patient and the patient's representative in the discharge planning process.

a. On March 3/11/20, a review of Patient #2's medical record was conducted. Patient #2 was admitted to the facility on 1/28/20 due to a fall at home. Upon admission, it was determined the patient lived with her two sons. Patient #2's medical record showed there was no documentation of the involvement of Patient #2 or the patient's son in the creation and evaluation of the discharge plan throughout Patient #2's hospital stay. Patient #2 was discharged home at 10:30 a.m. on 1/30/20. The case manager documented a note on 1/30/20, the day of discharge. The note read, the discharge plan was discussed with the patient and the patient's son the morning of discharge. The note also read, the son was concerned about taking the patient home since he had to work all day and would not be at home during the day with her. There was no evidence in Patient #2's medical record which showed the patient's son was included in the discharge plan prior to the day of discharge. The facility failed to follow their policies and ensure the involvement of the patient and/or family members as active participants in the discharge planning process for post-discharge care.

b. On March 3/12/20 at 12:14 p.m., an interview was conducted with Physician #1. Physician #1 stated as a provider, he was fairly involved with the patient and family on the plan for discharge. Physician #1 stated the discharge plan began a few days before discharge. Physician #1 stated he would enlist the help of the social worker and therapists to investigate patient's needs. Patient #2's medical record was reviewed. Physician #1 stated the patient was discharged home with her sons and they took her straight to Sterling for her dialysis treatment. Physician #1 stated her sons seemed involved in her care. Physician #1 stated he was unaware of the case manager note with the son's concern in regards to taking his mother home.

c. On 3/12/20 at 1:09 p.m., an interview was conducted with Registered Nurse (RN) #2. RN #2 stated the discharge plan began with the family and their wishes. RN #2 stated re-evaluation of the discharge plan occurred if the family had concerns. RN #2 stated discharge concerns were communicated to case management. RN #2 stated the case manager saw the patient on a daily basis.

d. On 3/12/20 at 3:04 p.m., an interview was conducted with Case Manager (CM) #3. Patient #2's record was reviewed with CM #3. CM #3 stated she remembered the Patient #2's son expressed concerns about taking the patient home since he worked during the day. CM #3 stated the conversation between the CM and son took place the morning of the patient's discharge. The facility failed to provide evidence from the patient's medical record the patient's son was involved in the creation and evaluation of the discharge plan.

The facility failed to ensure the discharge plan was started prior to the day of discharge and failed to ensure the family of the patient was involved with the creation and evaluation of the discharge plan. The failure was in contrast to the facility policy.