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Based on 1 of 4 record reviews, policy review and staff interview's, it was determined that a patient (#1) representative was not honored the right to participate in discharge planning related to her cognitively impaired mother's care and was not informed of her freedom to choose among participating Medicare providers.

Findings include:

Per record review, Patient #1 was brought to the Emergency Room (ER) because of left hip pain due to a fall that occurred at an Assisted Living facility (Bradley House) where the patient resides. She has the diagnosis of Carotid Artery Stenosis, CVA, decreased vision to left eye, Glaucoma in the right eye and is legally blind. She also has the diagnosis of Osteoporosis. The patient was admitted from 12/22/23 through 12/26/22 due to hypoxia, difficulty with ambulation and urinary retention. A Chest CT scan revealed pulmonary emphysema and an ascending aortic aneurysm.

The patient displayed confusion throughout her stay. According to physician and nurse notes, the patient is confused, frequently forgets where she is and is unaware of time and thinks she is at home with her daughters. Redirection to reality did not help. A physical therapy note (12/24/22), reveals the patient thinks she lives "at home with her parents, sister, aunt and cousins." The patient was referred to skilled nursing facilities (Grace Cottage, Thompson House, Pine Heights and Vernon Green) per a Case Management note but does not indicate this information was relayed to the patient's representative/daughter. (12/24/22).

The patients History and Physical (12/23/22), shows a phone conversation between the physician and the patient's daughter. The name listed is not the patient's daughter although reports that "at baseline she (the patient) does have cognitive impairment, however, was doing well at the present house until yesterday." The assessment indicated patient "A&O to self only". A few days later 12/25/22 a physician note reveals that a conversation with the patient's daughter (name not noted by physician) took place to discuss the plan of care at the patient's bedside. It was noted that a subacute rehabilitation facility would be best as she is unable to go back to Bradley House but does not reflect facility of choice or response from the patient's representative/daughter.

On 12/26/22 (a holiday for some staff) the patient's daughter went to visit her mother at the hospital. The patient had already been discharged to a skilled nursing facility (Pine Heights). A nurse note (12/26/22) states "Pt DC to Pine Heights." The note does not indicate at what time, if family was notified, what belongings went with her, mode of transportation and condition of the patient at time of discharge.
The hospitals policy Subject: CARE TRANSITIONS: Care Management/Quality Department (03/03/2020) pg. 3., #3 states "Consent for Transfer will be obtained from the patient and/or family and other pertinent documents completed" and a Care Transitions: Discharge Checklist (03/30/2020) indicates Family Notification: Contact patient's family/significant others about anticipated discharge date/time. Confirms means of transportation.

The hospital did not notify the daughter of the patient's discharge per facility policy and did not include her regarding decisions as to which skilled nursing facility her mother would go to, or what mode of transportation would be used. The patient was cognitively impaired per evidence in the medical record and unable to make her own decisions. Discharge instructions did not contain the patient representative or patient signature indicating they received such instructions. Per interview on 06/14/23 with the current interim case manager, "all documentation would have been sent to the receiving facility." There is indication of an Interdisciplinary (IDT) Team meeting that took place on 12/24/23, but there is no documentation as to what was discussed. The patients Advanced Directives (April 23, 2013) shows that her daughter was appointed as her agent to make all health care decisions in the event the patient is unable to. The patient's daughter is listed on the face sheet as the emergency contact.

Interview on 06/15/23 with the Case manager, Director of Risk management and Chief Nursing Officer confirmed the above missing documentation to support a smooth discharge.

Based on 1 of 4 record reviews, policy review and staff interview's, it was determined that a patient (#1) representative was not honored the right to participate in discharge planning related to her cognitively impaired mother's care and was not informed of her freedom to choose among participating Medicare providers.

Findings include:

Per record review, Patient #1 was brought to the Emergency Room (ER) because of left hip pain due to a fall that occurred at an Assisted Living facility (Bradley House) where the patient resides. She has the diagnosis of Carotid Artery Stenosis, CVA, decreased vision to left eye, Glaucoma in the right eye and is legally blind. She also has the diagnosis of Osteoporosis. The patient was admitted from 12/22/23 through 12/26/22 due to hypoxia, difficulty with ambulation and urinary retention. A Chest CT scan revealed pulmonary emphysema and an ascending aortic aneurysm.

The patient displayed confusion throughout her stay. According to physician and nurse notes, the patient is confused, frequently forgets where she is and is unaware of time and thinks she is at home with her daughters. Redirection to reality did not help. A physical therapy note (12/24/22), reveals the patient thinks she lives "at home with her parents, sister, aunt and cousins." The patient was referred to skilled nursing facilities (Grace Cottage, Thompson House, Pine Heights and Vernon Green) per a Case Management note but does not indicate this information was relayed to the patient's representative/daughter. (12/24/22).

The patients History and Physical (12/23/22), shows a phone conversation between the physician and the patient's daughter. The name listed is not the patient's daughter although reports that "at baseline she (the patient) does have cognitive impairment, however, was doing well at the present house until yesterday." The assessment indicated patient "A&O to self only". A few days later 12/25/22 a physician note reveals that a conversation with the patient's daughter (name not noted by physician) took place to discuss the plan of care at the patient's bedside. It was noted that a subacute rehabilitation facility would be best as she is unable to go back to Bradley House but does not reflect facility of choice or response from the patient's representative/daughter.

On 12/26/22 (a holiday for some staff) the patient's daughter went to visit her mother at the hospital. The patient had already been discharged to a skilled nursing facility (Pine Heights). A nurse note (12/26/22) states "Pt DC to Pine Heights." The note does not indicate at what time, if family was notified, what belongings went with her, mode of transportation and condition of the patient at time of discharge.
The hospitals policy Subject: CARE TRANSITIONS: Care Management/Quality Department (03/03/2020) pg. 3., #3 states "Consent for Transfer will be obtained from the patient and/or family and other pertinent documents completed" and a Care Transitions: Discharge Checklist (03/30/2020) indicates Family Notification: Contact patient's family/significant others about anticipated discharge date/time. Confirms means of transportation.

The hospital did not notify the daughter of the patient's discharge per facility policy and did not include her regarding decisions as to which skilled nursing facility her mother would go to, or what mode of transportation would be used. The patient was cognitively impaired per evidence in the medical record and unable to make her own decisions. Discharge instructions did not contain the patient representative or patient signature indicating they received such instructions. Per interview on 06/14/23 with the current interim case manager, "all documentation would have been sent to the receiving facility." There is indication of an Interdisciplinary (IDT) Team meeting that took place on 12/24/23, but there is no documentation as to what was discussed. The patients Advanced Directives (April 23, 2013) shows that her daughter was appointed as her agent to make all health care decisions in the event the patient is unable to. The patient's daughter is listed on the face sheet as the emergency contact.

Interview on 06/15/23 with the Case manager, Director of Risk management and Chief Nursing Officer confirmed the above missing documentation to support a smooth discharge.