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Based on interview and document review, the facility failed to order, and implement, recommended home care services for 1 of 10 patients (P21). This resulted in an unsafe discharge home for P21 who required wound care services and assistance with activities of daily living (ADLs).

Findings include:

A Common Entry Point (CEP) report dated 8/11/23, was submitted to the State Agency (SA) by a non-hospital affiliated complainant. The report identified P21 contacted the complainant on 8/4/23 and inquired about facility placement. On 8/8/23, the complainant presented to P21's home and found P21 was unable to walk or transfer himself, much less stand, without assistance due to significant weakness. The VA reported previous placement at a care facility for approximately six weeks due to pressure wounds on his 'bottom,' where four hours after being discharged from that facility, he fell and required ambulance transport to the hospital. After 10 days, P21 was then 'thrown out of the hospital,' as he no longer qualified to be there. P21 identified he lacked assistance with wound care and the wounds worsened as no services were set up for him prior to his discharge.

P21's emergency department (ED) provider note, identified P21 arrived on 7/3/23 via ambulance, for a chief complaint of failure to thrive with an inability to care for himself, along with ambulation difficulties. P21 was free of cognitive deficits. P21 discharged three hours prior from an outside hospital swing bed (post-hospital skilled care), where he resided for several months. There, P21 refused nursing home placement multiple times and thus was discharged home with home care services. Once home, P21 discovered he was unable to ambulate with all carpet and house rugs in his way. He denied falling in those three hours. The ED provider identified P21 was medically stable after being assessed for acute difficulty walking, and acute failure of outpatient treatment; however, P21 required nursing home placement. P21 was admitted to the facility due to lack of bed availability at the previous swing bed.

P21's medical record identified the following patient classification status order information:
1. 7/3/23 -7/4/23 = Inpatient.
2. 7/5/23 - 7/18/23 = Observation.

A Hospitalist Progress Note dated 7/4/23, completed by medical doctor (MD)-D, identified P21 was diagnosed with multiple diagnosis, but not limited to, chronic wound with wound VAC (vacuum assisted closure) and severe obesity. The note indicated: "Definitely would not want to go home as he could not be home even for about 3 [three] hours." The Disposition identified the case manager would assist P21 with safe discharge planning.

An Occupational Therapy (OT) Initial Evaluation and Discharge Summary dated 7/5/23, indicated that no occupational therapy needs were identified as P21 had reached his highest level of independence with previously provided therapy since August of 2022 and P21 waited SNF placement as he was unable to return home.

A Physical Therapy (PT) Initial Evaluation dated 7/5/23, indicated P21 presented with lower extremity functional weakness, decreased activity tolerance and impaired functional mobility impacting his safety and independence. P21's primary barrier to discharging home was his severity of physical deficits. Additional barriers centered around lack of caregiver support. SNF placement was recommended with a poor rehab potential due to a lack of overall progression history, or maintenance of any progression over the last several months.

A Case Management Assessment dated 7/7/23, completed by case manager (CM)-D, identified P21 lived alone with his spouse where he had just discharged to from a swing bed facility three hours prior. P21 was free of home care services prior to admission. P21 required assistance with ADLs and household tasks. In addition, P21's children were his support system, along with a county worker. P21's preferred SNF or an assisted living facility (ALF) for short-term placement; however, as P21 identified he was unable to pay for such places, the CM-D would assist P21 with the medical assistance (MA) application process. P21 indicated he was on waiting lists for two identified nursing homes; however, he was against going to two other identified facilities and declined any facilities which were less than three stars (nursing home rating system). The assessment was free of home care information arranged prior to his swing bed discharge.

A Hospitalist Progress Note dated 7/10/23, completed by MD-D, identified P21 was financially restricted which caused significant hurdles for his [SNF and ALF] discharge planning.

A Case Management note dated 7/10/23, identified CM-D referred P21 to four ALF facilities.

A Department of General Surgery History and Physical dated 7/10/23, completed by nurse practitioner (NP)-C identified P21 required vacuum assisted closure (VAC) dressing to a sacral (end of spine in pelvic area) wound, in which P21 had limited assistance at home for management after discharge as his spouse also experienced limited mobility. It was determined the wound VAC dressing would continue to be utilized.

A Hospital Medicine Service note dated 7/13/23, identified due to P21's "recent maneuvers in regard to his financial situation he has eliminated himself from obtaining any support from the county/state of Minnesota. He continues to state that he cannot go home. Has nowhere to go."

A Case Management note dated 7/13/23, identified one of the 7/10/23 referred facilities denied P21's admission as they felt P21 was not a good fit due to his size and fall risk.

A PT Discharge Summary note dated 7/14/23, identified P21 lacked any progress with therapy and thus was discharged with a recommendation for SNF placement as P21 was unable to care for himself at home.

A Case Management note dated 7/14/23, identified CM-D updated P21 the discharge plan for that day was for him to return home with home health care as "staying in the hospital is not an option," and that she would make a referral to Senior Linkage (a free statewide service that helps older Minnesotans and their families and caregivers with various age-related issues and questions). P21 continued to state that going home was not safe and he refused to go despite CM-D's attempts at asking P21 where he would like to go.

A Hospital Medicine Services note dated 7/17/23, identified a continued pending placement.

A Case Management note dated 7/17/23, identified one of the 7/10/23 ALF referrals denied P21.

A Case Management note dated 7/18/23, identified CM-D, an MD [MD-D], and RN [registered nurse (RN)-J], approached P21 and informed him he was being discharged that day at 4:00 p.m., and transport was set up. In addition, Senior Linkage was contacted to reach out to him on 7/19/23, home care was being setup to come to his home for wound care VAC dressing changes, as well as weekly wound clinic appointments. P21 informed them he could not go home and refused to leave. P21 was talked to about sabotaging all discharge possibilities and the facility had a safe plan in place for him. It was time for him to be discharged home as no facility accepted him for admission. Further, the note indicated P21's daughter contacted CM-D and inquired about the situation as P21 contacted her. The note lacked additional details related to conversations with the Senior Linkage or home care services.

P21's After Visit Summary dated 7/18/23 and printed at 4:07 p.m., identified a clinic appointment setup for the wound nurse on 7/20/23; however, no scheduled appointment date for P21's primary physician (one week follow-up). The AVS provided education/instruction attachments for Fitting Your Walker, Exercises to Prevent Falls, and Preventing Falls: How to Prepare and What to Do; however, the AVS lacked education/instruction information related to the wound VAC or potential wound concerns and/or what to do in such situations. The AVS did provide Wound Care Instructions: "Change dressing daily using sterile technique." The AVS lacked identification of home care setup, follow-up, or any additional home care information.

P21's medical record identified P21 discharged on 7/18/23 at 4:17 p.m.

P21's medical record lacked a 7/18/23 nursing (RN) discharge progress note.

A Discharge Summary note dated 7/18/23, completed by MD-D, identified P21's Principal Problem was impaired mobility and ADLs. Secondary diagnoses included, but not limited to, chronic coccygeal wound, severe obesity, chronic pain and neuropathy, and depression. MD-D documented that herself, the case manager [CM-D], and nursing staff [RN-J], informed P21 he was medically stable and was being discharged home. Follow-up care with primary physician, blood work, and wound nurse were setup, along with "home services were arranged by [CM-D]." In addition, MD-D documented, "Patient has no medical reason to remain in the hospital. He required hospital inpatient care only if there is an acute medical issue. He is an extremely high risk for readmission as he has continued to refuse discharge. The [facility] ED department was notified."

P21's medical record lacked evidence of the following information:
1. Senior Linkage communication details related to discharge planning and discharge confirmation.
2. Facility initiated communication details with P21's family/representative prior to discharge to assist with discharge planning.
3. Potential County worker verification and communication to assist with discharge planning.
4. Potential facility ethics committee involvement in discharge planning.
5. Financial counselor or contracted agency met with, or talked with, P21 personally.
6. Transportation availability/financial abilities to/from weekly wound care appointments and/or any additional appointments.
7. Case management home care referral followup(s).
8. Case management communication with the home care agency ordered prior to discharge from the swing bed facility.
9. Communication with KCI (wound care VAC supplier) for status updates and confirmation of wound VAC supplies at home.
10. P21's ability to perform, or assistance while at home, for the AVS identified daily dressing changes with sterile technique.
11. A medical provider home care order.
12. Home care acceptance.

P21's EPIC (organizations medical record system), identified a telephone encounter note dated 7/20/23, that P21 contacted the swing bed facility for assistance with home care to come change his wound VAC and that he needed SNF placement as he fell after discharge due to impaired mobility. The note indicated the social worker would contact the home care agency to reinstate services; however, they needed a new order, a face-to-face, and they were not available "until next week."

During a telephone interview on 12/3/24 at 1:41 p.m., the complainant stated P21 was unable to get out of the chair, even with her and an accompanying staff member's attempted assistance. No home care, wound care, or therapy worked with P21 despite significant evidence he required such services. The complainant denied personally observing P21's wound(s) due to the inability to assist him with standing, and thus the complaint wound statements were based only off P21's comments. Due to the care P21 required, her agency was unable to provide services for him and she encouraged P21 and his wife to contact an ambulance for transport to the hospital.

When interviewed on 12/4/24 at 9:58 a.m., RN-A identified she was the med surg nurse manager. RN-A stated case management overall manages the processes to ensure a safe discharge. RN-A explained the discharge process included the IDT (interdisciplinary team) along with the patient and their family/representative when applicable and was based on recommendations for each area. Overall, case management managed home care communication(s). If home care was recommended, she expected an order and an accepting home care provider before the patient was discharged. That way, this information was provided to the patient when the AVS was provided to them. In addition, if a patient had wounds, she would have expected the patient to be provided educational information/instructions. RN-A identified she vaguely remembered P21 because of his financial concerns that impacted his discharge planning; however, she denied remembrance of any concerns from P21's discharge on 7/18/23 which would have flagged P21's discharge as unsafe. RN-A indicated she reviewed P21's chart and the chart lacked a home care order or an accepting home care company prior to P21's discharge.

During an interview on 12/4/24 at 12:15 p.m., NP-C stated upon P21's discharge, a follow-up appointment was made for him at the clinic, which was a typical process when someone went home with a wound VAC which assisted with clinical assessment processes; however, after review of P21's record, NP-C indicated P21 never kept the appointment setup upon discharge but he did contact the clinic that day and was provided with instructions to remove the VAC, use Dakin's (diluted bleach solution to prevent and treat skin and tissue infections), and put a dressing on the area. The clinic would send wound care supplies home with P21's daughter and he was further instructed to visit the clinic as soon as he was able. NP-C stated P21 never made any additional appointments with wound care.

When interviewed via telephone on 12/4/24 at 1:03 p.m., RN-C identified herself as the case management manager. She stated, in P21's case, she expected to find a home care order, an interagency report for home care, and a case management note located in P21's medical record that indicated a home care acceptance before P21 discharged and time the home care would reach out to him for services. RN-C stated she was unable to find this information in P21's chart and commented CM-D's 7/18/23 case manager note was not indicative of what case management did. CM-D's "process was very rogue," and she "cringed" when she read the note. If she would have read this note, at the time of P21's discharge, she would have followed-up on P21's discharge to assist with the process. RN-C indicated she was not updated about concerns related to P21's discharge processes and was unaware there were lapses in home care orders and accompanying acceptance. If she were updated about concerns, she would have encouraged county or origin involvement, a care conference with patient, family, IDT, etc. RN-C acknowledged P21's record lacked these additional discharge planning processes.

During a telephone interview on 12/4/24 at 1:40 p.m., the home care agency's (home care agency A) clinical manager (CM)-B reviewed P21's chart and identified when P21 discharged the swing bed on 7/3/23, a referral was placed; however, on 7/5/23, there was a note that identified home care did not accept the referral. CM-B identified P21's chart, between 7/3/23 and 7/23/23, there was no communication, or home care orders, for P21 from the hospital. On 7/24/23, a referral came in from an unidentified source for home care; however, once P21's records were reviewed, they determined P21 needed SNF care and thus they were unable to provide home care services. CM-B stated their home care agency and one other home care agency serviced P21's area and she expected if home care services were ordered for P21, a referral was placed for their review prior to P21's discharge, if P21 agreed to the referral.

When interviewed via telephone on 12/4/24 at 2:16 p.m., the other home care agency's (home care agency B) clinical manager (CM)-C stated their records only went back 90 days, unless the patient was a home care client. She was unable to locate P21's name in their system.

During a telephone interview on 12/4/24 at 2:55 p.m., CM-D stated she no longer worked for the facility; however, she remembered P21 and how badly P21 handled his finances at that time, thus P21 did not qualify for MA. CM-D identified, "We tried to do many things for him," and "We try whatever we can to get services." CM-D explained P21 was "fully capable" of returning home despite his not wanting to for unknown reasons. P21 refused ALF and SNF services as P21 stated he could not pay privately. CM-D lacked remembrance on the services P21 required and/or her follow-up with any potentially required services. She felt P21 utilized a wound VAC and she felt P21 was supposed to follow up with the wound clinic for management. CM-D stated if she completed home care follow-up, P21's chart would indicate it. CM-D stated she, and additional staff, approached P21 later in the day [on 7/18/23], as she wanted to lessen any potential behaviors, and informed him transportation was setup and he was being discharged. When P21 was informed security would be present for the discharge, the discharge "went smoothly after that."

When interviewed via telephone on 12/4/24 at 3:18 p.m., MD-D stated P21 was "very difficult to deal with." P21 did not qualify [financial assistance] for facility placement; however, P21 was adamant he could not return home and "outright refused" to discharge. MD-D explained, a decision was made for home care services to manage his wound care. Due to this, she expected P21's record to have a home care order, a face-to-face assessment for the home care, and staff follow-up for arrangements prior to his discharge. She was unable to remember any concerns with P21's discharge on 7/18/23 or any potential reasons why the medical record lacked her stated expectations.

During a telephone interview on 12/4/24 at 3:55 p.m., P21 stated he currently resided in a nursing home and that "more or less" the hospital "threw" him "out on the curb" and told him he "had to get out." P21 identified security was present for his discharge. "They figured I had money, and I did not have money." P21 denied home care worked with him once he returned home, or that anyone contacted him about services, and thus he "did not do too well" and "was not safe at home." P21 indicated his wife, nor his family, was involved with any decision making or discharge planning while he was in the hospital, and explained his wife was unable to assist him due to his and her ages and statures. Upon his discharge, he had to find his own assistance for cares and wound management which ultimately resulted in the end of the wound VAC treatments as he had no supplies for this when he returned home, no provided education/information on how to manage it, and no one to help him with it. In addition, he was unable to get to/from his medical appointments due to his mobility and financial statuses.

When interviewed via telephone on 12/5/24 at 8:48 a.m., RN-J stated she was approached by MD-D and CM-D on 7/18/23 and informed P21 was discharging that day, a ride was setup, and everything was good to go. When she approached P21 and informed him he was discharging that day, P21 became mad and threw a box of Kleenex at her and informed her that once he left, he would throw himself on the ground and come back in via the ED. In response, she messaged MD-D and CM-D and was informed to contact security for assistance. When she and another nurse approached P21 with security, P21 allowed assistance with the discharge without any additional concerns. RN-J explained she went over the AVS with P21; however, she was unable to remember details of what was on the form but if home care was recommended, she expected this was in the form and she would have gone over those details with P21.

During a telephone interview on 12/5/24 at 11:30 a.m., the director of nursing (DON) stated the discharge process started on admission and was driven by the case management team to ensure the discharge processes were organized, medical equipment was managed, and recommended referrals were ordered, communicated, and in place, especially home care services, to ensure each patient had a safe discharge plan. The DON reviewed P21's medical chart and identified P21 lacked a home care order and follow-up processes prior to his discharge.

A Discharge Planning & Patient Choice policy dated 10/12/21, directed that once the provider determined the medically necessary post-hospital care services and the patient choose a service provider from a list of offered choices, staff were to make referrals to the requested providers for availability determinations. If the patient's first choice was unavailable or could not meet the patient's needs, staff were to discuss alternative options and make additional referrals. The policy further directs the physician must approve the discharge plan and complete the final discharge orders and interagency referrals document to facilitate the continuum of care and implementation of the discharge plan. If a patient is self-pay or has concerns about the cost of care, a financial counselor or contracted agency will be available to meet with the patient in person or via phone.

A Discharge Planning Process in Acute Care Facilities policy dated 6/24/24, identified its purpose was to facilitate a safe transition of patients from the facility to the patient's home or to other health care or residential facilities upon discharge. In addition, the discharge plan was to incorporate assessment and planning of the patient's medical, psychosocial, and financial needs through coordinated efforts of the IDT; identify what services the patient required for a safe transition from the hospital; and to facilitate the shared responsibilities of health care professionals and community services. The policy directed an individual's discharge plan was to recognize the patient's specific needs and resources available in the community and to ensure these were available to them upon discharge, in which ongoing discharge plan reassessments based on changes in the patient's condition, available support, and/or post-hospital requirements was to be documented in the medical record. In addition, ongoing communication with the patient/family, IDT, and referral agencies was to be completed to ensure effective discharge planning was in place and changes in condition could be identified. If indicated, care conference(s) were to be arranged to review needs and create a discharge plan and all members of the IDT shared the responsibility for the patient's discharge plan.