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Based on policy review, facility document review, medical record review and interview, the facility failed to determine the appropriate post-hospital discharge destination for 1 of 3 (Patient #1) sampled patients. Patient #1 was discharged to a facility that was unable to meet her needs.

The findings included:

1. The facility failed to ensure the appropriate discharge planning process to identify post-hospital discharge needs and appropriate placement.
Refer to A0813

Based on policy review, facility document review, medical record review and interview, the facility failed to ensure the appropriate discharge planning process to identify post-hospital discharge needs and appropriate placement for 1 of 3 (Patient #1) sampled patients. Patient #1 was inappropriately discharged to a facility that was unable to meet her needs.

The findings included:

1. Review of the facility's "Discharge Planning" policy revealed, " ...Purpose: To identify the patient's clinical and social discharge needs through a multidisciplinary process ...This ongoing process is to insure optimal discharge plan and to meet the needs of the patient/family and loved ones involved in the care of the patient through assessment, and re-assessment as their medical condition changes ...The Case Managers/Social Worker's primary role in this process is as follows ...Support to patient/family-the patient's illness may necessitate a change in residence (to nursing home, rehab [rehabilitation], other family, etc. [et cetera, and so forth]); may result in a loss of independence or create financial concerns. The social worker, who is skilled in providing support to patient, will assist them in adjusting to these changes, which may include additional referrals to community and/or clergy services ...The Case Manager/Social Worker works with post discharge care facilities/services to provide the patient/family the most optimal care possible to meet their post discharge needs ..."

Review of the facility's "ISOLATION GUIDELINES" policy revealed, " ...The Centers for Disease Control and Prevention (CDC) isolation system for hospitals consists of Standard Precautions (formerly Universal Precautions) and four transmission-based categories ...As an additional measure, patients with certain communicable diseases are placed on transmission-based isolation precautions ...Contact Precautions ...Transmission. For agents requiring the use of contact precautions, transmission occurs when a person comes in direct contact with a patient or a patient's environment that is either infected or colonized with one or more of the targeted organisms ...In essence, any person or device that enters a room designated for contact precautions is considered to be in contact with a potentially infectious agent ...Room. Patients are placed in a private room ...Entering the room. All employees, staff, and healthcare workers wear gown and gloves before entering the room, even if no contact with the patient or environment is anticipated ..."

2. Review of the facility's "Interim guidance for ED [Emergency Department] and hospitalized patients presenting with suspected respiratory illness" flowchart dated 3/7/20 revealed, " ...Continue isolation as indicated (i.e. [id est, that is] influenza, RSV [Respiratory Syncytial Virus], metapneumovirus, etc) ..."

3. Medical record review for Patient #1 revealed Patient #1 was a 93 year old female who presented to Hospital ED #1 on 3/12/20 at 5:20 PM with a chief complaint of cough and fever for the past 24 hours.

Patient #1 was receiving hospice care services from Hospice #1 while residing at ACLF #1.

Review of the triage notes on 3/12/20 at 6:07 PM revealed the following:

Patient #1 had been sent to Hospital ED #1 by Assisted Living Care Facility (ACLF) #1 (where Patient #1 resided) via ambulance to be tested for coronavirus (COVID-19).

Patient #1 was triaged with a temperature of 99.5 degrees Fahrenheit, pulse rate 98, respiratory rate 19, blood pressure 134/67 and oxygen saturation level 94 % while on oxygen by nasal cannula (flow rate not documented).

Patient #1 was assessed as oriented with a Glasgow Coma Scale (diagnostic tool used to score the level of consciousness of patients) of 15 (fully awake and aware).

Patient #1 denied any travel outside the United States, any suspected exposure to COVID-19, any contact with a confirmed COVID-19 patient, or any fever (>100.4 degrees Fahrenheit), cough, shortness of breath or sore throat in the past 14 days.

Review of documentation by ED Physician #1 on 3/12/20 at 5:28 PM revealed the following:

ED Physician #1 documented the staff at ACLF #1 reported to Emergency Medical Services that Patient #1 had a fever up to 101 degrees Fahrenheit within the past few days, had been coughing and may or may not have had visitors from out of town.

ED Physician #1 documented Patient #1 stated she did not want to be in the ED, felt well and denied any of the symptoms reported by the ACLF #1 staff and requested to be discharged back to ACLF #1 upon arrival to the ED.

Review of physician notes on 3/12/20 at 11:51 PM revealed the following:

ED Physician #1 documented he felt Patient #1 did not need any testing for COVID-19 but would order the test so ACLF #1 would know the results (The COVID-19 test was collected on 3/12/20 at 7:40 PM and resulted on 3/19/20 at 7:11 AM. The test was negative for COVID-19).

ED Physician #1 documented Patient #1 tested positive for human metapneumovirus but had remained stable throughout her stay in the ED.

ED Physician #1 documented the ED had contacted ACLF #1, but ACLF #1 still refused to accept Patient #1 back.

ED Physician #1 documented Patient #1 would continue to stay in the ED while the hospital pursued their options.

Review of Case Management Social Work (CMSW) notes dated 3/13/20 at 9:51 AM revealed Social Worker #1 documented ACLF #1 refused to accept Patient #1 back, and the Social Worker from Hospice #1 was working with Patient #1's daughter to find placement.

Review of Case Management Social Work (CMSW) notes dated 3/13/20 at 9:51 AM revealed the following:

Social Worker #1 documented he spoke with Patient #1's daughter, and the arrangements were for Patient #1 to return to ACLF #1 with the family taking care of her until they (uncertain if Social Worker #1 meant ACLF #1 or the family) were able to locate a new placement.

Social Worker #1 documented Hospice #1 would continue to provide care, Patient #1 would be isolated to her room and they (uncertain if this was Hospice #1, family or ACLF #1) would arrange meals for her.

Social Worker #1 documented Patient #1's daughter would come to the ED to transport Patient #1 back to ACLF #1, and he had discussed the plans with the CMO.

Review of CMSW notes dated 3/13/20 at 1:04 PM revealed Social Worker #1 documented Hospice #1 requested Patient #1's medical record be sent to Skilled Nursing Facility #1, and Patient #1's daughter arrived at the ED to take Patient #1 back to ACLF #1.

Review of physician notes dated 3/13/20 at 11:57 AM revealed the following:

The Chief Medical Officer (CMO) documented Patient #1 had remained stable in the ED for over 14 hours.

The CMO documented he had multiple discussions with the nursing director at ACLF #1 who reportedly stated Patient #1 needed skilled facility placement (higher level of care than ACLF #1 could provide).

The CMO documented the hospital's Social Worker had been working with Patient #1 trying to arrange placement for the last 5 hours, and Patient #1 would be discharged back to ACLF #1 since she did not require acute hospitalization.

The CMO documented he had spoken with Hospice #1 who reportedly stated they would continue to try to coordinate placement for Patient #1 elsewhere.

Review of a physician's order dated 3/12/20 at 6:58 PM revealed Patient #1 was placed in Enhanced Isolation Precautions (Hospital #1's "Isolation Guidelines" policy revealed these precautions were for the prevention of transmission of novel respiratory pathogens and required healthcare workers to wear gloves, apron, gown, boot covers, personal respirator and protective eye wear (including goggles or face shield)).

Review of a physician's order dated 3/12/20 at 11:55 PM revealed Enhanced Isolation Precautions were discontinued but Isolation Precautions were continued until 3/13/20 at 1:08 AM (order for Isolation Precautions was made inactive at this time).

Review of the ED discharge summary dated 3/13/20 at 12:53 PM revealed discharge information was given to Patient #1's daughter, and Patient #1 was discharged to return to ACLF #1 with her daughter.

There was no documentation Hospital #1 discussed the discharge plan with ACLF #1, set up any discharge arrangements with ACLF #1 or established that ACLF #1 had accepted Patient #1 back to their facility.

4. In an interview in the Administration Conference Room on 3/19/20 at 10:26 AM, the CMO stated he came to the hospital on the morning of 3/19/20 and spoke with Hospice #1, Patient #1's daughter and the Executive Director for ACLF #1. The CMO stated Patient #1 had tested positive for human metapneumovirus but had been stable in the ED and did not require isolation. The CMO stated Patient #1's daughter did not want Patient #1 to stay in the ED for fear of exposure to other communicable diseases, and Social Worker #1 had made arrangements for Patient #1 to get a respite bed. When asked about ACLF #1's refusal to accept Patient #1 back, the CMO stated he had taken the word of Social Worker #1 that it had been worked out.

In an interview in the Conference Room on 3/19/20 at 10:43 AM, Social Worker #1 stated he worked with Hospice #1 to find alternative placement for Patient #1. Social Worker # stated he believed Hospice #1 was communicating the plan with ACLF #1. Social Worker #1 stated Hospice #1 was trying to find placement for Patient #1 at Skilled Nursing Facility #1, and the plan was to discharge Patient #1 back to ACLF #1 under the care of Hospice #1 until alternative placement could be established. Social Worker #1 stated he did not discuss the discharge plan with anyone at ACLF #1.

In an interview in the Conference Room on 3/19/20 at 11:28 AM, the Director of Patient Safety and Quality stated a patient who tested positive in the hospital for human metapneumovirus would be placed in isolation and require contact precautions.

In a phone interview on 3/19/20 at 12:55 PM, Hospice #1 Social Worker #1 stated she had been contacted by Social Worker #1 (from the hospital) about placement for Patient #1 in a skilled nursing facility. Hospice #1 Social Worker #1 stated she had made a referral to Skilled Nursing Facility #1, but there was not a bed available at that time. Hospice #1 Social Worker #1 stated she did not know Patient #1 was being discharged back to ACLF #1 until the Executive Director of ACLF #1 had informed them Patient #1 was already back at the facility. Hospice #1 Social Worker #1 denied knowing anything about a plan to discharge Patient #1 from Hospital #1 ED back to ACLF #1 until alternative placement could be found.

In an interview in the Conference Room on 3/19/20 at 1:09 PM, the Director of Case Management/Social Services stated ACLFs have the right to refuse a patient back to their care if they cannot provide the appropriate level of care. The Director of Case Management/Social Services stated if an ACLF refused to accept a patient back, the Social Worker or Case Manager would typically notify her, and they would explore other options. The Director of Case Management/Social Services stated she was off work on 3/13/20 and was not available at that time. The Director of Case Management/Social Services stated the Social Worker involved in Patient #1's case should have explored other options and developed a "Plan B."

In an interview in the Conference Room on 3/19/20 at 1:30 PM, Registered Nurse (RN) #1 stated he was Patient #1's primary nurse when she was discharged on 3/13/20. RN #1 stated the CMO had been in touch with the Executive Director of ACLF #1, and Patient #1 was cleared to be discharged. RN #1 stated he gave the discharge instructions to Patient #1's daughter (this was not the same daughter who ws listed as next of kin in medical record and stayed overnight with her, but one who had flown in from a western state (exact state unknown) to help provide care). RN #1 stated he did not call ACLF #1 to give report or notify ACLF #1 that Patient #1 was returning to the facility.

In a phone interview on 3/20/20 at 9:43 AM, Patient #1's daughter (listed as next of kin) stated she was informed that her mother had been sent to Hospital ED #1 to be tested for coronavirus. Patient #1' daughter stated the CMO told her they did not believe Patient #1 had coronavirus, but ACLF #1 refused to take her back without confirming a negative test for coronavirus. Patient #1's daughter stated she could not recall Social Worker #1 giving us a specific plan, but the family acted on their own. Patient #1's daughter stated they circumvented the usual process of discharge and snuck their mom back into ACLF #1 since her mother's apartment had an outside entrance.

In a phone interview on 3/20/20 at 12:53 PM, the Executive Director for ACLF #1 stated Patient #1 had exhibited symptoms of a respiratory illness during the week prior to her being sent to Hospital ED #1. The Executive Director stated her company required Patient #1 to be tested for coronavirus based on her symptoms. The Executive Director stated Hospice #1 reported they could not test her, and she called the Representative #1 from the state department of health who told her she would have to be sent to the hospital to be tested. The Executive Director stated the hospital had called her within an hour of Patient #1 being sent and was trying to send her back without testing her for coronavirus. The Executive Director stated she informed the CMO who was arguing with her that Patient #1 needed isolation and 24 hour nursing care which ACLF #1 could not provide. The Executive Director stated a staff nurse came to her office on the afternoon of 3/13/20 to inform her that Patient #1 was back in her room. The Executive Director stated Patient #1's daughter had brought her back through an outside entrance to ACLF #1 without her knowledge. The Executive Director stated ACLF #1 never got a call from Hospital ED #1 that Patient #1 was coming back, never received a call for report and never received any kind of plan for her discharge. The Executive Director stated she was told by the CMO that Patient #1 had tested positive for RSV and was never tested for coronavirus (the Executive Director did mention Patient #1 had tested positive for human metapneumovirus).