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Based on record review and interview, the facility failed to inform the patient and/or their legal representative of their discharge plan and establish a clear record of post-acute arrangements and communication for 1of 1 patient's (#1) transferred home and referred to Home Health and Palliative Care Services.

This deficient practice has the potential to place all patients in the facility at risk of negative medical outcomes on discharge due to a lack of patient/ provider communications as well as patient and caregiver knowledge deficits.

Findings included:

Record review of the physician's discharge summary for patient#1, dated 10/27/2022 at 1:11 pm revealed the following information:
- 60-year-old female with past medical history of hypertension, chronic kidney disease and diabetes mellitus. Patient was brought into the emergency room after being found down by her husband. She had been down approximately 1-2 hours and was with altered mental status ... Patient was found with metabolic acidosis and nephrology consulted; she was also started on a bicarb drip. During hospital stay, patient developed with Rapid Ventricular Response (RVR) and cardiology was consulted. Pt is weak, but she is adamant to go home, despite being offered to go to rehab/ SNF. She said that she is complaining that she can relate and do all her ADLs at home, she is going to have extra help with family members (per patient).

- Discharge diagnosis: Urinary Tract Infection, Sepsis, Elevated Troponin, Acute Kidney Injury, Bacteremia, Acute Hypoxic Respiratory Failure.


Record review of the Discharge planning notes for Patient#1, revealed the following:
- 10/24/2022 @ 1:33 pm: (Nurse Case Manager) Met with patient via bedside. Patient currently resides with spouse and was independent with Activities of Daily Living (ADL) prior to admission to include driving. Durable Medical Equipment (DME) CPAP. Plan is for patient to return home with spouse vs rehab post hospitalization. PT/OT ordered. Medical Power of Attorney (MPOA): None. She is not interested in setting up MPOA paperwork. Spouse is next of kin and would make decisions for her if she is unable to make them herself and she is ok with that.

- 10/27/2022 @ 3:42pm: (Social Worker) Patient discharged home today. A referral was sent to Home Health Agency. Patient also agreeable to palliative care. Patient also in need of oxygen at discharge. A concentrator and portable were given at bedside. Social Worker provided education on how to use equipment and referred her to biomedical company's YouTube video that also show how to use the equipment.

- Further review of the interdisciplinary record revealed no evidence that the Nurse Case Manager and/or the Social Worker conducted a thorough assessment of the patient's bio physical needs prior to discharge, contacted the patient's husband (primary support system) regarding her discharge planning needs, physical requirements, and educational opportunities relating to the patient's disease processes.

Record review of the Home Health Agency's Home Visit Assessment, dated 10/28/2022 revealed the following:
- Is the patient receiving assistance from persons other than home health care staff? NO

- Indicate Sanitation issues: CLUTTERED/ SOILED LIVING AREA

-Sensory Perception: Ability to respond meaningfully to pressure related discomfort: LIMITED: RESPONDS TO VERBAL COMMANDS BUT CANNOT ALWAYS COMMUNICATE DISCOMFORT OR NEED TO BE TURNED. HAS SOME SENSORY IMPAIRMENT WHICH LIMITS ABILITY TO FELL PAIN OR DISCOMFORT IN 1 OR 2 EXTREMITIES.

-Activity: CHAIRFAST. ABILITY TO WALK SEVERELY LIMITED OR NON-EXISITANT.

- Mobility: VERY LIMITED. MAKES OCCASIONAL SLIGHT CHANGES IN BODY OR EXTREMITY POSITION BUT UNABLE TO MAKE FREQUENT OT SIGNIFICANT CHANGES INDEPENDANTLY.

- Indicate patient knowledge base deficits:
" Technical Procedures
" Pathophysiology of disease
" Signs and symptoms to report
" Who and when to call for help
" Special diet/ fluid restrictions or requirements
" Basic principles of care
" Proper equipment use
" Home safety/ Emergency procedures
" Regulatory information (Patient Rights/ Rights of the Elderly, Advance Directives)
" Medications

Record review of the facility Policy entitled: Documentation Discharge Plan in the Medical Record; Policy # CO-CM-01-21, dated 01/2018, revealed the following:

(D) A needs assessment generally includes an assessment of factors that impact on a patient's needs for care after discharge from the acute care setting. These may include assessment of bio physical needs, the patient's and caregiver's understanding of discharge needs, and identification of post-hospital care resources.

In an interview conducted on 01/04/2023 at 2:30pm, the Director of Case Management confirmed the above findings, and revealed that the Nurse Case Manager assigned to patient#1 was not on duty at the time of the patient's discharge. However, the facility Social Worker took over her caseload that day and discharged the patient home. When asked by the surveyor what the expectation was for case management/ social work staff regarding patient and caregiver discharge instructions, education, and pre- discharge planning home visits, the Director of Case Management stated that "Any contact with the patient or family should be documented in the record."