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Based on observation, interview and record review the facility failed to ensure a safe and appropriate discharge plan was arranged for 1 of 5 sampled patients, Patient #1, as evidenced by the discharge and rehospitalization of Patient #1 due to the acuity of his medical condition.

The findings included:
Review of the clinical record for Patient #1 revealed he was initially admitted to the hospital on 05/30/18 with diagnoses to include bilateral lower extremity cellulitis and Stage 2-3 sacral pressure ulcer. Nursing and physician assessments document Patient #1 as being awake, alert and oriented and able to make his needs known. Further review of the clinical record revealed treatments were in place to address the lower extremity cellulitis and sacral pressure ulcer. Additionally, Patient #1 was receiving Physical Therapy (PT) services to assist with mobility and strengthening of his lower extremities.

Review of a History and Physical Note dated 05/30/18 conducted by the attending physicians Resident documents in part, 'The patient states that he has been having the lower extremity swelling and edema for the past 6 months, and it has gradually been getting worse. The patient is bed bound, and he does have trouble walking on his own due to pain. Now he is having blisters and an ulcer on the left heel.'

Review of Social Services-Case Management Progress Notes dated 06/01/18 documents the anticipated discharge plan was home with family care with Patient #1 being in agreement with the discharge plan.

Further review of the Social Services-Case Management Progress Notes dated 06/05/18 documents the discharge plan circumstances changed, and Patient #1 expressed he could no longer return home with family.

Review of the wound care Registered Nurse (RN) Progress Note dated 06/05/18 documents the patient's 'buttocks wound has actually worsened since admission.'

Review of the Social Services-Case Management Progress Notes dated 06/06/18 at 12:02 PM, the RN Case Manager documents a telephone conversation with Adult Protective Services in addition documents 'patient has wound butt and bilateral lower extremities; discussed with attending for needs at home.'

Review of the nursing unit RN Progress Note dated 06/06/18 documents the sacral wound with slight exudate and odor; cream applied as ordered.

Review of the Social Services-Case Management Progress Notes dated 06/06/18 at 12:17 PM, the RN Case Manager documents a conversation with Patient #1's family member regarding some names of possible Assisted Living Facility (ALF) placement options.

Review of the Social Services-Case Management Progress Notes dated 06/06/18 at 12:20 PM, the RN Case Manager documents the family has been made aware of home health visit arrangements.

Review of Social Services-Case Management Progress Notes dated 06/06/18 at 2:57 PM documents the family has been advised Patient #1 will be discharged to a 'family care home'.

Review of the Social Services-Case Management Progress Notes dated 06/06/18 at 4:27 PM documents the patient will go to the 'family care home' and the owner is a Licensed Practical Nurse (LPN) and will be assisting with ADLs (activities of daily living) and wound care as needed, further stating the patient's family member is agreeable to the discharge. Additionally, assistance was being provided to apply for state funding resources.

Review of the Social Services-Case Management Progress Notes dated 06/06/18 at 4:31 PM documents the home health agency has accepted the case and the family member was notified and would arrange ambulance transfer to the 'family care home'.

Further review of Social Services-Case Management Progress Notes revealed no documentation Patient #1 was involved with or apprised of his discharge status or future living arrangements and services.

Review of the Podiatry physician Progress Note dated 06/06/18 documents 'bilateral (lower extremity) venous stasis ulcers, worse on the left.' Additionally, the Podiatry physician documented 'informed by nurse that the sacral wound does appear worse.'

Review of the PT Progress Note dated 06/06/18 documents in part, 'Patient requires maximum assist with transfers - recommending SNF (Skilled Nursing Facility) prior to home.'

Review of the clinical record revealed Patient #1 was discharged from the hospital on 06/06/18 at 6:20 PM and transferred to a 'family care home' with home health services arranged to render wound care to Patient #1's bilateral lower extremity and sacral wounds.

Review of Patient #1's hospital discharge and admission history revealed at the insistance of the home health nurse, the patient returned to the Emergency Department on 06/22/18 from the 'family care home' and was readmitted to the hospital due to the worsening of the sacral pressure ulcer. Additionally on readmission Patient #1 had a Foley urinary catheter in place and was also diagnosed with a urinary tract infection.

It was discovered and determined by a State Surveyor after an onsite visit, the 'family care home' was operating as an unlicensed assisted living facility that did not have the resources to provide the higher acuity level of care Patient #1 required.

Review of the clinical record revealed an Infectious Disease physician consult note dated 06/23/18 documenting the patient has an infected necrotic left heel ulcer.

Review of the Podiatry physician consult note dated 06/23/18 documented the patient had a large left heel ulcer with significant necrotic tissue - likely Stage 2-3.

Review of a Surgical physician consult note dated 06/27/18 documented Patient #1 had a Stage 3 sacral ulcer and was ordered and receiving intravenous antibiotics, one every 12 hours and another every 8 hours. Patient #1 was receiving wound care daily in addition to PT services.

Review of a wound care RN Progress Note dated 08/03/18 documented 'sacral pressure ulcer 8 cm (centimeters) by 8 cm still unstageable but sure it will reveal itself to be a Stage 4.' Review of the photographs taken by the wound care RN on 08/03/18 revealed Patient #1 had wounds to the right heel, right lateral lower leg, left heel and sacrum.

Review of a PT Progress Note dated 08/03/18 documents under Progress Comments 'Requires SNF setting per PT standpoint.'

Review of a Discharge Planning note entry dated 08/06/18 at 1:11 PM by the RN Case Manager documents she has spoken with (name of person) director of (name of facility) who stated she is working with Patient #1's family to arrange for patient into her facility. There is no evidence of documentation Patient #1 was included in the decision for his placement needs.

On 08/07/18 at 10:30 AM, an interview was conducted with Patient #1 in his hospital room. Patient #1 was observed to be on a low air loss mattress with an overhead trapeze to assist with upper body mobility. Patient #1 stated he does not have full use of his lower extremities and is working with Physical Therapy (PT) to regain his lower extremity mobility. He demonstrated how he had very little movement of his lower extremities but stated his legs were moving a little now that he gets therapy and that was better than it was before. He stated when he was discharged from the hospital on 06/06/18 he was not aware of the plans. He stated his family member was involved with the arrangements however nobody talked to him about it. He stated the place that he was sent to was not equipped to look after him and they were overwhelmed with the care that he needed as he needs total assistance with mobility and transferring. He stated they would get him up in a chair and leave him there all day. He stated his family member paid for the room and board at that house due to his financial issues and as far as he was aware the hospital is assisting with an application for state funding for the future. He stated he was told by the Case Manager here today that because his course of antibiotics was completed they were looking for a place to send him to, but due to his insurance status they were having difficulty. He stated he did not want to go back to the other place because they were not able to provide the care he needed. He stated he was feeling nervous and scared about where they were going to send him next and they have not talked to him or included him in what the plans are.

On 08/07/18 at 11:05 AM an interview was conducted with the RN Case Manager working on Patient #1's case. She stated due to Patient #1's financial situation it is difficult to find placement however she is making arrangements with a new place she just discovered last Friday. She stated the facility is run by a LPN and is wheelchair accessible and she is arranging a hospital bed with trapeze. She stated they were told Patient #1 cannot go back to the place that he came back from because they found out it was not a licensed facility. An inquiry was made if the facility they were now making arrangements with is licensed by the state to which the RN Case Manager stated the LPN owner said they were licensed and she would assist with wound care as she was a LPN. A request was made to show evidence this facility was licensed. After accessing and reviewing the State health care provider web site, the facility Patient #1 was going to be transferred to is not a licensed entity. Additionally, the RN Case Manager was apprised Patient #1 had a Stage 3 pressure wound to his sacrum and was not an appropriate transfer and admission to an ALF as the regulations prohibit a patient to be cared for in an ALF who has a pressure sore staged at greater than a Stage 2. The RN Case Manager stated she was not aware of that regulation. During the interview with the RN Case Manager, the Social Services Manager arrived and was apprised the location where they were planning on transferring Patient #1 to is not a licensed health care facility to which she stated the LPN owner of the home stated that she was licensed. The Social Services Manager placed a call to the LPN owner of the home and requested she fax over a copy of the license. The Social Services Manager was also apprised Patient #3 has a Stage 3 pressure wound and is not a candidate for a boarding home or ALF. The Social Services Manager stated due to Patient #1's financial status it is very difficult to find placement and if he has a Stage 3 pressure ulcer he will need to be transferred to a SNF (Skilled Nursing Facility) however who would accept him knowing his financial status. The Social Services Manager was apprised that the application process for state funding has been initiated and there are SNFs in the county that will accept these patients knowing the state funding is pending to which she stated 'Would you know of the names of them?'

On 08/07/18 at 2:30 PM an additional interview was conducted with the RN Case Manager who stated she will be calling the LPN owner of the facility to let her know Patient #1 will not be transferred to her. She stated there is no official discharge order at this time and it looks like she will have to start looking into SNFs for placement.

On 08/07/18 at 2:35 PM an interview was conducted with the PT who wrote the Progress Note dated 06/06/18. An inquiry was made what was Patient #1's mobility status on discharge on 06/06/18 to which she stated the patient was just starting to stand and needed the assistance of 2 people. She stated he needed assistance for all mobility including bed mobility. She stated he had a sacral ulcer and cellulitis but did not have any issue with his heels at that time. She stated she recommended a SNF to continue to work towards increased strength, mobility and ability to transfer.

On 08/07/18 at 2:40 PM an interview was conducted with the PT who wrote the Progress Note dated 08/03/18. An inquiry was made about Patient #1's therapy progress to which he stated Patient #1 has made some gains, however his standing ability is limited due to the bilateral heel sores and sacral sore in addition he has to be non-weight bearing to the lower extremities due to the wounds on his heels. The PT stated the patient would benefit from the services a SNF could offer, however he was not sure if the patient had the benefits to qualify for SNF placement.

On 08/07/18 at 2:45 PM an inquiry was made to the Social Services Manager if the LPN owner of the home had faxed over the license yet to which she replied she heard back from the LPN owner who stated she does not have an official license at this time but they are in the process of obtaining one. The Social Services Manager stated this was the first time they were going to use this facility but they will not be using it because the LPN owner has been uncooperative.

On 08/07/18 at 3:00 PM an interview was conducted with the RN Case Manager who was involved with the discharge of Patient #1 on 06/06/18. She stated Patient #1 was living with a family member however due to circumstances he could not go back to that living arrangement. She stated the Social Services Manager found the 'family care home' so they set up home health to do the wound care and the family agreed to pay for transportation to the home and room and board. She stated the owner of the 'family care home' said she was a LPN and they have sent some other patients there in the past, some needing care and some that did not. An inquiry was made if she verified the LPN owner was a licensed nurse and was she aware the 'family care home' was not a licensed facility to which she stated they generally do not check on credentials. A further inquiry was made if she was involved with assisting Patient #1 with the application for State funding to which she stated there is a dedicated person on staff that deals with that and the case management department is not involved in that. She stated Patient #1 was eligible for some benefits that was how the home health was paid but she was not sure of the status of the other applications.

In review, Patient #1 was admitted to the hospital on 05/30/18 with wounds and decreased mobility. He was discharged on 06/06/18, 8 days later, to an unlicensed 'family care home' that was not qualified to meet his needs. He was rehospitalized on 06/22/18 with worsening wounds and continued poor mobility status. He was started on intravenous antibiotics for infected wounds, received daily wound care and was receiving physical therapy to improve his mobility status. On 08/07/18, 46 days later, the course of antibiotics was completed and the hospital case management staff had the intent to discharge him to another unlicensed 'family care home' until surveyor intervention brought to their attention the 'family care home' was not a licensed entity and even if it was, Patient #1 had a Stage 3 wound to the sacrum which disqualified him from being discharged to a licensed assisted living facility. On 08/07/18 at 3:10 PM the Social Services Manager, Regional Director of Case Management and RN Case Manager concurred they will have to reassess the discharge plan and attempt to find a Skilled Nursing Facility to accept the patient.

Review of the hospital Discharge Planning Policy states in part, 'Purpose: To describe the discharge planning process in an effort to prevent adverse health consequences upon discharge as well as to offer appropriate planning to minimize the likelihood of having a patient rehospitalized for reasons that could have been prevented. Scope: In accordance with Medicare Conditions of Participation, Discharge planning applies to all patients classified as an inpatient.'