HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 clinical records (Pt #1) reviewed for discharge planning, the Hospital failed to ensure adequate training and discharge planning evaluation for post-hospital care needs, as required.

Findings include:

1. On 1/19/2021, the Hospital's policy titled, "Discharge Planning" (approved 12/4/2019) was reviewed and required " ...Discharge planning is a coordinated effort by healthcare professionals to ensure a smooth transition from acute hospital care to other healthcare services consistent with the clinical and psychosocial needs of the patient and family ...The case management team plays a unique role in the discharge planning process by identifying a post-discharge caregiver(s) as needed and evaluating their willingness and ability to meet the patient's needs..."

2. On 1/19/2021, Pt #1's clinical record, dated 8/28/2020 to 12/11/2020, indicated the following:

- Pt #1 was admitted to the Hospital on 8/28/2020 with the diagnosis of respiratory failure.

- MD #1's Discharge Summary note (dated 12/10/2020) included "...During full hospital stay until today, Pt #1 required a higher level of care to address the following... Regular suctioning and prn [as needed] suctioning of secretions through trach [airway] to prevent mucous plugging... Continuous pulse oximetry to monitor for respiratory issues as Pt #1 is obtunded and unable to communicate to staff... Pt #1 requires humidity and suctioning to maintain airway clearance..."

- A Discharge Planner's (E #2) note, dated 12/8/2020, indicated, "Family requested to add additional days of training, explained that family training was done and no more further training to be granted..."

- E #2's note (dated 12/10/2020) indicated, "Received a voicemail from insurance discharge planner stated that family requesting for additional teaching ...explained that home health agency will send a RT [respiratory therapist] to teach the family trach care and suctioning ...Called and spoke with Z1 [Daughter] and she is demanding more family training as they are not comfortable with taking care of [patient]..."

3. On 1/20/2021 at 10:00 AM, an interview was conducted with Pt. #1's Physician (MD #1). MD #1 stated that ideally, that if the family needed more training with Pt #1's care needs, they should have had more hands-on training. MD #1 stated that it was difficult with COVID restrictions to do more hands-on training.

4. On 1/20/2021 at 10:30 AM, an interview was conducted with the Discharge Planner (E #2). E #2 stated that Pt #1's daughter (Z1) did request additional training on how to care for Pt #1. E #2 stated that Z1 was not granted additional training that was requested due to COVID restrictions.