HospitalInspections.org

Based on a review of documents and interviews, the facility failed to ensure that the hospital ' s discharge planning process must require regular re-evaluation of the patient ' s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.

Findings included:

Facility policy entitled, "Discharge Planning" stated in part,
"1. PURPOSE:
To identify process .for initiating Discharge Planning that meets each patient's needs and to assure all patients are discharged to the appropriate level of care at the appropriate time. The Discharge Planning assessment done on admission includes the physical, emotional, medical, social, spiritual and financial needs of the patient and family as well as any identified equipment needs and post
discharge needs..

7. Ongoing Case Management Responsibilities are:
· Ongoing communication with the Interdisciplinary Team Coordinating the discharge plan with other team members
· Communicating the discharge plan and progress toward completion of plan
· Acting as a resource to other team members, patient/family members and physicians
· Obtaining necessary authorization from third party payors for any ongoing patient care needs

8. The Case Management Team promotes awareness of available resources through education and dissemination of information to patients and families. In addition the Case Management/Social Services has on a file names and numbers of agencies, resources, and advocacy groups. Any referrals made will be documented in the Case Management/Social Services documentation system."

Review of the medical record for Patient #1 revealed the following:
* Physician note on 08/14/20 stated in part, " ...b/c of multiple fxs, will get APS involved ..."
* Case management note on 08/18/20 at 1147 stated in part, "SW discussed pt's case with attending physician. concern regarding pt's rib fractures as well as L3 fracture. SW called APS and filed report with [name]#5424 (Report ID#:73811161). SW will continue to follow."
* Case management note on 08/18/20 at 0322 stated in part, "SW received call from pts APS caseworker [name and phone number]. [Name] stated pt is familiar to him and stated he would like to come by the hospital to lay eyes on the pt tomorrow morning. sw will continue to follow.
* Case management note on 08/19/20 at 0129 stated in part. "...MD did not want to send patient back to group home until APS did safety eval. APS is involved."
* Case management note on 08/19/20 at 0234 stated, "sw called and left voicemail with APS caseworker [name] requesting call back. SW will continue to follow."
* Case management note on 08/21/20 at 1053 stated, "sw notified HH liaison of pt' s discharge order. sw provided charge RN with RN's phone number for report and group home manager's number for transport. SW to remain available as needed."
* Physician note on 08/20/20 stated in part, " ...b/c of multiple fxs, pending APS/SW/CM to do safety check ..."
* The Discharge Summary on 08/21/20 stated in part, "- b/c of multiple fxs, pending APS/SW/CM to do safety check at the time of dc. facility aware."

Based on documentation in the medical record, the patient's physician wanted Adult Protective Services (APS) to follow up regarding the patient's fractures in order to ensure discharge was to a safe environment. Based on documentation in the medical record, the social worker contacted APS, however there is no documentation that the safety check was completed prior to discharge per physician direction.

The safety check and follow up regarding the fractures before discharging the patient to another facility represents a change in condition that created changes to the patient discharge plan, however APS findings or whether the safety check was completed prior to discharge was not documented. It cannot be established the safety check was completed prior to discharge to ensure patient was discharged to a safe environment.

In interview on 04/20/21 staff members #1 and 2 verified the above findings.