HospitalInspections.org

Based on interview and record review, the facility failed to ensure 1 of 11 sampled patients received a discharge plan which addressed their post-discharge care. The facility failed to ensure all necessary information about care was provided to assist post care treatment (Patient #6).

This deficient practice had the likelihood to cause harm in all patients who were discharged from the hospital.

Findings include:


Review of a physician's history and physical dated 04/14/2022 at 9:24 p.m., revealed Patient #6 was a 94-year-old male who was transferred in from another hospital for an enlarged liver and gallstones. According to the same history and physical Patient #6 had diagnoses which included pleural effusions, urinary retention, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, atrial fibrillation and coronary artery disease.

On 04/16/2022 Hospitalist progress notes revealed Patient #6 had acute hypoxic respiratory failure and required 3 Liters of oxygen, probably secondary to the pleural effusion/infiltrate.

On 04/19/2022 the pulmonologist documented "breathing improved, no significant cough or sputum production on 2 liters per minutes nasal cannula with home requirement of 1.5 liters..."

On 04/24/2022, physician critical care progress notes had documentation that Patient #6 was off Levophed (used to treat hypotension) overnight and his hemoglobin remained level without additional transfusions in a couple of days. The physician documented" consider adding back Lasix as well if hemodynamics will tolerate." According to the progress notes Patient #6 had decreased range of motion, dependent edema, cool fingertips and toe and poor nail growth on the toes.

On 04/25/2022 at 12:59 p.m., a physician's discharge order revealed Patient #6 was to be discharged home.

On 04/25/2022 at 12:59 p.m., a physician's discharge summary revealed Patient #6 was supposed to start back taking the diuretic Lasix 20 milligrams, but it did not mention how often.

On 04/25/2022 at 1:00 p.m., wound care notes revealed photos were taken of patient #6's heels, but there was not one of the buttock. There was documentation that the "heels were intact on earlier exam, alert and ready to go home and the buttock discolored and intact." The photos showed the left heel was covered in a layer of skin that had edges which were peeling back. The right heel was red.

There was no documentation of what the home plan would be for care of the skin.

Review of case magement notes dated 04/25/2022 at 1:28 p.m., revealed staff talked to Patient #6's daughter via phone." She reports that the patient will be going to stay with her and her husband ...They would like to resume home health with Purple Hearts. She reports that patient does not have access to a useable wheelchair. Referral sent to Lincare ..."

The aftercare summary (patient discharge instructions) was dated for 04/25/2022 and being printed off at 2:44 p.m. The summary did not include oxygen therapy, frequency of Lasix nor wound care.

During an interview on 09/20/2022 after 1:00 p.m., the following was reported:

Staff #30 (registered nurse) confirmed there was no documented nursing assessment of the discharge and not being able to find any other case management notes which addressed all the needs at discharge. Staff #30 (registered nurse) said that the nursing documentation should be on a discharge care plan, but there was not one on the chart.

Staff #32 (case management) confirmed they had addressed the referral for a wheelchair and home health on patient #6. Staff #32 (case management) said she could not find the documentation that they sent to home health concerning the patient's care needs. Staff #32 (case management) confirmed the documentation was not there concerning Patient #6's oxygen therapy.

During an interview on 09/22/2022 after 11:00 a.m., registered nurse #31 (home health agency) confirmed Patient #6 was assessed by her the following morning (04/26/2022.) She found Patient #6 with a distended abdomen, having difficulty breathing, in distress, and with 4 plus edema to his legs. Patient #6 had on the oxygen that he usually wears continuously at home. Registered nurse #31 said Patient #6's oxygen saturation would not stay above 88-89 percent even with oxygen on. Because of the congestive heart failure and the need to be diuresed she called 911 and sent him back to the hospital. Registered nurse #31 said that Patient #6 had a small decub on his bottom that was barely open and macerated white. There was nothing on it and there was no kind of treatment.


Review of the facility's policy named "Discharge Planning" and dated 05/2013 revealed the following:

" ...The purpose of the discharge planning is to provide patients with a safe, coordinated, comprehensive plan for hospital discharge that ensures transition from the hospital to an alternate care setting or home based on patient/family needs ..."

" ...Discharge planning is a coordinated function of the healthcare team including management, nursing staff, physicians, ancillary staff and patients/families ..."