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Based on medical record review, document review and interview, the facility failed to ensure a safe discharge that provided for Patient #1's continuing care needs.

See findings under Tags 800, 805 and 813.

Based on medical record review, document review and interview, the facility's discharge planning process did not provide for the continuing care needs for Patient #1 post discharge. Despite having been identified as needing services, Patient #1 was discharged to home without the necessary homecare services being in place.

Findings include:

Review of admission/discharge planning sheet admission/discharge dated 2/5/20 revealed the Patient #1 was sent to the ED by the visiting nurse for evaluation after falls at home.

Review of admission/discharge planning sheet dated 02/06/20 revealed Adult Protective Services (APS) called the hospital and expressed concerns that Patient #1 is not safe living independently at home, stating the patient scored a 13 out of 30 on his mini-mental state exam, does not take his prepared medications and has no family nearby to assist him. It was noted that the patient was currently receiving visiting nurse services, along with Meals on Wheels.

Review of nursing note dated 02/09/20 revealed Patient #1 left the facility via wheelchair with belongings. Provider order noted to discharge Patient #1 home today. There is no documentation indicating referrals were made and/or services were in place for homecare services upon Patient #1's discharge home.

Review of post discharge nursing progress note dated 02/10/20 revealed a call was placed to APS. It was noted that the APS case worker is going to work on getting Managed Long-Term Care (MLTC) in place for Patient #1, but that the process can take 6-12 weeks to get fully integrated services. An email was sent to the visiting nurse agency to see if they are accepting Patient #1 back. The visiting nurse agency replied that they will not accept the case/Patient #1 because they feel it is an unsafe situation. A call was placed to the Office for the Aging (OFA) informing them of the discharge and the need to resume Meals on Wheels as soon as possible. A message was also left with OFA to check availability of aide/companion service until MLTC can fully be put in place and a referral was sent to an alternate homecare agency requesting nursing and therapy services..

Review of policy "Patient and Family Services-Discharge Planning"dated 12/07/18 and since revised 06/15/20 revealed all acute care patients are assessed at the time of admission and throughout the hospitalization for any continuing care and follow-up needs. The hospital discharges a patient based upon assessed need and resources available to meet those needs. This includes identification of patients at risk for failed discharge with the following factors: live at home alone, have no family, close relatives, no informal caregivers and/or next of kin. When the discharge planning evaluation indicates a need for home health care services, the patient/representative is provided a list of services available that serves the patient ' s geographic area. No patient is discharged until all services are in place.

Interview on 08/04/20 at 11:30 AM with Staff (L), RN Discharge Planner verified the above information.

Based on medical record review, document review and interview the facility did not ensure appropriate arrangements for home care services were in place prior to Patient #1's discharge to home.

Findings include:

Review of admission/discharge planning sheet dated 2/5/20 revealed Patient #1 was sent to the ED by the visiting nurse for evaluation after falling at home.

Review of the discharge note by the Nurse Practitioner dated 02/09/20 revealed Patient #1 was medically stable for discharge to home with visiting nurses and home physical therapy.

Review of nursing note dated 02/09/20 revealed Patient #1 was discharged to home.

Review of post discharge nursing progress notes dated 02/10/20 revealed an email was sent to the home care agency who was involved with Patient #1 prior to admission to see if they are accepting Patient #1 back. The home care agency replied that they will not accept Patient #1 as they feel it is an unsafe situation.

Interview on 08/04/20 at 10:30 AM with Staff (I), RN Discharge Planner, revealed on 02/09/20 a fax with a copy of Patient #1's discharge summary was sent to the home care agency that the patient had been receiving services from prior to hospitalization. Staff (I) stated when a patient has been previously receiving services, they do not verify that the home care agency will accept the patient back prior to the patient's discharge.

Review of policy "Patient and Family Services-Discharge Planning" dated 12/07/18 and since revised 06/15/20 revealed patients are not to be discharged until all services are in place.

Interview on 08/04/20 at 11:30 AM with Staff (L), RN Discharge Planner verified the above information.

Based on medical record review, document review and interview the facility did not ensure Patient #1 was appropriately referred and that services were in place for post-acute care home care services prior to discharge.

Findings include:

Review of admission/discharge planning sheet dated 02/06/20 revealed Adult Protective Services (APS) called the hospital and expressed concerns that Patient #1 is not safe living independently at home, stating the patient scored a 13 out of 30 on his mini-mental state exam, does not take his prepared medications and has no family nearby to assist him. It was noted that the patient was currently recieving visiting nurse services, along with Meals on Wheels.

Interview on 08/04/20 at 10:30 AM with Staff (I), RN Discharge Planner, revealed that she sent a fax to the visiting nurse agency for services for Patient #1. She stated that they do not verify the availability of staff or if a patient is accepted back for homecare services prior to discharge. If the patient had nursing services before (hospitalization), they send over a fax to the agency.

Review of the fax that was sent to the visiting nurse agency dated 02/09/20 at 12:16 PM revealed a fax cover sheet with a copy of Patient #1's discharge summary. A specific referral for home care services was not included.

Review of nursing note dated 02/09/20 revealed Patient #1 left the facility via wheelchair with belongings. Physician order noted to discharge Patient #1 home today. There is no documentation indicating referrals were made and that homecare services were in place upon Patient #1's discharge home.

Review of post discharge nursing progress note dated 02/10/20 revealed a call was placed to APS. It was noted that the APS case worker is going to work on getting Managed Long-Term Care (MLTC) in place for Patient #1, but that the process can take 6-12 weeks to get fully integrated services. An email was sent to the visiting nurse agency to see if they are accepting Patient #1 back. The visiting nurse agency replied that they will not accept the case/Patient #1 because they feel it is an unsafe situation. A call was placed to the Office for the Aging (OFA) informing them of the discharge and the need to resume Meals on Wheels as soon as possible. A message was also left with OFA to check availability of aide/companion service until MLTC can fully be put in place and a referral was sent to an alternate homecare agency requesting nursing and therapy services..

Review of policy "Patient and Family Services-Discharge Planning"dated 12/07/18 and since revised 06/15/20 revealed all acute care patients are assessed at the time of admission and throughout the hospitalization for any continuing care and follow-up needs. The hospital discharges a patient based upon assessed need and resources available to meet those needs. No patient is discharged until all services are in place.

Interview on 08/04/20 at 11:30 AM with Staff (L), RN Discharge Planner verified the above information.