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Based on record review and staff interview, the facility failed to have a post-discharge plan of care that was developed with the participation of the patient and his/her family, which would assist the patient to adjust to his/her new living environment for one of five patients reviewed (Patient #1).

The findings include:

A record review of Patient #1 revealed that he/she is a paraplegic with multiple wounds including a Stage 4 on his/her coccyx. Patient #1's chart contained no documentation that an assessment was done of the patient's ability to treat the wounds at home after discharge or that the facility offered home health care. There was no healthcare provider order for homecare, however, in interviews with the Medical Director and the Director of Case Management, they both agreed that home care should have been offered and that if there was no healthcare provider order, the Case Manager should have called the physician to recommend an order. There was no documentation found that the facility ever talked to Patient #1 about discharge or what interventions would be needed to make a smooth transition home at the time of discharge.

During an interview on February 18, 2010 at 1 pm with the Medical Director, he stated that if he was the physician, he would have ordered home healthcare for a patient with wounds but Patient #1 stated a sister was going to be taking care of the patient after discharge including the wound care. The Medical Director stated that he would expect if a patient had stated a relative was taking care of their wounds, he would make sure the relative was able and willing to do wound care. The Medical Director stated that he believed the attempt was made to provide home health but also agreed that there should be documentation stating the fact the "pt refused" the service.

In an interview with the Director of Case Management on February 18, 2010 at 10 am, she stated that if a patient has wounds and there is no order for home healthcare, the Case Manager should call the physician to recommend that he order home healthcare. However, there was no documentation that this was done.

These findings were confirmed in an interview with the Risk Manager on February 18, 2010 at 2:45 pm.