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Based on interview and record review the facility failed to re-evaluate and adjust the patient's care plan after the patient's family was no longer able to accept and care for the patient. Specifically, the facility discharged a patient to another state with no post hospital care in place in 1 of 2 patients discharged out of state (Patient #10). This resulted in the patient being sent to a hospital emergency department in another state without prior acceptance and resources in place.

Findings include:

Policy:

The policy, discharge planning read, the facility utilizes an interdisciplinary approach to discharge planning which begins on admission. An interdisciplinary plan of care with goals, treatments and services was developed consistent with the medical plan of care and evaluated for each patient. The patient's family or designated decision maker was involved in the care and the treatment decisions in accordance with the patient's wishes. The plan of care was utilized in forming the discharge plan of care. Evaluation of needs was performed upon admission and throughout hospitalization so post hospital care needs are identified before discharge. Screening evaluations are completed/overseen by nurse Case Managers and Social Workers. Ongoing discharge planning was conducted through the patient's course of care while in the hospital. The results of the evaluations are discussed with the patient or the individual's designated caregiver. The patient and the patient's family are prepared for post-hospital care. The social worker identifies the patient's discharge needs through an assessment of social, emotional, and economic needs related to illness and injury. The social worker (SW) evaluates and coordinates discharge planning for psychosocially complex patients (i.e., abuse/neglect; mental illness; domestic violence; family coping with multiple issues precipitated by illness/hospitalization) and Human Services reporting and involvement. SW facilitates the appropriate education/utilization of community resources, works with patients/families to enable development of realistic post-hospitalization plans and facilitates the implementation of plan so patients/families can achieve maximum benefit from resources offered. The discharge planning process was continually reassessed. This includes a review of responsive discharge plans adequately addressing patient needs.

References:

According to the Clinical Social Worker Case Manager job description position summary, the SW case manager (CM) assessed patients and/or patient's family, caregivers, and/or legal representatives and arranges for needed interventions. Plans interventions to help patients cope with social, emotional, economic and environmental problems and provided short term treatment planning for mental, emotional and behavioral disorders, conditions and additions. The SW CM duties and responsibilities included, participating in case reviews to evaluate care management and progress towards goals. Consult with healthcare team member to promote, monitor, and evaluate compliance with patient's treatment plan. Assist with discharge planning and processes. Identify appropriate resources, including transportation, housing, healthcare and social/spiritual services, and provides referral as part of the discharge plan.

1. The facility failed to re-evaluate the patient's plan of care, to include post hospital care/placement, to meet the needs of the patient after the patient and the patient's family were no longer in agreement with the plan of care put in place by the interdisciplinary team and carried out by the case manager.

a) On review of Patient #10's medical record, the patient presented to the emergency department on 5/4/18 at 5:04 a.m., via ambulance. The emergency department physician stated Patient #10 was a 77 year old male evaluated for altered mental status, oriented to person and year only and lacked capacity. The physician documented Patient #10's sister, who lived in state, was contacted and unwilling to come escort the patient home, out of state. The patient was admitted and social work contacted to assist with placement.

On review of the entire medical record for Patient #10, no capacity evaluation was documented.

On 5/4/18 at 10:12 a.m., Patient #10 was seen by the social worker (SW #1). SW #1 documented, in a care coordination progress note, the patient was currently considered homeless and lacked transportation. SW #1 documented Patient #10's wife was contacted, who lived out of state with her nephew/caregiver. Neither had seen the patient since February, 2018, four months prior to the patients admission to the facility, but stated the patient was at baseline.

Patient #10 was documented to have no medical durable power of attorney (MDPOA) or decision makers in place.

SW #1 documented the nephew was not opposed to having the patient back in the state, but the family could not take care of him in the home and was unsure of his placement options. SW #1 documented she had contacted Adult Protective Services (APS) in state to make a report of elder abandonment.

On 5/4/18 at 1:45 p.m., SW #1 added to her documentation, Patient #10's nephew called to report, Patient #10 was threatening the family and the family was uncomfortable with Patient #10's threats.

According to the admission history and physical (H&P) documented by the physician on 5/4/18 at 2:26 p.m., Patient #10 was confabulating (distorted) and was very tangential (erratic) with his thought process, not safe to go home by himself, and would need appropriate placement with coordination with his family. The physician documented contact was made by facility staff with the patient's wife and nephew, who lived out of state and documented they were not able to take care of him and unwilling to take him in. The physician noted APS had been contacted for elder abandonment.

On 5/6/18 at 3:09 p.m., the physician documented, in the daily progress note, Patient #10 was only oriented to himself and not to place or person. He was confabulating and was very tangential with his thought process; he had increased need for assistance with activities of daily living; was not safe to go home by himself and needed appropriate placement with coordination with his family.

On 5/7/18 at 3:38, RN #2 documented she discussed the plan of care, interventions and potential discharge with Patient #10. Patient #10 was documented as stating he "had many places he could go but not with my wife." RN #2 then documented the patient showed no evidence of understanding the situation and the plan of care.

At 5:11 p.m., CM #3 documented the plan was for Patient #10 to return home with his family and CM #3 was working on finding an escort to accompany the patient as the patient was not safe to fly alone. CM #3 then documented finding Patient #10's boarding pass, contacting the airline to confirm if Patient #10 had a credit for the ticket and seeking funding from the facility for assistance to pay for an escort and airfare to return the patient to family out of state.

This plan was continued, despite the wife stating she was unable to care for Patient #10 any longer and the facility contacting APS for abandonment of the patient on 5/4/18.

On 5/8/18 at 12:35 p.m. the day of discharge, CM #3 documented she continued to coordinate the discharge plan for Patient #10. CM #3 stated she had spoken to Patient #10's wife, nephew and sister and as of 12:30 p.m., Patient #10's family was not willing to commit to assisting the patient when he arrived at the airport, out of state, nor were they able to take the patient into their care. CM #3 then documented she had secured an escort to assist the patient to fly out of state and assist Patient #10 with admission to another facility (hospital) should Patient #10's family not be present to pick him up from the airport.

On 5/8/18 at 5:53 p.m., a case manager documented contacting APS where the patient had residency was traveling to.

On 5/8/18 at 9:41 p.m., the patient was discharged with an escort to the airport for a flight out of state.

b. On 6/27/18 at 5:00 p.m. an interview was conducted with RN #2, who cared for Patient #10 on 5/6/18 and 5/7/18. RN #2 stated Patient #10 did not want to go back to his wife and confirmed documentation in the medical record on 5/7/18.

RN #2 reviewed Patient #10's medical record to include CM #3's notes on 5/8/18, the day of discharge. RN #2 stated, after review, Patient #10 had no plan in place for post hospitalization care. RN #2 stated Patient #10's family no longer was able to accept responsibility for the patient and further stated the situation would have been the same as if the facility had let him walk out the door; he had no place or person to accept responsibility for him here or out of state, yet the patient was sent out of state. RN #2 stated when Patient #10's family refused him, the situation changed and the discharge plan should have changed with it.

On 6/28/18 at 8:25 a.m., an interview was conducted with CM #3 who cared for Patient #10 from 5/6/18-5/8/18. CM #3 stated she spoke to Patient #10's wife several times via the phone due to the wife living out of state. CM #3 stated Patient #10's family was unable to come from out of state to pick up Patient #10. CM #3 stated she felt Patient #10's wife "got scared" when CM #3 was able to provide the patient an escort, an airline ticket and return Patient #10 to his wife. CM #3 stated "she got scared I could make all these things happen; she found out I knew what I was doing and that I could make him show up on her doorstep" after discharge.

CM #3 stated she was told Patient #10 was visiting but was an out of state resident with out of state insurance benefits. CM #3 stated the patient required post-hospital placement which would be more easily expedited in his state of residence so she began a plan of how to facilitate a discharge back to his state. CM #3 stated Patient #10, his sister and his wife were involved in the patient's plan of care. This was despite the physician documenting on 5/4/18 the patient lacked capacity and the facility had contacted Adult Protective Services (APS), in state and out of state, for elder abandonment.

CM #3 stated, Patient #10's "wife knew she was responsible for her husband because they were legally married." CM #3 further stated Patient #10's wife needed to help coordinate Patient #10's care and if she couldn't do it on her own, she needed to find additional family who could assist her.

CM #3 stated Patient #10 was discharged and escorted on a flight out of state. The plan was if the escort got a call from Patient #10's wife, to change course, the patient would be taken to his wife. This was despite the previous phone calls with the patient's wife in which she stated she could not care for the patient. If the wife didn't call then Patient #10, was to be taken to a local hospital emergency department once he landed. CM #3 stated Patient #10's wife made the choice for the patient to be taken to the hospital emergency department, out of state, because she did not call the escort and say to bring the patient home; "when she didn't call, she made that choice for him".

CM #3 then stated as far as the facility was concerned, the patient was safe and what happened in a different state was on them; they needed to find him long term placement. CM #3 stated the plan was a multidisciplinary team decision and was in the patient's best interest.

CM #3 was unable to provide any facility guidance which discussed patient discharge from the tertiary facility (an advanced healthcare system with specialized care) to an outside hospital emergency department in another state. Further, CM #3 was unable to provide facility guidance which stated a wife was legally obligated to take care of a husband, despite stating unable to do so. CM #3 stated she felt "it was more of an ethical obligation because when a person got married it was "in sickness and health".

On review of Patient #10's medical record there was no evidence the facility established and secured post hospital care or placement in which the patient had been accepted.

On 06/28/18 at 9:37 a.m., an interview was conducted with the case manager lead (CM Lead #4). CM Lead #4 stated a patient's plan of care was important to make sure the patient and family needs and goals were addressed. On review of Patient #10's medical record, CM Lead #4 stated, according to the documentation the patient had no plan in place for after hospitalization. CM Lead #4 further stated she did not believe and was unaware of any facility guidance which stated a wife was legally obligated to take care of a person, despite stating they were unable to do so.

On 06/28/18 at 1:02 p.m., an interview with the Director of Care Management (Director #5) was conducted. Director #5, after review of Patient #10's medical record, stated the patient was discharged with no plan in place, the facility could not confirm the patient had a safe place to go and was unsure of where the patient was going post hospitalization, all of which she stated would be key to a plan of care.