HospitalInspections.org

Based on record review and interview, the facility failed to ensure an appropriate reassessment of discharge needs were communicated to the family responsible for the patients care in 1 of 4 patients discharged with home health services (Patient #1) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Discharge Planning" #10886063 last approved 12/15/2021 under Definitions Case Manager revealed "a registered nurse or licensed social worker who performs discharge screening assessments." Evaluation revealed "This should include the likelihood of a patient's capacity for self care or for care in the location from which he or she entered the hospital." Under Plan implementation revealed "Implementation entails arranging for patient services at the next level of care and acquiring the necessary equipment and supplies. Under Re-evaluation revealed "The medical record should reflect the plan of care as discussed with the individual or individual(s) acting on his or her behalf."

Review of Patient #1's medical record revealed Patient #1 presented to the Emergency Room 10/25/2022 at 8:00 AM by ambulance, after a fall, s/he tested positive for COVID-19, and was admitted to the medical/surgical unit 10/25/22 at 9:17 AM where her/his acute symptoms were treated. Physical Therapy Evaluation 10/28/2021 at 12:30 PM revealed "Very significantly below baseline functional independence level." Care Management note 10/29/2021 at 10:27 AM revealed "therapy evaled..." (evaluations) "reccommending (sig) SAR" (Subacute Rehabilitation) for rehabilitation and "there aren't any accepting SNFs (skilled nursing facilities) for + (positive) COVIDs." Physical Therapy (PT) Daily Treatment Note dated 11/04/2021 at 12:30 PM under Assessment revealed "no significant progress in therapy with very little constructive participation since admission on 10/25/2021. Occupational Therapy (OT) daily note on 11/04/2021 at 11:15 AM under Recommendations "subacute rehab" (rehabilitation). OT note 11/04/2021 at 4:00 PM revealed "Call to [Complainant A] ... At this time, pt (patient) requires minimal assist with cares and a wheeled walker for mobility." Care Management note dated 11/05/2021 at 10:14 AM revealed "Team indicated that pt could return home with family support" and home health. Family support was not defined. Nursing flow sheet 11/05/2021 revealed Patient #1 was incontinent twice requiring help with changing. Occupational Therapist Daily Note on 11/05/2021 at 3:00 PM under Dressing Lower Body revealed "total assist." Under ambulation revealed "Moderate assist." Occupational Therapist Daily note dated 11/05/2021 at 3:39 PM "Summary revealed patient "would like to return home... Recommend patient return home with family, 24 hr (hour) assist and home OT/PT (Occupational therapy and Physical Therapy). S/he will need an ambulance transfer into the home and a bedside commode." MD I's progress note 11/05/2021 at 7:56 PM revealed social worker communicated with [Complainant A] before the discharge and [s/he] agreed with the plan of patient coming home."

There was no documentation of a family discussion of Patient #1's condition or daily needs in the medical record. After Visit Summary (AVS) printed 11/05/2021 at 5:34 PM, signed by Patient #1 revealed "Patient should remained (sig) quarantined at home until 11/09/21." Patient #1 was discharged home on 11/05/2021 at 11:13 PM with an ambulance transport.

There is no documentation in Patient #1's medical record that Patient #1's family was provided a bedside commode, that the family was notified when Patient #1 was to be transported home by ambulance on 11/05/2021, or that Patient #1's family understood Patient #1 was to be in quarantine until 11/09/2021.

On 1/18/2022 at 3:30 PM during interview with Case Manager Supervisor L, Supervisor L stated that case managers are responsible to convey updates and recommendations to patient families. Supervisor L stated it was not clear who communicated Patient #1's needs to the family. Supervisor L stated arrangements for ambulance transportation was completed after case management left for the day, "nursing" was responsible and "it was not" documented.

On 1/19/2022 at 9:30 AM during a telephone interview with Licensed Clinical Social Worker (LCSW) F, review of Patient #1's medical record indicated Patient #1 was "significantly below baseline functional independence level," that Patient #1 was incontinent and needed "total assist" with dressing. When questioned if Patient #1's family was aware of this, LCSW F stated, "I don't recall what we talked about."