HospitalInspections.org

Based on interview and record review, the facility failed to:
1) Provide a discharge planning evaluation to include an evaluation of the patient's need for post-hospital services, the availability of those services, and include an evaluation of the likelihood of the patient's capacity for self-care and the possibility of the patient being cared for in the environment from which he entered the hospital.
2.) Discuss the results of the discharge evaluation with the individual acting on the patient's behalf.
3.) Reassess the patient's discharge plan for factors that may affect continuing care needs and the appropriateness of the discharge plan.
4.) Transfer or refer the patient to an appropriate facility for follow-up care.

This affected 1(one) of 10 sampled patient # 1. ( refer to A-0806, A-811, A-0821, and A-0837)

Based on interview and record review, the facility failed to provide a discharge planning evaluation to include an evaluation of the patient's need for post-hospital services, the availability of those services, and include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he entered the hospital for 1 (one) out 10 sampled patients (SP) #1.


The findings:

Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission.

On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration).

Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes.


The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note.

On 3/26/17, the day of the pt. discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube.

The pt. was discharged on 3/26/17 via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions.

Interview with the Director of Case Management on 7/24/17 at 2:20pm revealed SP#1 initial Discharge Planning Evaluation was performed on 3/10/17 and then the next reevaluation in the medical record was on 3/24/17. She further stated that discharge planning reevaluations are done every 72 hours and at every patient change of condition. Further interview revealed that SP#1 came from the assisted living facility (ALF) on 3/10/17 and was discharged back to the same ALF on 3/26/17.


Record review also showed that SP #1 was readmitted to the hospital on 03/29/2017, and the patient expired on 04/07/2017. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration.


Review of the facility's policy: Documentation; Dept.: Utilization Management, Review date: 10/15 revealed that the Case Manager will (A) obtain information from the pt. family, and other relevant sources to make an accurate evaluation, (E) Frequency of documentation in the medical record will be documented on the discharge plans and updated at least every 72 hours. (F) The final disposition and follow-up will be documented once the pt. is discharged in the Case Management Discharge note. The facility failed to follow this policy

Review of the facility's policy "Discharge Planning Process" (revised 10/15) state that Discharge Planning involves the evaluation of the patient and family needs, strength, limitations and resources. Components of Discharge Planning are education, identification of needs and coordination of post-hospital care in collaboration with other members of the healthcare team. The discharge plan must take into account all realties of both the patient's condition and existing laws, rules, regulations and regulated agency requirements, along with availability of community resources.

Based on interview and record review, the facility failed to discuss the results of the discharge evaluation with the individual acting on the behalf of 1 (one) out of 10 sample patients (SP) #1.

The findings:


Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission.

On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration

Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes.


The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note.

On 3/26/17, the day of the pt. discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube.

The pt. was discharged on 3/26/17 via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions.

Record review showed that SP#1 capacity to consent to care and services was evaluated on 3/16/17 and determined that the patient is incapacitated. On 3/16/17, the Designation of Proxy Form show the Proxy designation was the brother.

Interview with the Director of Case Management on 7/24/17 at 2:20 pm revealed that SP#1 came from the ALF on 3/10/17 and was discharged back to the same ALF on 3/26/17.

Record review also showed that SP #1 was readmitted to the hospital on 03/29/2017, and the patient expired on 04/07/2017. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration.


The policy "Discharge Planning Process", (revision date: 10/15) state the Case Manager will identity and implement a realistic; coordinated plan for continuity of post-hospital care for patient of all ages. The policy further state the patient/family understanding of their role in implementing the discharge plan is verified and documented in the [named] system.

Based on interview and record review, the facility failed to reassess the patient's discharge plan for factors that may affect continuing care needs and the appropriateness of the discharge plan for 1 out of 10 sampled patients (SP) #1.

The findings:

Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission.

On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration

Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes.


The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note.

On 3/26/17, the day of the SP#1 discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube.

The pt. was discharged on 3/26/17 via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions. The patient was returned to the previous ALF which had no licensed staff to provide feedings via the peg tube.

Record review also showed that SP #1 was readmitted to the hospital on 03/29/2017, and the patient expired on 04/07/2017. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration.

Interview with the Director of Case Management on 7/24/17 at 2:20pm revealed SP#1 initial Discharge Planning Evaluation was performed on 3/10/17 and then the next reevaluation in the medical record was on 3/24/17. She further stated that discharge planning reevaluations are done every 72 hours and at every patient change of condition. Further interview revealed that SP#1 came from the assisted living facility (ALF) on 3/10/17 and was discharged back to the same ALF on 3/26/17.

The policy: titled "Documentation" Dept.: Utilization Management, (Revision date: 10/15) state that the Case Manager will (A) obtain information from the patient family, and other relevant sources to make an accurate evaluation, (E) Frequency of documentation in the medical record will be documented on the discharge plans and updated at least every 72 hours. (F) The final disposition and follow-up will be documented once the patient is discharged in the Case Management Discharge note. The facility failed to follow this policy.


Review of the facility's policy "Discharge Planning Process" (revised 10/15) state that Discharge Planning involves the evaluation of the patient and family needs, strength, limitations and resources. Components of Discharge Planning are education, identification of needs and coordination of post-hospital care in collaboration with other members of the healthcare team. The discharge plan must take into account all realties of both the patient's condition and existing laws, rules, regulations and regulated agency requirements, along with availability of community resources.

Based on interview and record review, the facility failed to transfer or refer the patient to an appropriate facility for follow-up care in 1 out 10 sampled patients (SP) #1.


The findings:

Record review revealed that sampled patient (SP) #1 came via ambulance from the Assisted Living Facility (ALF) on 3/10/17 with a complaint of a change in mental status and poor oral intake. Physical exam shows the patient is emaciated, underweight, alert, awake, with urinary catheter, decreased range of motion to extremities, contractures to hands and to lower extremities. Pt does not follow command. This was noted on the History and Physical dated 3/10/17 on admission.

On 3/20/17, SP#1 went for a procedure for placement of a feeding tube directly to the stomach due to impaired swallowing and risk for choking (aspiration

Review of the Physician orders revealed that on 3/24/17, 3/25/17, and 3/26/17, there were orders to discharge the pt. to the Skilled Nursing Facility (SNF), and to continue with feedings via the feeding tube with water flushes.


The review of the Case Management Report revealed that on 3/25/17, a skilled nursing facility (SNF) was called however there were no bed available. It further noted that after review of the chart, SP#1 lives in a group home and a message was left to the person associated with the facility (name indicated) to call regarding the patient discharge back. It is noted that the discharge disposition is HOME. There are no other case management documentation after this note.

On 3/26/17, the day of the SP#1 discharge, it is noted on the Adult Shift Assessment authored by the nurse that the SP#1 is confused, nonverbal, and unable to assess and responds to tactile stimuli. The patient has a urinary catheter. SP#1 continued to receive nutritional feedings of Jevity via the feeding tube.

The pt. was discharged on 3/26/17 via stretcher with continues feedings as ordered and water flushes, with follow-up to physicians in one week as noted on the Nursing Discharge Summary. The pt. was unable to sign and two nurse witnesses was noted on the Nursing Discharge Instructions. The patient was returned to the previous ALF which had no licensed staff to provide feedings via the peg tube.

Record review also showed that SP #1 was readmitted to the hospital on 03/29/2017, and the patient expired on 04/07/2017. The History And Physical dated 03/29/2017 showed SP #1 came from an Assisted Living Facility. He was brought due to constipation and abdominal pain. The assessment showed the patient had severe constipation, and dehydration.

Interview with the Director of Case Management on 7/24/17 at 2:20pm revealed SP#1 initial Discharge Planning Evaluation was performed on 3/10/17 and then the next reevaluation in the medical record was on 3/24/17. She further stated that discharge planning reevaluations are done every 72 hours and at every patient change of condition. Further interview revealed that SP#1 came from the assisted living facility (ALF) on 3/10/17 and was discharged back to the same ALF on 3/26/17.

The policy "Discharge Planning Process", (revision date: 10/15) state the Case Manager will identity and implement a realistic; coordinated plan for continuity of post-hospital care for patient of all ages. The procedure includes: Necessary referrals to post acute services will be made by the case manager or social worker (home health agencies, skilled nursing facility, LTACH (Long-term Acute Care Hospitals), DME (Durable Medical Equipment). The patients must be informed of Medicare certified providers in their geographical area who provide the level of service required at discharge. A choice letter will be signed by the patient/family prior to discharge.