HospitalInspections.org

Based on medical record review and interviews, the facility failed to provide a discharge evaluation for post hospital services for 1 patient (Pt #2) out of 3 patients reviewed.

The findings include:

Review of the facility policy, "Patient Rights and Responsibilities," dated 9/2015 showed "...reasonable continuity of care and to be informed of any continuing health care requirements following discharge."

Medical record review of Admission History and Physical dated 2/20/2024 at 11:06 AM, showed Pt #2 was admitted for further evaluation and treatment for Schizophrenia. Pt #2 lived at a nursing facility and the nursing home staff reported "...over the past few weeks the patient has become increasingly more agitated and has been experiencing psychosis. Staff at the facility report she has been refusing care, she has been noncompliant with medication. They report she has been verbally aggressive and has been yelling out. Staff also reports that she has been quite paranoid and delusional...reporting people at the facility are trying to harm her...She has also been neglecting self-care and has refused to bathe."

Medical record review of a Physical Therapy Evaluation on 2/20/2024 at 4:46 PM, showed Pt #2 ambulating with supervision for short distances "according to the nurse...(Pt #2) refused to get up with the therapist." Review showed there was no documentation physical therapy did an evaluation of Pt #2 prior to her discharge to review for any discharge needs.

Medical record review of the Master Treatment Plan dated 2/21/2024 at 10:30 AM, showed Pt #2's long term and short term goals. The plan included Social Work Interventions which included:
" Assess patient for depression using Geriatric Depression Scale.
" Hold cognitive group 3-5 times/week.
" Family contact 1-2 times/week for education, progress, and support strategies.
" Coordinate discharge and aftercare, including facility placement if indicated.
" Assist patient in creating a safety/crisis plan upon discharge.
" Provide discharge planning that will include help for supervision and medication compliance.

Medial record review of Safety Determination Request Form dated 3/18/2024, filled out by SW #1 showed Pt #2 "...is a long-term care resident with an extensive psychiatric history. Patient has limited social support. Patient requires 24/7 care and supervision related to diagnosis of Schizoaffective disorder...Patient is able to ambulate; however, she demonstrates poor safety awareness, poor insight, poor judgement, impulsive behavior, and poor interpretation of the environment placing the patient at increased risk for falls...Patient experiences intermittent incontinence and requires assistance with activities to maintain basic hygiene as well pericare. Patient requires firm boundaries to prevent self-neglect as she frequently refuses to engage in hygiene related activities or to bathe...Patient is unable to live in a community setting due to paranoia, persistent delusional thought. History of medication compliance and risk for self-neglect. Patient currently benefits from a safe and structured environment that allows freedom of movement...Patient requires 24/7 nursing care to ensure that her medical, physical, mental health and self-care needs are maintained and managed. Patient is at increased risk for malnutrition, self-neglect, and medication noncompliance. Patient also demonstrates impaired insight, impaired judgement, and impaired decision-making capacity...Patient has limited caregiver support in the community and relies on nursing home care and support to meet her ongoing needs. Patient has a sister in the community, but she is unable to provide direct care activities for the patient."

Medical record review of Social Worker Notes dated 3/21/2024 through 4/11/2024, showed discharge planning was started. On 3/21/2024, the hospital was notified the patient failed her PASRR (Preadmission Screening and Resident Review, a federal requirement to help ensure appropriate placement in nursing homes for long term care) and was not able to return to the nursing home she had resided in. The plan changed "to focus on group homes and boarding homes." Continued review showed the hospital was unable to secure housing for Pt #2.

Medical record review of Social Worker Notes dated 4/5/2024 at 9:10 AM, showed SW #1 updated Pt #2's sister on progress, "The sister asked about what the process would be if insurance is unable to provide housing...advised the patient's sister would be responsible for securing housing post discharge...sister asked 'so you expect me to take her home with me'...responded yes.....Patients' sister asked 'what if I refuse to come and get her?' The Social Worker's notes reveal the patients's sister was advised the hospital's Risk Management and APS [Adult Protective Services] would be apprised of the situation as she cannot legally abandon her sister at the hospital.

The medical record lacked documentation to plan for the patient needs at her sister's house.

Medical record review of Social Worker Notes dated 4/12/2024 at 1:30 PM, showed SW #1 met with Pt #2's sister. "Patients' sister cited multiple social issues which will complicate her ability to manage her sister's care in her home...Patients sister requested chucks to protect her vehicle from possible incontinence during the 2.5 hours' drive home." There is no evidence SW #2 discussed with Pt #2's sister regarding post discharge needs for immediate care.

During an interview with Manager of Case Management on 2/4/2025 at 9:00 AM showed the hospital will try "...everything they can do to get placement for a patient who can't go home...we will try to get help for the family as much as possible...We do everything we can to help them once they get home." Interview continued and revealed SW #1 was no longer employed by the hospital and the Case Manager confirmed the immediate post discharge needs were not met for Patient #2.