HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of seven (7) medical records reviewed, staff failed to update the discharge plan of a patient with declining functional needs prior to discharge to ensure a safe discharge (Patient #1).

Findings include:

Review of the medial record of Patient #1 revealed a 77-year-old with a history of Asthma, Chronic Obstructive Pulmonary Disease, Bladder Cancer, and Diabetes. The patient was admitted to the Ambulatory Surgery Unit for a same-day procedure (Restaging Transurethral Resection of Bladder Tumor - 'TURBT') on 5/17/22 at 6:57 AM. The patient developed substernal chest pain following the procedure and was admitted to the Post Anesthesia Care Unit (PACU) for observation. At 7:48 PM, she was transferred to a medical unit for continued observation.

On 5/18/21 at 11:32 AM, Resident note documented that on examination, the patient was found to have mild chest pain and diffuse abdominal pain.
At 12:57 PM, initial Case Manager (CM) assessment completed. Plan: Plan is for the patient to be discharged back to the Group Home when stable."
On 5/19/21 at 10:40 AM, initial Social Work (SW) assessment documented: Functional Level - Ambulation-assistive device; Bathing-assistive person; Communication-difficulty understanding not related to language barrier; Dressing-assistive person; Toileting-assistive person. SW plan: "A safe dc back to Group Home."

On 5/23/21 at 8:04 PM, RN documented: ... Percocet administered for complaint of pain. Patient assisted with turning and positioning. A 2-hour discharge notice is in effect. Discharge planned for 5/24/21.

On 5/23/21 at 10:00 PM, Social Worker assessment documented: "Patient states her stomach hurts. Medical team gave patient a 24-hour notice."

Review of RN Daily Flowsheet documented the following for Musculoskeletal general mobility:
On 5/17/21 at 9:00 PM - generalized weakness. The same level of general mobility was documented on 5/18/21 at 3:13 PM, 5/19 at 12:55 AM, 5/20 at 8:55 AM and 11:54 PM, 5/23/21 at 8:56 PM, and 5/24/21 at 11:40 AM.

Braden Risk Assessment: Activity-ability to walk
5/17/21 at 9:00 PM bedfast. Similarly, on 5/18/21 at 3:13 PM, 5/19/21 at 9:19 AM, 5/20/21 at 8:55 AM, 5/21/21 at 8:26 AM 5/22/21 at 10:42 AM, and 5/23/21 at 7:43 AM.

The patient was discharged to the Group Home on 5/24/22 at 7:10 PM.

There was no reassessment of the patient's ability to walk. There was no documented discussion with the Group Home to determine their ability to care for the patient and there was no involvement of the patient's representative in her discharge plan.

Review of facility's policy titled: Discharge Planning" Effective 04/2022 states: "The process for planning any discharge will continue throughout the patient's stay in the hospital ..."

During interview on 9/22/22 at 2:24 PM, Staff B, Attending Physician stated: The patient was morbidly obese with frequent admissions for COPD. Her functional ability was limited. She was living with friends in the house in a basement. She needed a Continuous Positive Airway Pressure (CPAP-a machine that keeps the airways open when sleeping) but the home could not accommodate it. She needed a higher level of care ...I wanted to get her in a Nursing Home ... The last admission, she went to a different facility ... No, I never spoke to the owner of the Group Home. In my understanding, she lived in a private home. I wasn't sure they administer her meds properly. Her private home was very small, and they couldn't get the equipment in ...I documented this information on a prior admission. The Case Managers and Social Workers are aware of it ..."

At interview on 9/22/22 at 2:47 PM, Staff C, LCSW stated: " ...In hindsight, I did not follow the case through. She became more complex the longer she remained in the hospital. The Case Manager would need to take another look at the discharge plan to see what kind of services she needed. I was out for the next week or two. This is a huge problem here. All the teams don't come to the Interdisciplinary meeting."

During telephone interview on 9/23/21 at 1:23 PM, the Operator of the Group Home stated: "No one called to tell anyone she was coming...They sent her here in a stretcher...She should be walking. I took her inside with the help of a next-door neighbor ..." During a follow up interview on 9/29/22 at 3:00 PM with the Group Home Operator, she added that EMS personnel left the patient at the door, and they couldn't tell her why she was unable to walk. Shortly after the patient arrived at the Group Home, 911 was called and she was taken to another facility where she died.