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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation, §482.43 Discharge Planning was out of compliance.

A-0812- Standard: The hospital must include the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan. Based on document review and interview, the facility failed to ensure the initial and ongoing discharge planning evaluations for all patients were completed and documented in the medical record. This failure was identified in 3 of 6 medical records reviewed for patients discharged home (Patients #1, #2 and #5).

A-0820- Standard: The hospital must arrange for the initial implementation of the patient's discharge plan. As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care. Based on document review and interviews, the facility failed to ensure patients and family members were involved in discharge planning activities on an ongoing basis in order to prepare the patient and family for post-hospital care. This failure was identified in 3 of 6 medical records reviewed for patients discharged home (Patients #1, #2, and #5).

Based on document review and interview, the facility failed to ensure the initial and ongoing discharge planning evaluations for all patients were completed and documented in the medical record. This failure was identified in 3 of 6 medical records reviewed for patients discharged home (Patients #1, #2 and #5).

Findings include:

Facility policy:

The policy, Case Management Documentation Policy, stated when case management services are provided to a patient, clear and concise entries must be made in the patient's electronic medical record in order to communicate with physicians, nurses, and other personnel involved in the patient's care. Pertinent information related to the following was to be included: assessment of patient problems and needs, plan for provision of services, periodic progress as plans develop or get revised. A final note will be entered into the electronic medical record of those patients requiring post-acute services, including: the planned patient disposition, planned mode of transportation, and patient/family agreement with the discharge plan.

The policy, Case Management Discharge Plan, stated all patients will be evaluated for possible discharge needs within 24 hours of admission. The Case Management assessment will include, but (is) not limited to, the patient's demographics and psychosocial status. A plan will be developed based on identified patient needs. Case Management notations are made in the electronic medical record.

The policy, Case Management Plan, stated the initial Case Management Plan will be completed for the patient within 24 hours of their admission, utilizing the Admission Assessment, for the purpose of determining those that will require intensive discharge arrangement.

1. The facility failed to ensure initial and ongoing discharge planning evaluations for all patients were completed and documented in the medical record.

a. Record review was conducted for Patient #1, a 69 year old inpatient admitted on 5/15/18 due to complications related to respiratory failure. On 5/15/18, due to the patient's increased oxygenation needs, Patient #1 was intubated (an invasive tube that enters the mouth and into the airway in order to place a patient on the ventilator) and placed on a ventilator (a breathing machine that provides a patient with oxygen when they are unable to breathe on their own) for respiratory support. The patient was ultimately extubated (removal of breathing tube), but still required continuous oxygen after discharge on 5/19/18.

(1) Record review revealed a lack of documentation related to ongoing inpatient discharge planning evaluations, case management documentation, and ongoing patient/family involvement in the discharge plan.

Record review identified case management (CM #1) documented once during the patient's four day inpatient stay, on 5/19/18 at 3:33 p.m., the day of discharge. There was no documentation in the medical record of a completed case management plan or of any attempts to develop ongoing discharge planning communication with the patient and family. Record review also found no documentation of completed demographic or psychosocial status assessments by case management in order to determine post-hospital planning and services. These findings were contrary to facility expectations, including utilizing the admission assessment to determine which patients would require intensive discharge arrangements.

Further record review found a revision in the patient's discharge plan without documentation the patient and family were involved. According to the instructions documented on the Interdisciplinary Discharge created by the discharging provider on 5/19/18 at 3:00 p.m., the patient was to "wear oxygen 24 hours" at 4 liters when at home until outpatient follow-up. However, CM #1's discharge note on 5/19/18 at 3:33 p.m. explained on the day of discharge, the provider revised the plan for oxygen delivery and requested the patient discharge with an oximyzer (a special oxygen nasal cannula that provides a higher oxygen content in order to increase oxygenation) and high flow concentrator (an oxygen delivery system with settings to provide a higher oxygen flow, typically up to 10 liters, in order to meet a patient's oxygen requirement).

Review of the record revealed no documentation the patient and family were involved in the revision of the discharge plan to a different home oxygen delivery system. There was also no documentation the provider or interdisciplinary team provided in-hospital discussion with the patient regarding the indication for and use of a high flow concentrator prior to the patient being discharged. Finally, the change in discharge plan was not documented in the discharging provider's discharge instructions given to the patient to take home.

(2) On 2/15/19 at 11:07 a.m., an interview was conducted with CM #1 regarding Patient #1's discharge. CM #1 reviewed the medical record and confirmed there was no documentation of ongoing case management discharge planning, assessments and evaluations for Patient #1. CM #1 stated she met with Patient #1 on the morning of 5/19/18 and informed the patient of the plan to discharge that day. CM #1 stated on 5/19/18, she was stopped by the discharging provider who stated the consulting pulmonologist decided s/he now wanted the patient to go home with a high flow concentrator and an oxymizer because the high flow concentrator would be able to deliver up to 10 L of oxygen to the patient.

CM #1's documentation and interview regarding Patient #1's discharge plan conflicted with the provider's documented discharge instructions given to the patient to take home which read Patient #1 was only to wear 4 L of continuous oxygen. There was also no documentation by the consulting pulmonologist or discharging provider the patient and family was informed, understood, and agreed with the change to a higher oxygen delivery system up to 10 L.

(3) Review of a grievance report by the wife of Patient #1 and initially reported to the facility on 5/23/18, revealed it read the pulmonologist consult had spoken with her and Patient #1 earlier in the day on 5/19/18, but had not informed the patient and family there was a plan to discharge that day. The report read, "the communication between staff, patient, and family was not sufficient." The wife also reported concerns "the home care and discharge teaching were rushed and incomplete" and "she did not feel comfortable" with her husband leaving the hospital and going home. Other concerns noted in the grievance: "discharge was very chaotic and disorganized and [patient and family] were rushed out the door;" the patient and family's questions regarding the oxygen equipment and amount of oxygen were "never answered;" and the patient and family received no explanation as to who authorized the patient's discharge and "the reasoning behind it." According to the grievance, on the night after discharge, Patient #1 was found unresponsive at home and was unable to be revived.

b. Record review was conducted for Patient #5, a 94 year old inpatient admitted on 2/9/19 and discharged on 2/12/19, following cardiac treatment of a non-ST elevated myocardial infarction (the medical term for a heart attack).

Contrary to facility expectations, review of the patient's record revealed case management had not completed an admission assessment of the patient. Further review found no documentation of ongoing patient and family discharge planning involvement. Rather, the only documentation by a case manager was on 2/12/19 at 11:27 a.m., approximately 4.5 hours prior to the patient being discharged. According to the Case Management Note she called the patient's daughter to discuss the discharge plan for home healthcare and she noted the daughter "was upset that nobody had contacted her regarding the discharge plan for today."

On 2/14/19 at 12:10 p.m., the director of case management (Director #5) reviewed the medical record for Patient #5 and confirmed there was no case management discharge documentation related to ongoing discharge planning activities, family involvement, or assessments. Director #5 identified that case management was ordered for consult on 2/9/19, yet the only case management note was documented on 2/12/19 when case management began discussing home health options with the patient, approximately 4.5 hours prior to discharge.

c. Record review was conducted for Patient #2, a homeless 57 year old inpatient admitted on 2/8/19 for four days after arriving at the facility's emergency department with complaints of chest pain and subsequent cardiac treatment. Contrary to facility expectations, review of the record found no documentation of case management's admission assessment, ongoing discharge planning evaluations, or patient involvement.

d. On 2/14/19 at 9:09 a.m., an interview was conducted with a case manager (CM #2) regarding the discharge planning process.

CM #2 stated every patient admitted to the hospital received a discharge plan. She stated case management attempted to see every patient within 24-48 hours of admission in order to discuss the patient's current needs, current level of service in the hospital, and begin anticipating the patient's needs upon discharge. CM #2 stated the facility's goal was to avoid unanticipated discharges so the patient could be aware of possible discharge plans. CM #2 stated family conferences could be initiated if the need for increased family involvement was identified. CM #2 stated case managers were to document all evaluations in the patient's electronic health record (EHR) within case management narrative notes.

CM #2 also stated the facility conducted interdisciplinary rounds daily at approximately 10:00 a.m. on the inpatient units. Interdisciplinary rounds included the medical providers, a pharmacist, physical therapist, occupational therapist, nursing, speech therapy, case managers, respiratory therapy, and dietary as applicable to the acuity of the patient. According to CM #2, clinicians who participated in interdisciplinary rounds would take personal notes, but there was no "official" documentation into the medical record.

e. On 2/14/19 at 10:10 a.m., an interview was conducted with CM #3. CM #3 confirmed case management attempted to see all admitted patients within 24-48 hours. CM #3 stated case management documented evaluations in the narrative notes of the EHR in order to ensure that review of the medical record would identify case management's ongoing discharge plan. CM #3 stated family involvement and communications with patients should be documented in the medical record. CM #3 stated family involvement was important in order to ensure family members knew what care the patient needed once discharged.

CM #3 reviewed the medical record of Patient #1 during the interview and identified gaps in discharge planning activities.

CM #3 reviewed the case management discharge note, documented on 5/19/18 at 3:33 p.m. According to CM #3's review, there was no ongoing discharge planning documentation from case management noted in the medical record. CM #3 stated the documentation indicated the patient was not visited by case management until the day of discharge. CM #3 also noted there was no evidence of ongoing discharge planning and communication with the family. CM #3 confirmed the physician's discharge instructions stated the patient was to use 4 liters (L) of continuous oxygen at home, with no mention of the high flow concentrator or oxymizer. CM #3 also noted the change in oxygen equipment occurred right before the patient was discharged. According to CM #3, the patient's discharge appeared "rushed" because of the inconsistent discharge instructions and the lack of ongoing case management documentation throughout the patient's stay.

CM #3 stated the facility had not provided any reeducation, or process improvement activities following Patient #1's discharge.

f. On 2/14/19 at 12:13 p.m. an interview was conducted with Director of Case Management (Director #5). Director #5 stated case managers were to document assessments and evaluations in the patient's medical record. Assessments were to include review of the patient's post discharge needs, home safety, assistive devices, any services used at home, concerns for personal safety, or goals for discharge to ensure they are comfortable going home and reflected in the medical record. Director #5 stated case managers typically reviewed discharge planning for all admitted patients, but not all assessments and communications were getting documented into the medical record.

Director #5 reviewed the medical records for Patients #1, #2, and #5 and confirmed a lack of ongoing case management discharge planning evaluations, assessments, or communications with patients and family on an ongoing basis. Director #5 stated it was important for case management to complete assessments and document them in the medical record in order to ensure a "viable discharge plan" was put in place for the patient.

Based on document review and interviews, the facility failed to ensure patients and family members were involved in discharge planning activities on an ongoing basis in order to prepare the patient and family for post-hospital care. This failure was identified in 3 of 6 medical records reviewed for patients discharged home (Patients #1, #2, and #5). (Cross-reference A812)

Findings include:

Facility policy:

The policy, Case Management Documentation, stated case managers will document the patient and family's agreement with the planned discharge plan. Education provided to the patient and/or family by the case manager was to be documented in the electronic medical record.

The policy, Case Management Plan, stated case management collaborates with the patient, family members, the treating physician, and the interdisciplinary team to clarify specific needs versus perceived needs, and to work with the patient/family in coordinating care and achieving an acceptable goal. If changes are required, the perceived needs are discussed with the patient and his/her family. Communication with the patient, family, support group and interdisciplinary team was to occur on an ongoing basis.

1. The facility failed to ensure Patients #1, #5, and #2 and their families were involved with discharge planning activities on an ongoing basis in order to prepare for post-hospital care.

a. Record review was conducted for Patient #1. Review of the medical record revealed a lack of ongoing discharge planning evaluations and a lack of ongoing patient and family involvement with discharge planning for post-hospital care.

Patient #1 was a 69 year old admitted as an inpatient on 5/15/18 due to complications related to respiratory failure. On 5/15/18, due to the patient's increased oxygenation needs, Patient #1 was intubated (an invasive tube that enters the mouth and into the airway in order to place a patient on the ventilator) and placed on a ventilator (a breathing machine that provides a patient with oxygen when they are unable to breathe on their own) for respiratory support. The patient was ultimately extubated (removal of breathing tube), but still required continuous oxygen after discharge on 5/19/18. According to the discharge instructions completed by the provider, the patient was to "wear oxygen 24 hours" at 4 liters (L) when at home until outpatient follow-up. The patient was not using home oxygen prior to admission.

Review of the record found case management (CM #1) documented one note during the patient's four day inpatient stay, on 5/19/18 at 3:33 p.m. the day of discharge.

There was no documentation in the medical record of a case management plan or of any attempts to develop ongoing discharge planning communication with the patient and family post-hospital care.

CM #1's Case Management Note, written on 5/19/18 at 3:33 p.m., read portable oxygen tanks were delivered to the patient's room prior to discharge but, after the oxygen was delivered, "the provider" requested the addition of an oximyzer (a special oxygen nasal cannula that provides a higher oxygen content in order to increase oxygenation) and high flow concentrator (an oxygen delivery system with settings to provide a higher oxygen flow, typically up to 10 liters, in order to meet a patient's oxygen requirement).

On 2/15/19 at 11:07 a.m., CM #1 confirmed the revision in Patient #1's discharge plan the day of discharge. CM #1 stated she met with Patient #1 on the morning of 5/19/18 and informed the patient of the plan to discharge that day. CM #1 stated on 5/19/18, she was stopped by the discharging provider who stated the consulting pulmonologist decided s/he now wanted the patient to go home with a high flow concentrator and an oxymizer because the high flow concentrator would be able to deliver up to 10 L of oxygen to the patient.

The change in oxygen delivery system, for the patient to use an oximyzer and high flow concentrator, was a revision from the initial plan for 4L continuous oxygen at home. Review of the record found no documentation the patient and family were made aware of and anticipated the oxygen equipment changes prior to the order for discharge.

There was no documentation by the discharging provider, the interdisciplinary team, or the consulting pulmonologist that the patient and family were informed, explained the basis for, understood and agreed to changes in the oxygen equipment prior to discharge. Also, the revision in the discharge plan to a higher home oxygen delivery system was not evident in the provider's discharge documentation.

In addition, review of the record found no evidence the patient and family received in-hospital teaching regarding the oxygen equipment or teaching related to the change in oxygen delivery system. Rather, according to the note, the family was to meet the oxygen supply company on their way home to change the home concentrator to a high flow concentrator, indicating no in-hospital training was provided prior to discharge.

Finally, review of Patient #1's record also revealed the patient was ordered the following newly prescribed medications: Apixaban (anticoagulant medication), atorvastatin (medication for the treatment of high cholesterol), diltiazem (medication to treat high blood pressure and chest pain), levofloxacin (antibiotic medication), prednisone (a steroid medication), and an albuterol inhaler (a medication used to treat or prevent bronchospasms). Review of the record found no evidence the patient and family members were provided any supplemental written instructions pertinent to the patient's newly prescribed medications.

A grievance by the wife of Patient #1, initially reported to the facility on 5/23/18, confirmed the facility failed to ensure the patient and family were prepared for post-hospital care. In the grievance, the patient's wife stated the consulted pulmonologist spoke to the patient and family earlier in the day on 5/19/18 but had not informed them there was a plan to discharge that same day. She wrote, "the communication between staff, patient, and family was not sufficient," "the home care and discharge teaching were rushed and incomplete," and "she did not feel comfortable" with her husband leaving the hospital and going home. The grievance further read the "discharge was very chaotic and disorganized and they were rushed out the door." Other concerns reported were that the patient and family's questions regarding the oxygen equipment and amount of oxygen were "never answered" and the patient and family were not told who authorized the patient's discharge and "the reasoning behind it." According to the report, on the night after discharge, Patient #1 was found unresponsive at home and was unable to be revived.

b. Record review was conducted for Patient #5. Review identified a lack of ongoing discharge planning documentation, and ongoing involvement with the patient and family member.

Patient #5 was a 94 year old admitted on 2/9/19 and discharged on 2/12/19 following cardiac treatment of a non-ST elevated myocardial infarction (the medical term for heart attack).

Review of the record revealed no documentation the patient and family were involved with discharge planning activities on an ongoing basis in preparation for post-hospital care. The only documentation of family involvement was a case management note documented on 2/12/19 at 11:27 a.m., approximately 4.5 hours prior to the patient being discharged. According to the case manager's note, she called the patient's daughter to discuss the discharge plan for home healthcare and noted the daughter "was upset that nobody had contacted her regarding the discharge plan for today."

b. Record review was conducted for Patient #2. Review revealed a lack of ongoing discharge planning and patient involvement in preparation for post-hospital care.

Patient #2 was a homeless 57 year old inpatient admitted on 2/8/19 for four days after arriving to the facility's emergency department with complaints of chest pain and subsequent cardiac treatment.

Review of the record found no documentation of case management's admission assessment, ongoing discharge planning evaluations, patient involvement, or preparation for post-hospital care.

2. Staff interviews revealed facility expectations regarding the implementation of Patient #1, #5 and #2 were not met.

On 2/14/19 at 10:10 a.m., an interview was conducted with CM #3. CM #3 reviewed the medical record for Patient #1. Based on the case management note documented on 5/19/18 at 3:33 p.m., CM #3 stated the discharge appeared "rushed." CM #3 stated documentation should identify the patient was seen throughout the inpatient stay, the family was involved, the home environment was assessed, home care was accepted or refused, discussions were held with the patient and family members, and the patient and family understood any equipment they were being discharged with.

On 2/14/19 at 12:13 p.m. an interview was conducted with the Director of Case Management (Director #5). Director #5 reviewed the medical record for Patient #1 and confirmed there was no documentation stating the patient and family were informed and understood the change to an oxymizer and high flow concentrator prior to the order for discharge. The director also stated there was no documentation of ongoing family involvement or assessment of the family support system prior to discharge.

Director #5 also reviewed the medical record for Patient #5 and stated the findings were not in compliance with the Case Management Discharge Plan policy because case management should be reviewing the patient's post-discharge needs daily while also assessing any home safety concerns and discharge readiness as the patient's medical needs change.

On 2/14/19 at 11:06 a.m., an interview was conducted with Registered Nurse (RN) #4 regarding discharge education. RN #4 stated discharge education should be ongoing during the patient's inpatient stay. She stated education at discharge should be done by the nursing staff in order to reinforce all teaching needed before the patient and family left the hospital.

RN #4 further stated the patient and family should be provided verbal and written instructions related to their medical diagnosis and any "medical needs" pertinent to the patient which should be reflected in the medical record. She stated if a patient was ordered any new medications, then verbal and written discharge education would be provided by the nurse to ensure the patient understood the side effects, timing, and indications for the medication. RN #4 stated discharge education was important to help ensure the patient and family were comfortable going home and understood the discharge plan.

RN #4 reviewed the record for Patient #1 and confirmed there was no documentation the patient and family were provided any verbal or written discharge teaching by the discharging nurse prior to leaving the hospital.

e. On 2/14/19 at 1:06 p.m., an interview was conducted with Director of Nursing (DON #6). DON #6 stated the discharging nurse was expected to provide written and verbal discharge instructions pertinent to the patient's condition and discharge needs. DON #6 stated it was important patients received written discharge instructions to go home with in order to help reinforce information provided verbally in case they forget.

DON #6 reviewed the medical record for Patient #1 and confirmed the record revealed no documentation the discharging nurse provided the patient and family any written instructions.

DON #6 stated she was aware of the discharge planning grievance completed by Patient #1's wife. She said there had been no change in process or no re-education had been provided to the nursing staff related to discharge planning and education since receipt of the grievance on 5/23/18 (see above).

f. On 2/14/19 at 4:43 p.m., an interview was conducted with Director of Nursing Education (Education Director #7). Education Director #7 stated the facility had no policy related to discharge instructions. She stated the nursing staff was supposed to document all sections of the discharge flowsheet in the electronic medical record (EHR), which would include providing written discharge instructions for patients to take home.

g. On 2/15/19 at 10:31 a.m., an interview was conducted with a hospitalist (Physician #8). Physician #8 reviewed the discharge instructions created by the discharging provider for Patient #1 and confirmed the discharge instructions were incomplete. Specifically, the instructions stated the patient was to wear 4 liters of oxygen continuously while at home, but there was no mention of the high flow concentrator, oxymizer, or increased oxygen delivery equipment for higher than 4 L. Physician #8 also confirmed the discharge documentation had not reflected whether the patient and family were informed of the change to an increased oxygen delivery system prior to the discharge order. Physician #8 stated that without accurate oxygen management instructions, the patient could risk hypoxia from not using enough oxygen, or potential oxygen toxicity from using too much oxygen.