HospitalInspections.org

Based on interview policy, and record review the facility failed to ensure an appropriate discharge to meet the needs of 1 (SP#1) out of 6 sampled patients (SP).

The findings include:

Review of sample patient (SP) #1 Social Worker/Case Management Forms dated 04/24/2019 on 3:04 PM documented Discharge Needs I: Discharge To/Transition To: Home independently. Discharge Needs II: Professional Skilled Services, Anticipated: Occupational Therapy, Physical Therapy, Speech/Language Pathology. Narrative Notes: Case Manager and Social Worker will continue to monitor patient's progress for discharge care coordination.


Review of SP#1 Physical Therapy (PT) Inpatient Evaluation dated 04/28/2019 at 8:13 AM documented Discharge Recommendations: Discharge to, Recommended PT: Acute Inpatient Rehabilitation Facility/Unit. Patient is expected to: participate a minimum of 3 hours per day, 5 out of 7 days per week or 15 hours per week total.

Review of SP#1 Physician Orders dated 04/28/2019 at 1:58 PM documented that an order was entered for Rehab Admission Coordinator Review.

Review of SP#1 Rehabilitation Hospital Referral dated 04/29/2019 at 11:06 AM documented referral comments: please review. Status: sent/not to be placed/closed. Referral placed 04/30/2019 at 11:09 AM and closed 04/30/2019 at 11:09 AM.

Review of SP#1 Speech Language Pathology Fluoroscopic Swallowing Study dated 04/29/2019 at 9:40 AM documented Impressions: Patient presents with severe oropharyngeal dysphagia. Recommend: Outpatient speech therapy.

Review of SP#1 Physical Therapy (PT) Inpatient Evaluation dated 04/29/2019 at 1:25 PM documented Discharge Recommendations: Discharge to, Recommended PT: Acute Inpatient Rehabilitation Facility/Unit. Patient is expected to: participate a minimum of 3 hours per day, 5 out of 7 days per week or 15 hours per week total. Professional Skilled Services Anticipated: Occupational, Physical Therapy.

Review of SP#1 Physician Order dated 04/29/2019 at 2:17 PM documented Home with Home Health Care when supplies given and patient taught how to feed self and give medications to self via feeding tube.

Review of SP#1 Physician Order dated 04/29/2019 at 2:25 PM documented Rolling Walker. Special Instructions: Rolling walker for safety. Type of Therapy: Maintenance.

Review of SP#1 Prescription dated 04/29/2019 documented a prescription for rolling walker.

Review of SP#1 Durable Medical Equipment Referral dated 04/29/2019 at 3:53 PM documented referral comments: delivery at home was first sent. Status: sent/placed/closed Referral placed 04/29/2019 at 11:09 AM and closed at 04/30/2019 at 11:09 AM.


Review of SP#1 Social Work Progress Note dated 04/29/2019 at 4:39 PM documented Discharge note: Social Worker received prescription for walker. Patient is being discharge home. Social Worker sent referral to deliver Durable Medical Equipment (DME) home. Patient was seen yesterday by physical therapy and recommendation was for acute rehabilitation. Social Worker sent referral for rehabilitation. No further Social Worker needs. Discharge Needs I: Discharge To/Transition To: Home independently. Discharge Needs II: Professional Skilled Services, Anticipated: Occupational Therapy, Physical Therapy, Speech/Language Pathology.

Interview with Senior Director Case Management and Social Work on 06/17/2019 at 1:45 PM revealed that the Physical Therapist recommended acute rehab and the attending physician recommended discharge home with home health care.

Interview with Senior Director Case Management and Social Work on 06/17/2019 at 3:19 PM Stated Staff B did not follow through with the rehab referral to verify if the patient was accepted or denied and failed to discharge the patient to the appropriate level of care as this patient had acute inpatient rehab potential.

Interview with Staff B dated 06/17/2019 at 2:43 PM revealed that the physical therapist recommended acute rehab. Staff B spoke with the patient regarding the recommendation, no family was at the bedside. Referral was sent for acute rehab and was under review when the medical team recommended discharge home with cane. Received prescription for cane and was processed through insurance. No order for home health care was received. Stated that patient was discharged home.

Interview with Senior Director Case Management and Social Work on 06/17/2019 at 2:51 PM revealed case management department conducted an investigation and found that Staff B did not advocate for the patient regarding physical therapy's recommendation of acute care rehab. Staff B sent referral and did not wait for a response for services or follow-up with the physician regarding the physical therapy recommendation.

Interview with Senior Director Case Management and Social Work on 06/18/2019 at 10:10 AM revealed that a referral was entered from physical therapy for an inpatient rehabilitation review. Stated the referral was placed into the system on the day the patient was discharged.

Review of Policy No. 210, Subject: "Discharge Planning", last revised: 05/14/2019 revealed III. Procedure: B. Focused Discharge Planning Assessment - 1. Patients with the likelihood of needing additional post-acute hospital services are further evaluated by clinical resource management personnel. A request for a focused discharge planning evaluation may be initiated through a physician order, case finding, referral or identification by nursing or other ancillary services such as physical therapy, or by patient or proxy request. C. Referrals, Patient Choice and Disclosure of Financial Affiliations. 1. Referrals for post-acute care services or placements will be coordinated by the unit's clinical resource management personnel. Referrals will be sent based on the patient's insurance network, patient preference and/or service area.