HospitalInspections.org

Based on record review and interview the facility failed to discuss and include in the discharge plan the participation of the individual acting on the patient's behalf for 1 of 11 sampled patients (SP #1).


The findings:

Record review showed that sampled patient (SP) #1 was brought in on 6/17/16 with report of increased respiratory secretions, mild hypoxia and signs of sepsis with tachycardia and fever and was admitted for acute care of sepsis, tracheal bronchitis and acute versus chronic decubital ulcer.

The Case Manager (CM) #2 progress notes showed on 7/6/16 and 7/8/16, that the mother/Proxy is currently in a 1-bedroom apartment and is not in agreement to send pt. to a SNF (Skilled Nursing Facility) and is making arrangement to take pt. (patient) home upon discharge.
On 08/01/2016 another note showed patient ' s mother and Doctor discussed D/C planning. Mother stated that she has found an apartment for which she will get the keys on 08/04/2016 and will be able to take SP #1 home upon discharge.

On 8/3/16, EQ Nurse Coordinator stated that D/C planning to home is unsafe since apartment is located on the second floor without elevator access and that mother was informed and mother voiced her frustration with entire situation and inability to take her son home.
On 8/5/16, DCF hotline called to report questionable unsafe discharge plan. DCF investigator came to evaluate patient at the bedside. The investigator concluded that if the patient has 24-hour care and home health visits then the patient may be discharge to the home with his mother on the 2nd floor without elevation. Late entry was made for 08/08/2016 showed that the supervisor, who after conservation with the EQ supervisor and the DCF worker advised CM that the patient was not cleared for D/C home and instructed her to proceed with referral to subacute facilities.

On 08/12/16, spoke to DCF investigator who confirmed advising patient ' s mother that she was given two weeks to secure safe housing (first floor apartment or upper floor with elevator access) and in the meantime pt. will remain in the facility.

Case Manager #3 progress note showed on 8/24/16, Intensive phone conversation today with pt.'s mom, in order to persuade her to accept son to transfer to SNF for continuous custodial care until ultimately transfer to her home.
Corporate Director of Case Management progress note showed on 9/1/16, long term care facility has accepted pt. for short term placement until housing is obtained on 9/15/16.

On 9/2/16, the pt. was accepted at the Skilled Nursing Facility #3; informed pt. ' s mother/Proxy of transfer to facility within this System while she is awaiting first floor apartment. Mother voiced her discontentment, stating the transfer cannot be done without her consent and she is not in agreement. Explained to mother that consent was not needed for transfer within the system and mother stated that she will sue the facility.

The Corporate Director of Case Management on 10/24/16 at 12:53 PM stated, there were several discussions about the discharge planning; the first option was the mom wants the pt. to go home and the other option was SNF (Skilled Nursing Facility) placement. The problem with the home when the CMS (Children's Medical Services Network) personnel talked to the CM that they are not agreeing with discharge (d/c) home because the mother lives on a second floor apartment (apt.). So we eventually got the DCF (Department of Children and Family) involved, the DCF made an assessment they said we agree that home was not optimal but there was no DCF hold so basically the mom was still able to make the decision. Because of the DCF and Children's Medical Services Network not agreeing to d/c home, so we sent the referral to another SNF. So the SNF said that the pt. was appropriate for their facility but when it was presented to the mom the mom refused. The mom said that she was looking for an apt. on the first floor and she found something in Homestead but it was on the second floor and the first floor will be available on 9/15/16. Eventually because there was now a specific availability of the apt. and we had the pt. who is medically stable for d/c, we referred the pt. to the Long Term Care (facility #3) for evaluation because it's within our health system. When the bed became available, the pt. was transferred to facility #3 which is part of the system and is appropriate for the pt 's level of care. The case manager informed the mom of the transfer but mom disagreed. So we informed her that facility is part of the System and will be able to provide the appropriate care that the pt. needs until the apt. becomes available on the 15th. Because the mom did not want the consent for CMAT (Children's Multidisciplinary Assessment Team) Services which is the authorization for SNF, the stay in the long term care facility #3 was not going to be billed to Children's Medical Services. The system was going to pay for it. We discussed this with our CMO (Chief Medical Officer) and RM (Risk Manager) and we also informed DCF and Children's Medical Services (Network). of the plan to d/c to long term care facility. The pt. was only supposed to stay there until the apartment became available on 9/15/16 but apparently he remained in the facility until his readmission here on 10/17/16.

Open medical record review of SP#1 present admission, the record showed that on 10/17/16 the patient was readmitted from the system's skilled nursing facility #3 due to fever and tachycardia with admitting diagnosis of acute febrile illness. The pt. is currently receiving treatment for antibiotic therapy and the discharge plan is to discharge pt. home with mother with all discharge planning needs.


The policy " Patient Right and Responsibilities " showed that the patient their advocate or their legal representatives have the right to necessary information, in clear and concise explanation, to enable them to make treatment decisions that reflect their wishes.

The policy " Discharge Planning " dated 07/2013, showed Throughout the patient's hospitalization the multidisciplinary team will monitor, coordinate and reassess the patient's progress towards treatment goals and review the discharge plan to determine if the plan is meeting the needs of the patient. The policy also state that patient/family will be involved in the discharge planning process. In planning the discharge services, the patient and or family are informed of their right to choose among the participating provider and when possible, their preference are respected when they are expressed.

Based on record review and interview the facility failed to reassess the patient's discharge plan for factors that affected the continuing care needs and the appropriateness of the discharge plan for 1 of 11 sampled patients (SP #1).


The findings:

Record review showed that sampled patient (SP) #1 was brought in on 6/17/16 with report of increased respiratory secretions, mild hypoxia and signs of sepsis with tachycardia and fever and was admitted for acute care of sepsis, tracheal bronchitis and acute versus chronic decubital ulcer.

The Case Manager (CM) #2 progress notes showed on 7/6/16 and 7/8/16, that the mother/Proxy is currently in a 1-bedroom apartment and is not in agreement to send pt. to a SNF (Skilled Nursing Facility) and is making arrangement to take pt. (patient) home upon discharge.
On 08/01/2016 another note showed patient ' s mother and Doctor discussed D/C planning. Mother stated that she has found an apartment for which she will get the keys on 08/04/2016 and will be able to take SP #1 home upon discharge.

On 8/3/16, EQ Nurse Coordinator stated that D/C planning to home is unsafe since apartment is located on the second floor without elevator access and that mother was informed and mother voiced her frustration with entire situation and inability to take her son home.
On 8/5/16, DCF hotline called to report questionable unsafe discharge plan. DCF investigator came to evaluate patient at the bedside. The investigator concluded that if the patient has 24-hour care and home health visits then the patient may be discharge to the home with his mother on the 2nd floor without elevation. Late entry was made for 08/08/2016 showed that the supervisor, who after conservation with the EQ supervisor and the DCF worker advised CM that the patient was not cleared for D/C home and instructed her to proceed with referral to subacute facilities.

On 08/12/16, spoke to DCF investigator who confirmed advising patient ' s mother that she was given two weeks to secure safe housing (first floor apartment or upper floor with elevator access) and in the meantime pt. will remain in the facility.

Case Manager #3 progress note showed on 8/24/16, Intensive phone conversation today with pt.'s mom, in order to persuade her to accept son to transfer to SNF for continuous custodial care until ultimately transfer to her home.
Corporate Director of Case Management progress note showed on 9/1/16, long term care facility has accepted pt. for short term placement until housing is obtained on 9/15/16.

On 9/2/16, the pt. was accepted at the Skilled Nursing Facility #3; informed pt. ' s mother/Proxy of transfer to facility within this System while she is awaiting first floor apartment. Mother voiced her discontentment, stating the transfer cannot be done without her consent and she is not in agreement. Explained to mother that consent was not needed for transfer within the system and mother stated that she will sue the facility.

The Corporate Director of Case Management on 10/24/16 at 12:53 PM stated, there were several discussions about the discharge planning; the first option was the mom wants the pt. to go home and the other option was SNF (Skilled Nursing Facility) placement. The problem with the home when the CMS (Children's Medical Services Network) personnel talked to the CM that they are not agreeing with discharge (d/c) home because the mother lives on a second floor apartment (apt.). So we eventually got the DCF (Department of Children and Family) involved, the DCF made an assessment they said we agree that home was not optimal but there was no DCF hold so basically the mom was still able to make the decision. Because of the DCF and Children's Medical Services Network not agreeing to d/c home, so we sent the referral to another SNF. So the SNF said that the pt. was appropriate for their facility but when it was presented to the mom the mom refused. The mom said that she was looking for an apt. on the first floor and she found something in Homestead but it was on the second floor and the first floor will be available on 9/15/16. Eventually because there was now a specific availability of the apt. and we had the pt. who is medically stable for d/c, we referred the pt. to the Long Term Care (facility #3) for evaluation because it's within our health system. When the bed became available, the pt. was transferred to facility #3 which is part of the system and is appropriate for the pt 's level of care. The case manager informed the mom of the transfer but mom disagreed. So we informed her that facility is part of the System and will be able to provide the appropriate care that the pt. needs until the apt. becomes available on the 15th. Because the mom did not want the consent for CMAT (Children's Multidisciplinary Assessment Team) Services which is the authorization for SNF, the stay in the long term care facility #3 was not going to be billed to Children's Medical Services. The system was going to pay for it. We discussed this with our CMO (Chief Medical Officer) and RM (Risk Manager) and we also informed DCF and Children's Medical Services (Network). of the plan to d/c to long term care facility. The pt. was only supposed to stay there until the apartment became available on 9/15/16 but apparently he remained in the facility until his readmission here on 10/17/16.

Open medical record review of SP#1 present admission, the record showed that on 10/17/16 the patient was readmitted from the system's skilled nursing facility #3 due to fever and tachycardia with admitting diagnosis of acute febrile illness. The pt. is currently receiving treatment for antibiotic therapy and the discharge plan is to discharge pt. home with mother with all discharge planning needs.


The policy " Patient Right and Responsibilities " showed that the patient their advocate or their legal representatives have the right to necessary information, in clear and concise explanation, to enable them to make treatment decisions that reflect their wishes.

The policy " Discharge Planning " dated 07/2013, showed Throughout the patient's hospitalization the multidisciplinary team will monitor, coordinate and reassess the patient's progress towards treatment goals and review the discharge plan to determine if the plan is meeting the needs of the patient. The policy also state that patient/family will be involved in the discharge planning process. In planning the discharge services, the patient and or family are informed of their right to choose among the participating provider and when possible, their preference are respected when they are expressed.