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Based on policy review, record review, and interview the hospital failed to ensure staff re-evaluated a patient's condition to identify changes that may require modification of the discharge plan for 1 (Patient 2) of 8 patient reviewed. This deficient practice places the patient at risk deterioration of current illness, ineffective transition of care from hospital to post discharge care, and possible hospital readmission.

Findings Include:

Review of facility policy titled "Discharge Planning: Patient Choice for Post-Acute Providers/Services Upon discharge" effective July 1, 2021. ..."Policy: A Hospital, as part of its effective Discharge Planning process, must focus on the patient's goals and treatment preferences and include the patient (and/or the patient's representative) and his or her caregivers/support persons as active partners in the discharge planning for post discharge care. The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from the hospital to post discharge care, and reduce the factors leading to preventable hospital readmissions."

Patient 2

Review of Patient 2's discharge medical record showed 68-year-old presents to the emergency department (ED) post cardiac arrest. Patient 2 took Macrobid (antibiotic) and she was found unresponsive on the floor in her house after taking the medication. Emergency Medical Services (EMS) showed she was in Pulseless Electrical Activity (PEA- unresponsiveness and impalpable pulse) on arrival. Patient 2 was admitted to the hospital on 03/17/23. The record showed Patient 2 was alert to self, repetitive questioning, and moved all extremities. Further review of the record showed, Patient 2 had hereditary spastic paraplegia (HSP) (progressive spasticity and weakness in the lower limbs) with intrathecal (fluid filled space between the thin layers of tissue that cover the brain and spinal cord) baclofen (muscle relaxer) pump.

Review of discharge planning evaluation dated 03/17/23 at 4:43 PM by Staff J, Licensed master social worker (LMSW) showed information obtained from Medical records and interdisciplinary team "ADL Limits: mobility or ambulation. Discharge barriers: None or NA. Discharge discussed with care team. Patient Representative agrees with discharge plan: "No."

Review of case management note dated 03/17/23 at 4:43 PM by Staff J, LMSW showed "Chart review as Pt just coming from in from ED. Patient apparently had Cardiac Arrest but woke up and all is well. Patient had reaction to a new medication. Anticipate discharge home soon with no needs."

Review of Patient 2's physician orders dated 03/17/23 at 6:44 PM showed an order for Occupational therapy (OT) to evaluate and treat, indication Post Cardiac Arrest for strengthening and therapeutic exercise.

Patient 2 did not receive an OT evaluation prior to discharge to assess for any deficit's status post cardiac arrest

Review of Patient 2's physician orders dated 03/17/23 at 7:19 PM showed an order for Physical Therapy (PT) to evaluate and treat: indication Post Cardiac Arrest, Gait/transfer training, Range of motion, Balance training, and strengthening.

Patient 2 did not receive a PT evaluation prior to discharge to assess for any deficit's status post cardiac arrest.

Review of case management note dated 03/24/23 at 4:13 PM by Staff Q, case manager "Received call from patient post discharge (DC) home. She states that she was discharged to home with Home Health Services (HHS) and it was not set up. Patient did not work with [PT/OT], and she did not have a consult order for them. Patient DC order is for home, self-care. Patient stated that her HSP she needs HHS. Informed patient that since she did not have an HHS order she would need to speak with her primary care physician (PCP) and they will be able to arrange HHS post DC. Patient provided list for HHS. Patient is tearful and stated she felt like this should have addressed and felt as she rushed out of the hospital. Patients concerns sent to Staff R, Patient Advocate to follow up with patient."

During an interview on 05/03/23 at 3:03 PM, Patient 2 stated that she had several concerns regarding her discharge. Patient 2 stated that she did not see anyone other than the doctor telling her she had to discharge. Patient stated that she felt rushed out of the hospital. Patient 2 stated that she had a catheter, and they did not assess whether she could go to the bathroom prior to discharge. She stated that they did not assess her for pain or send her home with any pain medication. Patient 2 stated that they did not provide any information on how to take care of her ribs. Patient 2 stated that she did not remember everything but does not believe anyone from case management talked with her or her spouse. Patient 2 stated that when she called the hospital, they stated that I would have to call my primary care physician.

During an interview on 05/03/23 at 11:30 AM Staff J, LMSW stated that she sees every patient in the ICU and patient that are considered high risk is anyone over 70, and that she makes them priority. When asked about Patient 2 and being sent home without home health services. Staff J stated that she didn't remember the patient but if it was a Friday afternoon it may not have been a thorough assessment.

Review of Patient 2's medical records showed an order for PT/OT evaluations, but Patient 2 was not evaluated by PT/OT prior to discharge. The case manager/social worker did not reevaluate the patient for any changes to Patient 2 discharge plan or check to see if PT/OT had evaluated the patient. Staff J, LMSW did not physically assess the patient, she completed the initial discharge planning evaluation based on a chart review and communication with the interdisciplinary team. Patient 2 and spouse were not involved with the discharge planning process or evaluation and were not provided an opportunity to share their concerns regarding discharging to home status post cardiac arrest.