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Based on the nature of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING, was out of compliance.

A0820 - Standard: The hospital must arrange for the initial implementation of the patient's recommended discharge plan. As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care. The facility failed to ensure when changes were made to the patient discharge plan, the patient was made aware of the changes and able to prepare to meet their post hospital care needs upon discharge in 1 out of 7 discharge records reviewed (Patient #3). This failure resulted in the patient not having the opportunity to accept and understand the changed discharge plan or instructions prior to leaving the facility.

Based on interviews and record review, the facility failed to ensure when changes were made to the patient discharge plan, the patient was made aware of the changes and able to prepare to meet their post hospital care needs in 1 of 7 discharge records reviewed (Patient #3).

This failure resulted in the patient not having the opportunity to accept and understand the changed discharge plan or instructions prior to leaving the facility.

FINDINGS

POLICY

According to the policy, Discharge Evaluation, Discharge Planning, and Discharge Documentation, The patient and/or the patient's representative will have a role in the discharge planning process and plan. Before the patient is discharge, the hospital informs the patient, and also the patient's representative when it is involved in decision making or ongoing care, of the kinds of continuing care, treatment, and services the patient will need. The interdisciplinary team (IDT) assesses needs in the following areas and identifies resources to meet these needs in the discharge plan, to include, housekeeping and transportation. The finding of the IDT meeting will be discussed with the patient or patient's representative, by the case manager, to allow for continued development of the discharge evaluation and discharge plan. In all cases, the case manager must inform the patient as to their freedom to choose among providers of post-hospital care. Patient preferences should be considered regarding their choice of services. For patient's discharge home, a brief description of care instruction's reflecting training provided to patient and/or family or other informal caregivers.

According to the policy, Discharge Criteria, case management will inform the patient and/or family/caregiver of expected discharge date throughout the stay. All clinical disciplines will provide training and education to the patient, spouse/significant other, or identified caregiver on the diagnosis, treatment plan, medications, and follow-up plan of care.

1. The facility failed to ensure Patient #3 was notified of his/her discharge prior to leaving the facility.

a) Review of Patient #3's medical record revealed, the patient was admitted to the facility on 06/21/17 and discharged on 09/07/17. Patient #3 had a history of paraplegia with a colostomy and suprapubic catheter present for elimination. S/he was admitted for care of an open infected wound with intravenous antibiotic therapy and pain management with a projected discharge of 4-6 weeks.

b) On 01/03/18 at 12:13 p.m., an interview was conducted with Physician Assistant (PA) #1 who provided the order for discharge for Patient #3. PA #1 stated the process for discharge included the interdisciplinary team (IDT) taking one to two days to establish the discharge date, arrange a definitive place to send the patient, and inform the patient of the plan as well.

PA #1 stated neither the IDT, nor the patient, had previously planned for him/her to be discharged on 09/07/17 and stated no definitive post-discharge placement had been arranged between the case manager and the patient. PA #1 further stated Patient #3's discharge was not a typical discharge process because the patient was essentially "discharged to the street." This was in contrast to facility policy.

c) On 09/07/17 at 5:45 p.m., Case Manager (CM) #3 documented, on the CM progress notes, Patient #3 was deemed medically stable and appropriate for discharge by the physician. CM #3 further documented Patient #3 was in a wheelchair, brought outside and given discharge instructions. Present outside the facility for the discharge was Physician #2, Physician Assistant (PA) #1, CM #3 and Security. CM #3 documented information given to the patient included a list of shelters along with a first come first serve clinic for follow up wound care. Patient #3, while outside called his/her mother and explained s/he was being discharged. Patient #3 was given a cab voucher to a hotel.

d) On 01/02/18 at 4:44 p.m., an interview was held with CM #3 who documented Patient #3's discharge. CM #3 stated the IDT and Patient #3, were unaware the patient would be discharged on 09/07/17. According to CM #3, Patient #3 was already outside of the facility in a wheelchair when the patient was informed s/he was discharged. CM #3 stated once Patient #3 was made aware of the discharge, Patient #3 contacted a hotel and arranged post hospital accommodations. CM #3 reviewed Patient #3's medical record and confirmed the discharge instructions were not signed by the patient and could not confirm the patient acknowledged understanding of the discharge instructions provided.

e) According to nursing daily care notes on 09/07/17 at 1:30 p.m., Patient #3 was with physical therapy. The next entry documented at 2:00 p.m., identified the patient was discharged. On review of the daily care notes for 09/07/17, no documentation revealed Patient #3 was aware, instructed or educated on being discharged or post hospitalization care.

f) On the Discharge Order and Instruction form dated 09/07/17, there was no documentation Patient #3 acknowledged the discharge instructions, understood the instructions provided or was given an opportunity to ask and have answered any questions the patient had. This was in contrast to facility policy.

Review of the discharge order and instructions form revealed, no documentation of instructions or education was provided to Patient #3 on his/her final diagnosis, a brief history of treatment provided by the facility and no instruction from the pharmacist -on medications the patient was to continue to take post hospitalization. This was in contrast to facility policy.

Included in the discharge instructions CM #3 documented the facility was to pack up and inventory Patient #3's belongings and coordinate with the patient's family for pick-up of the items. CM #3 further documented Patient #3 was provided a list of shelters to include the homeless shelter; which, according to CM progress notes, documented on 08/11/17 by CM #3, had denied the patient as appropriate for the shelter.

g) On 01/03/18 at 2:39 p.m., an interview was conducted with Physician #2 who was an attending physician for the facility and provided supervision of care for Patient #3. Physician #2 stated patients should be provided discharge paperwork and education in the patient's room prior to leaving the facility. Physician #2 stated Patient #3 was not made aware s/he was being discharged until Patient #3 was taken outside the facility on 09/07/17. Once outside the facility, Physician #2 went outside to meet the patient and give him/her the discharge paperwork.

h) On 01/03/18 at 4:01 p.m., an interview was conducted with the Chief Executive Officer (CEO #4) who had oversight of all facility operations. CEO #4 confirmed case management involved in the care of Patient #3 was hesitant of the patients discharge because the patient was awaiting for housing arrangements to be set up.

CEO #4, stated s/he was unaware the patient was provided discharge information outside of the facility. CEO #4 stated the expectation was that all patients receive necessary discharge documents and education prior to being discharged outside of the facility in order to ensure proper continuity of care.