HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to implement a safe and effective discharge plan for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy "Discharge Planning" revealed, "...MISSION: To improve the health and well-being of the communities we serve while providing exceptional and compassionate care. PATIENT RIGHTS: It is the right of the patient, in collaboration with his/her physician, to make decision regarding his/her care including reasonable continuity of care. Patient discharge/transfer policies are not based on patient or organizational economics...PURPOSE: ...To facilitate a discharge that will be...efficient, safe and comfortable for the Patient...GOALS:...To implement a patient-centered approach that will maintain or improve their condition after discharge and focus on patient/family concerns and accomplishments...Procedure...8. Patient/family education is an integral part of care for the Patient/family and is the responsibility of the multi-disciplinary team...10. Special discharge planning conferences may be scheduled when indicated because of complexity, problems, or special concerns.."

2. Patient #1 presented to the Hospital Emergency department on 5/12/2023 from a skilled nursing facility with a chronic foley catheter and hematuria. Patient #1 had a recent history of a spinal cord infarct C4 (the fourth vertebrae in the cervical [neck] area of the spinal column) -C7 (the seventh vertebrae in the neck area of the spinal column) resulting in weakness of the right upper and lower extremity. Patient #1 required occupational and physical therapy services due weakness and immobility during his hospitalization. Patient #1 had a stage 4 sacral decubitus ulcer measuring 10.5 centimeters (cm) X 5 cm X 3.5 cm upon admission. Patient #1 was discharged to a local motel alone on 6/1/2023 with a referral for Home Heath services, 4 bags of food, a wheelchair, a rolling walker and follow up appointments for Urology and the outpatient wound care clinic. Patient #1 was not independent in his Activities of Daily Living (ADLs). A safe discharge plan was not implemented by the hospital, when Patient #1's family refused to take Patient #1 into their home for post hospital care.

Refer to A 802

Based on policy review, medical record review and interview, the hospital failed to re-evaluate the discharge plan when the discharge disposition changed due to lack of family support, and therefore failed to implement a safe and effective discharge plan for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy "Discharge Planning" revealed, "...MISSION: To improve the health and well-being of the communities we serve while providing exceptional and compassionate care. PATIENT RIGHTS: It is the right of the patient, in collaboration with his/her physician, to make decision regarding his/her care including reasonable continuity of care. Patient discharge/transfer policies are not based on patient or organizational economics...PURPOSE: ...To facilitate a discharge that will be...efficient, safe and comfortable for the Patient...GOALS:...To implement a patient-centered approach that will maintain or improve their condition after discharge and focus on patient/family concerns and accomplishments...Procedure...8. Patient/family education is an integral part of care for the Patient/family and is the responsibility of the multi-disciplinary team...10. Special discharge planning conferences may be scheduled when indicated because of complexity, problems, or special concerns.."

2. Medical record review for Patient #1 revealed a 45 year old male transported via Emergency Medical Services (EMS) on 5/12/2023 from a skilled nursing facility with complaints of bleeding from his penis. Patient #1 had a foley catheter. The EMS narrative revealed, "...The patients symptoms started suddenly when the nurse flushed his catheter...Patient is oriented to person, place and time...transported emergency to [named Hospital #1 for emergency services from a urologist]...Patient #1 care was transitioned to Hospital #1's ED [Emergency Department] staff on 5/12/2023 at 6:30 AM."

Review of the Physician documentation from Hospital #1's ED revealed a medical screening exam was initiated at 7:00 AM with chief complaints of hematuria (blood in urine). The ED Physician documented, "Patient presents to the emergency room via EMS from [named skilled facility] . Patient with spinal cord infarction. He has limited range of motion. He has a sacral ulcer. He has a chronic foley catheter. This was changed last night. When the new catheter was reinserted, patient had gross blood. He is [has] had gross bleeding from the penis since then. He is on blood thinners for pulmonary embolism..." Patient #1 had lab work and a urinalysis in the ED. The ED Physician discussed the case with a hospitalist and Urologist. The ED Physician documented, "...Escalation of care considered Admission indicated, patient workup resulted criteria for observation/admission to the hospital. Brief synopsis patient with hematuria. Three-way Foley catheter placed (function like regular Foley catheters except that they have a third channel used to irrigate the inside of the bladder) and bladder irrigated with 6 liters of glycine. Initially, urine turned a light pink color. Never totally cleared...when irrigation was discontinued, gross blood returned...Infection may be present as well...Discussed case with Urology who will see in consult. Medicine is admitting..." Patient #1 was admitted to Hospital #1 on 5/12/2023 at 4:34 PM.

Review of the History and Physical Exam dated 5/12/2023 at 2:15 PM revealed,"The patient is a 45-year-old complicated Caucasian gentleman sent to the emergency room from [named facility] for gross hematuria. Patient has a chronic indwelling Foley catheter for neurogenic bladder. He is anticoagulated apixaban for DVT [deep vein thrombosis] and PE [pulmonary embolism] Admitted on November 4 [named another hospital in (named city)] and transferred to [named another hospital in (named city)] November 5. Patient stayed there 2 months. He was diagnosed with a spinal cord infarct C4-C7. He has weakness of the right upper and lower extremity. He is max assist and has been able to stand up only twice since his discharge [from hospital]. He says he is had at least 2 to 3 urinary tract infections while in the facility. Also has a stage IV sacral decubitus ulcer...Plan: Patient admitted to telemetry...Gentle IV fluid hydration. Empiric IV ceftrtiaxone and tailor to results of urine culture and sensitivities...Serial hemoglobin in light of hematuria. Blood product support as needed to keep hemoglobin above 7. SCDs and DVT prophylaxis..."

Review of physician orders dated 5/12/2023 at 5:21 PM revealed clean wound with soap and water or bath wipe, moisture barrier... change three times a day and as needed- when there is soliage, gently remove the stool and/or excess barrier with soap and water or bath wipe. Do not scrub the skin.

Review of physician orders dated 5/12/2023 at 5:23 PM revealed Apply wet to dry dressing, clean with wound cleaner twice daily.

Review of physician orders dated 5/14/2023 at 1:36 PM revealed clean wound with wound cleaner, moisten packing with wound cleanser twice daily.

Review of wound care documentation revealed the wound ostomy nurse assessed Patient #1 on 5/14/2023 and documented the sacral wound at Stage IV measured 10.5 centimeters (cm) X 5 cm X 3.5 cm with undermining depth 6 with closed well defined edges.

On 5/22/2023, the wound ostomy nurse documented sacral wound as Stage IV measured 9 cm X 4 cm X 3 cm with undermining depth 6 with a small amount of Serosanguineous exudate, and well-defined edges.

On 5/30/2023, the wound ostomy nurse documented sacral wound as Stage IV measured 8 cm X 4.5 cm X 3 cm with undermining depth 5.5 with a small amount of Serosanguineous exudate, and well-defined edges.

Review of Social Service/Case Management notes revealed the following:
5/14/2023 at 3:35 PM- "...Spoke with pt. [patient], he stated he plan to return to [skilled facility he was residing at prior to hospital admission] at d/c [discharge] Referral sent..."

5/15/2023 at 3:45 PM- "SW received cosnult [consult] for financial assistance. SW met with pt in room. pt stated that he has no insurance and has a very large bill at [named skilled nursing facility where patient was residing prior to hospital admission]. pt has no insurance so he is not receiving PT [physical therapy] services. pt was very impressed by what PT was able to do in hospital and wants to know if he would be able to transfer to [named a specific Rehab hospital]. pt stated that if he could walk again, he will be able to stay with his aunt...SW left voicemail with director [named CM Supervisor] for guidance [guidance] on this..."

5/18/2023 at 12:20 PM-"Pt was denied Medicaid per facility. [skilled Nursing facility patient was residing at prior to hospitalization] stated that if pt pays 30 day up front, they will accept pt back. pt stated that he only has 19,000 to his name. pt has a home, but his ex-girlfriend lives there and he has an order of protection to stay away from her. pt aunt cannot let him live with her due to him not being able to take care of himself. Pt brother works 4 am to after 5 pm and is unable to care for him. pt cannot clean himself and is unable to tell when he needs to use the restroom. pt has motor-wheelchair with cushion. pt states he has no one take help take care of him and no where to go. Pt states he also does not have transportation to wound care. SW also provided pt with indigent forms to complete. SW sent email to Social Services Management [Management]."

5/18/2023 at 4:19 PM- "Per [Skilled Nursing facility] [named Patient #1] will be required to pay $7,905 up front and work out a payment plan with billing for the total owed bill of $31,620. SW will discuss this with pt tomorrow morning and detrimine [determine] dc [discharge] plan."

5/19/2023 at 11:50- "SW spoke with pt in room. SW explained that a DC needed to be made. SW explained that pt can either go to [skilled nursing facility where patient was residing prior to hospitalization] and pay the upfront cost and make a payment plan for the owed bill (pt refuses to go back) Sw stated that pt can go to another facility but upfront bill will have to be paid and their has to be a dc plan in place. SW explained that sw can arrange a family meeting by phone for pt aunt, brother, and himself to discuss a dc plan. Pt stated it would not matter and that no one can take him due to them working or not able. Pt then stated either way, pt does not feel comfortable returning home when he is still bleeding [blood in urine]. Pt wanted urology to be consulted again. SW notified ID [Infectious Disease] and DC huddle team during de huddle. SW following for updates on urology. SW will also set up phone call meeting with family and pt."

5/19/2023- 2:40 PM- "SW contacted [named Patient #1's brother] and discussed dc plan options. [Patient #1's brother] stated that they- him and his wife are very concerned about the pt bed wound...stated he had no idea how to clean and take care of it. But he is willing to learn. However, he is concerned that pt will be alone for over 12 hours per day and no one will be able to change pt when he has a BM [bowel movement]. [Patient #1's brother] is also concerned that there is no way to get pt to wound care...asked if there was any way to have wound care brought to home...also option for day nursing? SW will ask HH [home health] if these are options. SW following...will provide information to Supervisor."

5/19/2023 at 3:51 PM- CM [Case Manager] received request from SW asking if patient could pay up front for HH nursing and PT...CM spoke with [named home health agency affiliated with Hospital #1] states they could not take. CM spoke with patient at bedside. He gave permission for CM to send referrals to all HH companies that cover area...Sent each company a message asking if private pay would be an option..."

5/22/2023 at 12:40 PM- "SW contacted [named Patient #1's brother] and discussed dc plan options. SW had CM come into office and explain over the phone all HH prices and what they offer. CM also explained other options of Inpt [Inpatient] rehab and Select hospital option, however, that is a more difficult option that may not happen. Brother was understanding. Brother is willing to bring pt home at dc when medically ready. He just asks to be shown how to care for cathader [catheter] and wound care. Per DC huddle, pt is not currently medically ready for dc. SW following."

5/22/2023 at 2:06 PM- "Difficult discharge plan. CM spoke with pt at bedside and made him aware that [named a HH agency] has agreed to accept him but he would have to pay up front for 2 weeks...Pt states HH isn't worth it and he isn't going to pay for that. CM explained another option for be for pt to go to [named outpatient wound clinic for infusion]...Pt states that's not an option because everyone he knows works. CM explained that it might be where someone might have to take off work for a couple of days or hours to help him get to and from. Pt states no one can do that. CM explained at this point, CMs hands are tied as pt has no insurance and pt not being agreeable to any options CM has presented. CM asked pt about the IC [indigent care] paperwork that he was presented with. Pt states he doesn't have a pen. CM asked pt if he asked for a pen. Pt also states he can't fill it out on his own. CM asked if he had asked for help. States he is interested in private paying at [named rehab hospital affiliated with Hospital #1]...CM made [named rehab hospital affiliated with Hospital #1] aware. CM went to update SW in her office and she was on the phone with pts brother...CM laid everything about for pts brother. At this point, the only option for CM to arrange anything to help pt is for them to pay for HH and IV antibiotics. Pt brother asking about price for [named rehab hospital affiliated with Hospital #1]...Pt brother asking for an email with an explanation of everything. [named rehab hospital affiliated with Hospital #1] denied pt as he has an outstanding balance at another facility. CM spoke with CM Director...who states since pt does have assets, the hospital will not pay/make contract with a facility. ONLY option for pt at this time is either going home with [named outpatient wound and infusion clinic] OR going home with HH and IV antibiotics...Pt's brother states that he would like to think about this information and present it to pt. States it comes better from him and pt is more receptive to him than us. CM sent secure email to pts brother including the SW, with all of the prices and the 2 options."

5/22/2023 at 2:15 PM- "Pt's brother asking about appealing Medicaids decision and that process [insurance denial] CM asked [skilled nursing facility patient was residing at before hospital admission] and they state that pts family can call the facility and talk with someone about that. Pt brother asking for IC information...CM sent secure email to [named representative with IC contracted by hospital to assess for resources]..If pt 100% IC approved, CM could arrange services..."

5/23/2023 at 11:17 AM- "...spoke with pts brother...regarding DCP [discharge plan]...states they do not want to spend money on HH for the level of care they will be getting...CM explained since no HH, he will have no help at home...asking about a CHOICES [Medicaid eligible in home care services] CM explained pt does not have Tenncare and you have to have the insurance to use their program...[Patient #1's brother] states that him or his wife is going to have to quit their jobs to take care of the patient and they aren't really wanting to do that as they still need to provide for their family.. CM explained that could go on today and apply for pt insurance and that would help tremendously. [Patient #1's brother] stating pt has no more money left, only has $1000 to his name...DCP at this time is to dc home with pts brother..."

5/30/2023 at 11:12 AM- "Pt states he now has insurance...CM sent a secure email to UR [utilization review] for insurance verification team to be notified. Pt states he is interested IPR [inpatient rehab]...CM explained that CM already checked with [named specific rehab hospital] and they stated since pt has an outstanding bill at another facility, they were unable to accept ....Pt very rude and aggressive towards CM...Pt states if he is unable yo go to IPR, he will return to [named skilled facility patient was residing at prior to hospitalization]. CM explained that CM unsure if he is able to do that as the facility has already stated they will not accept pt back...Pt says they can not legally do that..."

5/30/2023 1:03 PM- "..insurance verification has tried to look up the policy number that pt provided but unable to find anything. IPR is not an option as pt has no insurance, wounds, and DCp per liaisons...CM updated SW as pt states he is going to return to [named skilled nursing facility he was residing at prior to hospitalization]..."

5/30/2023- 2:47 PM- "CM made MD aware that if pt is medically ready for dc, he can place dc order. At this point in time, pt is self pay and there are no other options for dc for pt. Pt and family can continue on working on getting insurance and getting to a facility from home..."

5/30/2023- 3:24 PM- "SW explained to pt that insurance is not showing active...Pt also stated he would like a sit down meeting with his brother, pt., Sw and administrator. SW explained that this will need to be scheduled and that everyone cannot stay at the hospital until his brother gets off work at 6 pm tonight..."

5/31/2023- 11:23 AM- "Pt chart updated to show pt new insurance. SW sent referrals to [named multiple nursing facilities in the area]..."

5/31/2023 at 11:53 AM- "CM asked [named representative at a Inpatient Rehab facility in (named city)] to reval [re-evaluate] pt since new insurance...per [name representative] pt has a limited coverage insurance that has no IPR benefits..."

5/31/2023 at 12:15 PM- "CM called pts insurance...Pt also has no SNF [skilled nursing facility] benefits...will ask SNFs if we can do a one time agreement [between hospital and facility to pay for SNF care]..."

5/31/2023 at 1:20 PM- "SW met with pt at bedside. SW explained that sent referrals to local SNFs. pt stated he does not want SNF and to stop pursuing it because they cannot give him intensive therapy like he wants. SW explained that pt does not have rehab benefits. pt again stated hospital can send him back to [skilled nursing facility where patient was residing prior to hospitalization] and demand they take him back. SW explained that is not how it works, SW cannot make a facility accept someone...He states SW cannot just put him on the street and not have a safe dc plan SW explained that a safe DC plan was offered in multiple options. Pt is refusing to do HH, SNF, or pay to go to [skilled nursing facility where patient was residing prior to hospitalization]...SW sent [named internal messaging system] to MD [Medical Doctor] explaining that SW is no longer able to assist and can no longer assist in DC options due to pt refusing."

5/31/2023 at 2:17 PM- "SW spoke with [Patient #1 brother]...explained all options and that pt will need to dc to [skilled nursing facility where patient was residing prior to hospitalization] paying upfront or pt will be dc home. Brother is refusing and asking to speak with supervisor and pt advocate. SW provided brother number to supervisor..."

6/1/2023 at 11:00 AM- "cm director called and spoke with patients brother...brother was updated that when the MD thinks patient is medically ready, he will put in a discharge order and we will try to get him what assistance we can but we are very limited as the insurance he purchased doesn't have any benefits. he stated he was told it had rehab benefits. he was assured we had contacted them [insurance] and it does not. he ask for the number to the insurance company and it was given...."

6/1/2023 at 2:00 PM- "CM director, dc advocate and case manager went to inform patient of a discharge order, patient was informed that he has a discharge order and we will be happy to get him equipment, wound care supplies, HH if he is agreeable and we could assist with paying for it...cm director informed patient he would be discharged today."

6/1/2023 at 2:38 PM- "SW was made aware that pt brother is not taking pt into his home at this time due. SW contacted [named representative at a local motel] and stated that pt would need a low level floor from 6/1/2023- 6/8/2023. SW completed hotel form. SW gave hotel form to nurse for DC and instructed that it is given to the receptionist at hotel..."

6/1/2023 at 2:50 PM- "CM provided pt nurse with 4 food bags to provide to pt when he is being discharged..."

6/1/2023 at 4:29 PM- SW picked up medication from pharmacy and provided it to nurse to give pt..."

6/2/2023 7:22 AM- "LATE ENTRY for 6/1...CM asked ID [infectious disease physician] if she was willing to sign HH for pt until he is able to follow up with PCP [primary care physician]..ID asked if he is going to a NH. CM explained that family has refused to take him home, so hospital is placing pt in a hotel, as medically ready to dc. ID asking if he will have a low air loss mattress at the hotel and if HH will provide wound care daily. CM explained that pt and pt family want pt to stay in the hospital but pt has no IPR/SNF/HH/DME benefits for we are unable to arrange anything...explained that CM is not able to arrange a low air loss mattress. CM explained pt provided with wheelchair and rolling walker. CM explained that pt has an electric wheelchair and a roho [pressure relief cushion for seat] cushion of his own that he bought. CM also explained that HH would not go daily, but pt has an appointment with [outpatient wound care clinic]. CM explained that pts brother was made aware he needed to be educated on wound care but he refused. ID stating she is unsure if she wants to sign HH [orders] and she would speak with me tomorrow CM also received a call from A4 Clinical Manager stating that another family member has shown up [to refuse discharge of Patient #1]...we will proceed with dc to hotel... Pts family member then states that no one spoke to her or the brother regarding DCP. CM advised the clinical manager if necessary, they call security...that family member is hindering dc..."

Review of the discharge summary date 6/1/2023 revealed "...Hospital course...Patient admitted and seen by urology for his hematuria which was felt due to foley trauma. Urine cleared over time with irrigation...Started on ceftriaxone for UTI [urinary tract infection] pending cultures. Cultures ultimately resulted in resistant Proteus and Providencia. ID consultation obtained and antibiotics changed ...to cover both organisms (completed course on 5/29/2023) After clearance of hematuria his home apixaban was started without complication. A few days after restarting apixaban, the patient started having hematuria again for which apixaban was held...Cystoscopy done showed mild bladder inflammation, no tumor, and a healed lesion in the bulbar urethra which was felt to be the likely initial source of the bleeding, but not so clear the source of the bleeding once put back on apixaban. Out of concern for rebleeding if put back on apixaban and need to treat DVT/PE, considered that the patient had been treated for DVT/PE over 6 months. Reimaged the patient to find no evidence of central PE or DVTs bilaterally. Pulmonary consulted for additional guidance on anticoagulation IVC [Inferior vena cava ] filter placed (An IVC filter is a small device that can stop blood clots from going up into the lungs)...Although the patient had been treated for more than 6 months and without signs of VTE [Venous thromboembolism] (a term referring to blood clots in the veins), his mobility is extremely limited currently. With increased mobility, maybe more reassuring to not treat him in the future with anticoagulation and consider IVC retrieval. Chest CT [Computerized Tomography] also noted a LUL [left upper lobe] nodule that pulmonary will follow up outpatient ...Follow up with pulmonary and Interventional Radiology appointments made prior to discharge. Follow up also made for urology in the setting of chronic foley catheter. Follow up care also set up for outpatient wound care clinic of sacral wound. Follow up with PCP as well. Disposition: Per progress note from 5/31/2023 Medically clear but dispo [disposition]difficult. Discharged from NH [nursing home] they will not take him back; he has a balance of charges with them. Patient feels that the NH broke federal rules in discharging him which he is contesting. Did not have insurance to provide for alternate dispo. He has supportive brother who needs more supports to take the patient in. During the hospitalization the patient obtained a new insurance which was confirmed on 5/31 and is being pursued now for possible placement. However, insurance has no SNF/Rehab benefit...On day of discharge (6/1/2023) patient vitals were stable...comfortable on physical exam Discussed with patient his medical clearance, he voiced understanding that he is medically clear. He also voiced concerns over lack of SNF/HH benefits and thought that he should qualify for post acute benefits. Social services addressed patient concerns, refer to social services notes for further details...Discharge Diagnosis and Plan...Patient Discharge condition: Stable Discharge Disposition Home/Self Care..."

Review of a nursing note dated 6/1/2023 at 5:52 PM revealed, "Pt with discharge order in this afternoon. Pt and family fighting discharge. Attempted to go over education with pt but he refused. Reviewed wound care orders with brother. Pt left via wheelchair van escorted by security to EMS van. I personally walked down and made sure pt's belongings, wound care supplies and food supplies."

Review of the discharge instructions and follow up appointments for Patient #1 revealed the hospital arranged an appointment at Hospital #1's outpatient wound care center for 6/5/2023 at 7:45 AM and a follow up appointment with Urology on 6/9/2023 at 2:00 PM. There was no documentation Patient #1's family was available to provide the transportation to the required follow up appointments. Patient #1 was unable to drive himself due to physical impairments, and did not have insurance to assist in payment for transportation services.

3. Review of electronic communication between the Executive Director of Case Management and the Hospital #1's Home Heath Agency Care Coordinator revealed Hospital #1 arranged to pay for home health nursing and physical therapy for Patient #1, while residing at the motel from 6/1/2023 through 6/8/2023.

4. During an interview with the Case Management and Social Services team involved with discharge planning for Patient #1 on 6/5/2023 at 1:30 PM, The Executive Director (ED) of Case Management stated Patient #1's brother refused to take him home and discharge to a hotel was the only option. The ED of Case Management stated the hospital paid for a hotel for 1 week, provided transportation to the hotel, scheduled a wound management appointment, provided wound supplies, paid for the hospital affiliated home health agency to follow up with patient at hotel, and provided 4 bags of food, a walker and a wheelchair. When asked if there was a policy to address discharging a patient to a hotel for short term housing, the ED of Case Management stated there was no policy. The Director of Case Management stated the patient and family did not like the discharge plan, but the brother refused to take the patient. The ED of Acute Care Service stated, "It was a safe discharge plan..."

During a telephone interview on 6/5/2023 at 1:55 PM, Patient #1's brother stated Patient #1 was discharged to a motel on 6/1/2023, he had inability to walk, had a foley catheter and a pressure sore on his sacrum, and the hospital made a referral for home health to come visit 2 times per week. Patient #1's brother stated Patient #1 had paralysis to his right hand and limited range of motion on his right side as a result of a stroke in November 2022. Patient #1's brother stated Patient #1 was unable to care for himself and unable to stand without assistance, but the hospital discharged him to a motel that the hospital paid for one week. Patient #1's brother stated they transported his brother to the motel in a van with 4 bags of food including, "granola bars he [Patient #1] can't open, a jar of peanut better he can't open, cans of soup, he can't open..." Patient #1's brother stated he and his wife had to work full time and were not able to take his brother to his home and he explained that to the hospital social worker. Patient #1's brother stated his brother lost his private insurance and had been denied for TennCare due to owning a home. Patient #1's brother stated he purchased insurance for his brother while he was hospitalized but he was told it did not cover skilled facilities, or rehabilitation hospitals. The nursing facility Patient #1 was in prior to this hospital admission refused to take Patient #1 back because he had a large balance, due to no insurance coverage. Patient #1's brother stated he went to the motel to check on his brother on 6/1/2023 at approximately 4:00 PM. Patient #1's brother stated there was mold, mildew and cockroaches in the motel room and the linens on the bed were dirty. Patient #1's brother stated he had to get another tenant at the motel to help him get Patient #1 into a wheelchair. Patient #1's brother reported Patient #1 required a 2 person transfer. Patient #1's brother stated, "I took him home...could not leave him there..." Patient #1's brother stated he told the hospital 2 weeks ago he was not able to take Patient #1 home because both he and his wife work full time. He stated he and his wife don't know how to do catheter care. Patient #1's brother stated Patient #1 was getting no in home services because the insurance does not cover it. Patient #1's brother stated, "He [Patient #1] can't get up without assistance, can't even clean himself up if he has a bowel movement and he has to have help getting into a wheelchair..."

During an interview on 6/6/2023 at 9:35 AM, Occupational Therapist (OT) #1 verified she competed Patient #1's initial OT evaluation on 5/16/2023 and provided therapy services to Patient #1 several times during his hospitalization. OT #1 stated she did not know Patient #1's baseline but she felt like he made progress in OT therapy while hospitalized. When asked if she felt it was safe for Patient #1 to be discharged to a motel alone she stated "I don't feel comfortable answering that." OT #1 verified Patient #1 required stand by assist, and described stand by assist as "You are not touching the patient but you are present." OT #1 verified her discharge recommendation on each of her therapy notes was to a rehabilitation facility.

During an interview on 6/6/2023 at 9:47 AM the Director of System Accreditation stated Patient #1 had family that could check on him at the hotel. She further stated, "they [family visited him at the hospital so we knew they were available..."

During an interview on 6/6/2023 at 9:55 AM, the Director of System Accreditation stated Patient #1's discharge was not based on economics. The Director of System Accreditation stated "He [Patient #1] was medically stable for discharge...we had arranged all potential care..set up appointments." The surveyor asked how Patient #1 was to be transported to the wound care center appointment. The Director of System Accreditation stated the family members agreed to transport him to necessary appointments. The surveyor asked for documentation that the family agreed to transport Patient #1 to his appointments when he was discharged to the motel. The surveyor was not provided any documentation related to the family being in agreement with the discharge to a local motel or that they would provide transportation to the outpatient wound care center. Patient #1's brother lived in another town and worked full time driving a gravel truck.

During an interview on 6/6/2023 at 10:07 AM, PT #1 verified she completed Patient #1's initial PT evaluation on 5/14/2023 and provided PT services to Patient #1 on 5/25/2023. PT #1 verified Patient #1 used the hospital bed rail for bed mobility. When asked how he would perform bed mobility without a bed rail, PT #1 stated, "It would take more time if he didn't have a rail...I can't say if he could do it without a bed rail...I can just tell you that was our goal in therapy. PT #1 stated she did recommend a skilled unit for continued rehabilitation services at discharge. Pt #1 verified on 5/25/2023 she documented Patient #1 required "Needs Practice/supervisor for Bed to Chair transfers" When asked to describe what that meant she stated, "Needs to practice with the therapist." PT #1 verified on 5/25/2023 she documented Patient #1 required "a lot" of help to move to and from the bed to chair and "a lot" of help to stand up from chair using arms and "a lot' of help to walk in the room. PT #1 stated a lot of help in those areas meant Patient #1 required moderate to maximum assistance with those activities of daily living. When asked if a discharge home alone was safe for Patient #1, PT #1 stated, "All I can tell you is what I recommended on 5/25/2023...was rehab facility..."

During an interview on 6/6/2023 at 11:48 AM OT #3 verified she provided therapy services for Patient #1 on 6/1/2023, the date of discharge. When asked about her documentation that the patient required "supervision or set up" for grooming, OT #3 stated, "bring it to him ....comb, toothbrush, patient was in the bed at that point." OT #3 stated she did not know if Patient #1 was able to transfer from the bed to his wheelchair independently. OT #3 stated 6/1/2023 was the first date she provided therapy for Patient #1. When asked to explain what "Modified Independence" for bed mobility in her note meant, she stated, "No physical assistance needed but he did use the bed rail." When asked how Patient #1 would manage bed mobility without a hospital bed/bed with rail, OT #3 stated, "I'm not sure what he would do." OT #3 stated Patient #1 sat up independently by using the bed rail. OT #3 stated Patient #1 did not have the full use of his right hand. OT #3 verified she documented Patient #1 required "A little" assistance bathing, putting on his upper body clothes and personal grooming. OT #3 stated, "Patient #1 was not totally independent, or I would have put "none" [indicat