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Based on interviews with Patient Family Representative (Rep), staff interviews, and review of Electronic Health Record (EHR), the facility failed to ensure the patient's right to be informed of his/her health status to make an informed decision. As a result of this deficiency, REP was not able to provide care for P1 upon discharge and P1 had to be re-admitted to another hospital.

Findings include:

On 04/06/22 at 10:10 AM, a review of P1's EHR documented, P1 was 93 years-old and hospitalized from 02/06/22 to 02/11/22 with a diagnosis of Sepsis/Infection, Dementia, Diabetes, Hypertension, High Cholesterol, Irregular Heart Rate. An Initial SW/CM Assessment Note (written on 02/07/22 at 11:53 AM) documented during a telephone interview P1's family stated P1 is independent and is resistant to assistance with activities of daily living, lives on the ground floor of a two-story house and there are two steps that lead into the house. On 02/11/22 at 1:25 PM, CM documented a face-to-face meeting was conducted with the beneficiary's representative regarding the Important Message from Medicare notice, to which Rep denied any face-to-face meetings with CM or SW prior to discharge.

During interviews with Rep on 04/06/22 at 12:20 PM, Rep described the experience of P1's admission, stay, and discharge from the hospital. Rep stated she was not able to visit P1 while he was in the hospital due to COVID-19 restrictions. During discharge, Rep and Registered Nurse (RN)9 attempted to transfer P1 into Rep's personal vehicle for transportation home. However, P1 could not walk and required transportation home via ambulance or transportation van. Rep stated prior to going into the hospital, P1 could walk independently and on the day of discharge, she was surprised that P1 could not walk and that she was not informed that there was a change in P1's ability to walk. Rep and RN9 were unable to transfer P1 into Rep's vehicle for transportation home and at that point, Rep informed RN9 she did not have the strength to safely transfer P1 in and out of the car or up the steps and did not have the strength to assist P1 with walking, as she was the only one providing care. RN9 informed CM that Rep did not feel safe taking P1 home and they were unable to get P1 into the vehicle. At that point, CM provided Rep with a list of transportation options to take P1 home. Rep stated she asked if this was even safe, considering she could not properly care for P1 in his current state. Rep recalled feeling "pressured" into accepting the discharge and was told P1 was medically cleared and had to be discharged home, there were no other options. Rep said prior to physically picking up P1, she was unaware that P1 could not walk and confirmed that she was not notified of P1's decline prior to attempting to get P1 into the car the day of discharge. Rep stated if she was informed of P1's decline prior to discharge, she would not have agreed to take him home because she could not safely care for P1. Rep reported she called the hospital multiple times to get information regarding P1's health status, but she did not receive a call back. Furthermore, Rep stated she did not know that she could have contested P1's discharge and denied having a face-to-face meeting with CM or SW regarding the Important Message from Medicare on 02/10/22.

On 04/07/22 at 10:20 AM, conducted an interview and concurrent record review with the Director of Nursing (DON), CM, and Social Worker (SW). CM and SW recalled that Rep could not transfer P1 into the vehicle, and at that point, a list of transportation options was provided to Rep. Inquired if Rep's inability to safely transfer P1 into the vehicle was an indication that the discharge was unsafe. CM and SW replied that P1 had been medically cleared for discharge. The DON, CM, and SW confirmed there was no documented evidence that the hospital communicated with Rep regarding P1's decline in his ability to walk.

On 04/07/22 at 1:00 PM, an interview was conducted with RN9. RN9 recalled on the day of discharge, RN9 and Rep, could not transfer P1 into the vehicle to go home. At that point, Rep questioned if it was safe to take P1 home and stated she did not know how she was going to get P1 out of the car and up the stairs because she didn't have the strength needed. RN9 alerted CM to the situation and reported informing CM that Rep was concerned about how she was going to get P1 home and take care of him by herself. RN9 reported CM provided a list of transport options and Rep called to make transportation arrangements. RN9 reported P1 was taken back into his room and waited approximately 3-4 hours for transportation arrived.

Based on interviews with Patient Family Representative (Rep), interviews with staff, and review of Electronic Health Record (EHR), the facility failed to recognize and offer a discharge planning evaluation for Patient (P) 1. As a result, Rep was not able to provide care for P1 upon being discharged and P1 had to be re-admitted to another hospital.

Findings include:

During interviews with Rep on 04/06/22, 12:20 PM, Rep described the experience when she was told that P1 (who was her father) was being discharged from the hospital. Rep received a call from the hospital Case Manager (CM) saying P1 was cleared for discharge and needed to be picked up. Rep drove to the hospital and discovered that P1 could not walk by self and needed transportation home via ambulance or transportation van. At this time, Rep knew that she could not provide the needed care because this was the same reason for P1's hospitalization in the first place. Rep did not have the strength to lift P1 and did not have the strength to assist with walking or transferring. Rep said she felt "pressured" into accepting the discharge, said she was not offered a discharge planning evaluation, and was told there was nothing the hospital could do because P1 was "cleared for discharge". Rep made the arrangement for transportation, which took several hours, and the discharge did not happen until around four hours later. Rep said soon after P1 got home, ambulance needed to be called and P1 was re-admitted to another hospital.

Staff interview on 04/07/22 at 10:20 AM, Social Worker said there was no policy and/or process in place for making patients, including patient's representative aware that they may request a discharge planning evaluation, and that the hospital would perform an evaluation upon request.

Staff interview on 04/07/22 at 10:30 AM, Director of Nursing was queried and acknowledged that Rep could have been offered a discharge planning evaluation.

Review of EHR on 04/06/22 at 10:00 AM, P1, age 93, hospitalized from 02/06/22 to 02/11/22 with a diagnosis of Sepsis/Infection, Dementia, Diabetes, Hypertension, High Cholesterol, Irregular Heart Rate. Physical Therapy Note on 02/08/22 wrote patient tried to voice things but was not able to understand what the patient was saying. Patient was mumbling words. Attempted to guide patient to sitting but was not able to follow instructions. Physical Therapy Note on 02/09/22 wrote patient not able to participate in skilled physical therapy. Patient not opening eyes. Discharge Note on 02/11/22 wrote patient was discharged home with a wheelchair.