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Based on interview and record review, the hospital failed to comply with the Condition of Coverage for Discharge Planning as evidenced by:

Failure to contact family members or to notify them of the patient's discharge; provide appropriate transportation for discharge; provide proper personal clothing upon discharge; and provide safe transfer to another facility (refer to A 820).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality and safe health care environment for the patients.

Based on interview and record review, the facility failed to ensure Patient 1 had a safe discharge to a board and care home (a special facility designed to provide those who require assisted living services) when Patient 1's family members were not notified of Patient 1's discharge. Patient 1 was discharged alone, in hospital gowns, via a regular taxi, instead of a wheelchair van as arranged. These failures had the potential to impact the patient's care and safety.

Findings:

Review of Patient 1's H&P (history and physical, the initial clinical evaluation and examination) dated 4/1/18, indicated the patient was ninety (90) years old and admitted to the hospital on 4/1/18. The CC (chief complaint, the most significant problem) indicated shortness of breath and "his baseline is confused from dementia" (a general term for a decline in mental ability severe enough to interfere with daily life including memory loss).

Review of Patient 1's Discharge Planning/Admission Assessment Form dated 4/1/18, indicated the primary responsible party and "anticipated Journey Home Partner" was family member A (FA A). It indicated his family would assist with transport when the patient was discharged.

Review of Patient 1's Palliative care (a specialized medical care for people with life-limiting illnesses focusing on providing relief from symptoms and stress of a serious illness) - MULTI-DISCIPLINARY NOTES dated 4/2/18, indicated the designated decision maker for the patient was family member B (FM B) and alternate decision makers were FA A and FM C. It indicated the patient lacked ability to make his own decisions either temporarily or permanently.

Review of Patient 1's nursing assessment, from 4/2/18 at 7 a.m. to 4/5/18 at 3:44 p.m., indicated the patient was oriented to person, which means the patient knows his own name and significant others and is disoriented (cognitive disability) to place and time.

Review of Patient 1's Discharge Planner dated 4/3/18, indicated the patient's family would assist with transport when the patient was discharged.

Review of Patient 1's Discharge Planner dated 4/4/18, indicated patient care coordinator B (PCC B) attempted to reach FA A and left a voice message regarding the patient's "possible" discharge on the following day.

Review of Patient 1's physician order dated 4/5/18 at 11:49 a.m., indicated discharge from the hospital.
Review of Patient 1's Physical Therapy Evaluation dated 4/5/18 at 1:53 p.m., indicated the additional considerations for Patient 1 included fall precautions, hard of hearing, and dementia. Patient 1's range of motion indicated his right and left lower extremities had functional limits and the patient required minimal assistance for transferring and walking. The identified physical therapy problems were decreased functional mobility and strength. The discharge recommendation was to use a wheelchair or car.

Review of Patient 1's Discharge Planner dated 4/5/18 at 2:17 p.m., indicated PCC B arranged a wheelchair van using a taxi voucher. There was no documented evidence the patient's family members were informed of the patient's actual discharge.

Review of Patient 1's Nursing Notes dated 4/5/18 at 5:02 p.m., indicated registered nurse F (RN F) reviewed the discharge instructions with the patient and there were no belongings in the room. There was no documentation whether the patient understood the discharge instructions including medications and care at home.

During a telephone interview on 4/19/18 at 11:30 a.m., PCC B who had coordinated Patient 1's discharge, stated he had arranged the wheelchair van transport for Patient 1, there was a problem with the van scheduling, and the van did not come. PCC B stated there was a breakdown in communication shift to shift and the need for the wheelchair transport was not communicated to the evening shift. He stated when the van did not come to pick up Patient 1, the nurse should have contacted any PCC. He stated on 4/4/18, he made a courtesy call to FA A and he did not require calling Patient 1's family member regarding the discharge because the patient was alert and oriented.

During an interview with RN C on 4/19/18 at 1:50 p.m., she reviewed Patient 1's nursing assessment, from 4/2/18 at 7 a.m. to 4/5/18 at 3:44 p.m., and stated she would not give any discharge instructions to the patient if the patient was not fully oriented. She stated she would call the family member to let them know regarding the patient's discharge. RN C reviewed Patient 1's Discharge Planner notes and stated PCC B left a voice message to FA A regarding his possible discharge but there was no documented evidence Patient 1's actual discharge was related to his family member.

During an interview with unit assistant D (UA D) on 4/19/18 at 3 p.m., she stated she worked on 4/5/18 when Patient 1 was discharged. When she started working on 4/5/18 around 3 p.m., assistant nurse manger E (ANM E) asked her to call a regular taxi for Patient 1 and RN F talked to her and Patient 1 was not ready to discharge. She stated RN F was very busy on that day and ANM E asked her four times, between 3 p.m. to 5 p.m., to call the Patient 1's taxi because another patient in the emergency department was waiting for admission almost for two days. UA D stated ANM E pushed her to call a taxi and she did not hear a wheelchair van was arranged. She stated patient care technician G (PCT G) and PCT H helped ready Patient 1 for discharge. She stated she called a regular taxi and the patient left the unit at 5 p.m.

During a visit to Patient 1's board and care (B&C) home on 4/19/18 at 8:15 p.m., Patient 1's caregiver (CG J) in the B&C home stated Patient 1 returned from an acute care hospital on 4/5/18 at approximately 5 p.m. Patient 1 was in a taxi, dressed in hospital gowns, and had no shoes or socks on his feet. CG J stated two caregivers transferred Patient 1 from the taxi to a B & C's wheelchair and transported him inside the B & C home.

During an interview on 4/20/18 at 8 a.m., PCT H stated she stated she brought Patient 1 down to the main lobby using a wheelchair and assisted him to a taxi. She stated she held Patient 1 as he stood up to get in the taxi from a wheelchair, made him sit and turn, and placed both legs inside the taxi because he was unable to do it himself. She stated she returned Patient 1's wheelchair to the hospital.

During an interview on 4/20/18 at 9:25 a.m., ANM E denied he asked UA D to call a taxi for Patient 1.

During an interview on 4/20/18 on 10:10 a.m., the director of coordinator of care services (DCCS) stated when a patient was discharged, staff informed the family member of the patient's discharge and arranged appropriate transportation. When the patient did not have appropriate clothes, the patient would be referred to PCCs or social workers. She stated there were donated clothes for patients in the emergency department. After reviewing Patient 1's taxi voucher, she stated it did not clearly indicate a wheelchair van was arranged. She stated PCC B had worked with Patient 1 for two days.

During an interview on 4/20/18 on 11:15 a.m., PCT G stated since Patient 1 had no personal clothes available, she placed two hospital gowns on him when he was discharged.

During a telephone interview on 4/20/18 at 12:45 p.m., FA A stated she learned on 4/5/18 Patient 1 had been sent back to his board and care home by taxi. She stated none of Patient 1's family members were notified of Patient 1's discharge. FA A stated the staff at the board and care were shocked when Patient 1 was sent home via a taxi and dressed in two hospital gowns.

Review of the hospital's 9/28/16 policy "Admission, Discharges and Transfers" indicated to obtain a preferred contact person and make a reasonable attempt to notify that individual prior to the patient's transfer to another facility.

Review of the hospital's 1/2016 policy "Patient Rights And Responsibilities" indicated the patient has the right to personal privacy as manifested by the right to wear appropriate personal clothing.

Review of the hospital's 4/19/18 Job Description "Patient Care Coord(inator) Case Mgr (manager)" indicated to develop, evaluate, and coordinate a comprehensive discharge plan in conjunction with the patient/family.

Review of the hospital's 11/21/16 policy "Discharge Planning Process" indicated hospital nursing is responsible for assessing every patient and identifying and addressing routine discharge needs. Patient care coordinator coordinates necessary services and communication among members of the health care team, patient, and family.