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Based on medical record (MR) review, document review and interview, in two (2) of five (5) medical records reviewed, the patients' discharge planning evaluations did not include a detailed review of the individual patient's post-hospitalization needs (Patient # 8, Patient #10) .


Findings include:

Review of medical record (MR) for Patient # 8 noted: 83-year-old patient, with history of multiple co-morbidities, arrived at the facility's Emergency Department (ED) by ambulance on 9/6/2017 11:33 AM, with a chief complaint of shortness of breath (SOB). The patient was admitted to a short stay unit (SSU) on 09/06/2017 1708 (5:08 PM). The admitting diagnosis was CHF (congestive heart failure) exacerbation.


The patient had an initial discharge assessment on 9/7/2017 at 2:47 PM, and the case manager documented that the patient stated she had home oxygen but no home attendant and no CHHA (certified home health agency) service. The discharge planning evaluation did not include follow-up regarding the patient's oxygen need and did not include an evaluation of the patient's ability for self-care, and need for services post-hospitalization. There was no further discharge planning follow-up.

On 9/8/2017 1830 (6:30 PM), the physician wrote an order to discharge the patient to home/self-care. The patient refused the discharge. The facility's staff attempted to discharge the patient on 9/8/2017 at 7:30 PM, 9:06 PM and 10:45 PM. These attempts failed. The patient and daughter refused to leave the hospital stating that the patient's home oxygen tank needed to be refilled and the concentrator of the tank was broken.


It was noted on 9/8/2017 at 10:26 PM, the physician discharging the patient documented the reasons why the patient needed to leave the hospital. However, the provider did not identify the patient's need for further discharge planning/psychosocial evaluation.

As per hospital policy, titled: "Discharge Procedure," last reviewed 01/2017, when further discharge planning/psychosocial evaluation is indicated, the License Independent Practitioner (LIP) alerts the assigned social worker; the LIP can place an order for "IP Consult to Social Work." This physician did not follow the discharge planning procedure, as the provider did not alert or order a consult to social work.



Review of MR for Patient #10 noted: 85-year-old Cantonese speaking patient, with history of CVA x 5 and seizure disorder, presented to the ED on 9/1/2017, after a fall at home. The admitted diagnosis was left ear lobe laceration.

On 9/3/2017, the social worker (SW) noted that the patient was medical cleared for discharge.
The initial discharge evaluation, dated 9/3/2017, indicated that the patient had "no discharge needs identified."
There is documentation by the SW that the patient had HHA (home health attendant) services Monday to Friday. The documentation also noted "The patient was hospitalized on Saturday 9/2/2017. Therefore, HHA services did not need to be reinstated, as they will resume on Monday 9/4/2017." This discharge plan did not include an evaluation to determine all of the patient's post discharge needs.

The patient was not discharged on 9/3/2017. The reason the patient remained in the hospital was not documented in the medical record. There is documentation that the SW met with patient's daughter and the goal was discharge to home with home care, as the patient's daughter declined SAR (short term acute rehab). It was noted that the patient's daughter accepted CHHA service and a referral was made to a CHHA for PT ( physical therapy), OT (occupational therapy) and Speech therapy/Language services.
On 09/04/17 1000 (10:00 AM), patient was referred for PT evaluation and the patient/family declined the service. No other therapy referrals were made and the patient was not evaluated by all services that were included in the discharge plan.
The discharge planner informed the patient's daughter that a community referral was made to the CHHA and the CHHA would make the determination on the care to be rendered. The discharge plan did not ensure services identified were available before discharge.

During interview with Staff I, Director of Social Work and Staff H, Director of Case Management on 9/21/2017, at approximately 11:30 AM, staff acknowledged that these patients did not have a complete and individualized discharge planning evaluation.

Based medical record review and interview, in two (2) of five (5) medical records reviewed, the discharge planner did not ensure that timely evaluation and post-hospital arrangements were made prior to discharge, to avoid unnecessary delays (Patient # 8, #12).

Finding include:

During the tour of the Unit 5A (surgical/medical unit) on 9/20/2017, it was identified patient # 12 was scheduled for discharge today pending skilled nursing facility placement.


Review of medical record (MR) for patient # 12 noted: 81-year-old patient, with multiple co-morbidities, presented to the facility's emergency department (ED) on 9/15/2017 19:44 (7:44 PM) and was admitted for work up of altered mental status.

On 9/16/2017 1:43 PM, the patient had a discharge planning assessment ant it was noted that the patient was not safe at home.
On 9/18/17 1600 (4:00 PM), the discharge planning reassessment performed, indicated that the patient lived at home with HHA (home health aide) service. However, at nights, after HHA leaves the home, the patient wandered. A recommendation for subacute rehab was discussed and agreed upon with the patient's family members. It was noted that on 9/18/2017, the patient's family selected five (5) skilled nursing facilities, in order of preference.

On 9/20/2017 at 10:05 AM, the physician wrote a discharge order and at 10:29 AM, the medical team cleared the patient for discharge. The care management assistant (CMA) completed the sub-acute rehab referral on 9/20/2017 at 4:17 PM.

During follow-up on 9/21/17, it was noted that the discharge notation for 9/20/2017 was not included in the medical record. During interview on 9/21/2017 approximately 10:20 AM, Staff U, nurse on Unit 5A, stated the patient was not discharged on 9/20/2017 because the facility had not received an acceptance from the skilled nursing facility (SNF). The patient was discharged today (9/21/2017) and she was awaiting transportation.


During interview with Staff V, Social Work Administrator on 9/21/2017, approximately 11:30 AM, this staff acknowledged that there was a delay in the discharge.


Similar finding was identified for patient # 8, with a delay in discharge.

Based on medical record (MR) review, document review, and interview, in one (1) of 12 medical records reviewed, the facility did not conduct a reassessment of the discharge plan to ensure an appropriate discharge. (Patient #1)


Findings include:

Review of the Medical Record (MR) for Patient #1 documented: this 32 year-old-male who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 6/30/17, after attempting to jump from a second story of his home, onto the neighbor's porch. The patient sustained bilateral calcaneus (ankle) fractures which required surgical interventions. Due to the injuries and surgical interventions, the patient received rehabilitation for 8-12 weeks.


On 7/5/17 at 10:38 PM, Progress Note by the Licensed Medical Social Worker (LMSW) documented a Psychosocial Assessment. Documentation included a Screening for Discharge Planning. The discharge plan indicated for the patient to be discharged to home. He was living with his parents and would be staying in the living room when returning to the house, where a bathroom was. Patient stated that his parents wished him to go to inpatient rehab or to behavioral health prior to discharge. It was explained to patient that to go to either of these settings, patient would need to be mostly independent with ADLs.


On 7/6/17 at 10:49 AM, Progress Note by MSW documented SW spoke with the patient's mother. Mother conveyed frustration to SW and stated she did not know if she was willing to take the patient home. The SW explained patient's weight bearing status, which would impede him going into an inpatient drug rehab program, and would also pose an issue for shelter placement, as patient would require both a wheelchair and commode upon discharge.


On 7/14/17 at 10:57 AM, there is documentation in the MR that patient would be discharged on this day or 7/15/17. SW spoke with patient and explained that all Durable Medical Equipment (DME: wheelchair, commode, and sliding board) have been approved and will be given upon discharge. The patient stated that he was still unsure if he can stay with his mother, but will be able to stay with his grandmother who lives three blocks away. Patient also stated that his uncle lives three blocks from his grandmother and that he will have somewhere to go.
The SW called the mother, while at the patient's bedside, and left a message twice. The mother called back when SW left the room and stated that she did not want the patient to return home, and that the grandparents are "too elderly" to deal with the patient.


On 7/15/17 at 9:21 AM, Physician's Note documented patient was discharged to home with discharge instructions provided.


There was no documentation in the medical record that a reassessment of the discharge plan was conducted.

There was no documentation that the unavailability of the caregiver/support post-discharge was escalated to the Discharge Planning Team for a discharge plan reassessment.


Review of the the policy on "Discharge Procedures," last reviewed 01/2017, states, "The social worker/care manager, in collaboration with the interdisciplinary team, is responsible for reassessment of the discharge plan in the following circumstances including: Whenever there are changes in available support ..." The facility did not ensure that its policy was followed.


On 9/21/17 at 12:38 PM, during an interview with Staff D, MSW and Staff I, Director of Social Services, both staff acknowledge the findings.


On 9/21/17 at 1:00 PM, Staff I, Director of Social Services was interviewed.
Staff I acknowledged a reassessment of the Discharge Plan was not conducted.