HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to ensure that home health services were coordinated to ensure a safe level of care upon discharge.

Findings include:

1. On 5/24/2021, the Hospital's policy titled, "Regional Discharge Planning" dated 06/2018 was reviewed. The policy required, "...c. The Care Management Team will coordinate referrals for the patient or their legally designated decision makers to designate home care agencies, rehabilitation facilities, skilled nursing facilities, etc., to assure a smooth transition from the hospital to the next level of care."

2. On 5/24/2021, Pt #1's clinical records (for hospital stays 11/3/2020-11/18/2020 and 11/28/2020-12/7/2020) were reviewed and indicated the following:

-Pt #1 was admitted to the Hospital on 11/3/2020 with a diagnosis of CIDP (chronic inflammatory demyelinating polyneuropathy - a neurological disorder characterized by progressive weakness and impaired sensory function in the legs and arms) and generalized weakness. Pt #1 was discharged on 11/18/2020, to home with home health.

- The Physician order, dated 11/18/2020, included, "Discharge to: Home with Home Health, Condition at discharge: Stable"

-The Physician order, dated 11/18/2020, included, "Physical Therapy Discharge orders - PT [Physical Therapy] by home health, weakness and CIDP."

-MD #2's progress note, dated 11/18/2020, included, "...Will discharge with Home PT either today or tomorrow."

-The Case Management (E#2) discharge plan, dated 11/18/2020, indicated that Pt #1 chose a local home health agency to receive her nursing and physical therapy after discharge from the Hospital. E#2 added to the note that, "Due to COVID test results pending, [home health agency] will be on hold until a negative result is given - RN and [Pt #1] aware of above ..."

-Pt #1 had a COVID-19 test done on 11/18/2021, and Pt #1 was discharged home with orders for home health.

-Pt #1's COVID-19 test results indicated that Pt #1 was positive for COVID-19. However, the positive result was not obtained prior to Pt #1's discharge.

-Discharge planning notes did not include that any alternative home health agencies (agencies that accepted COVID-19 positive patients) were offered to or arranged for Pt #1, to ensure that Pt #1 received home health services if Pt #1's results were positive for COVID-19.

-Pt #1 was re-admitted to the Hospital on 11/28/2020 with a diagnosis of respiratory failure and positive COVID-19 results. Pt #1 was discharged from that stay on 12/7/2020, to her home with the same home health agency (that would not conduct home health visits for COVID-19 positive patients), without a negative COVID-19 test result.

-Discharge planning notes indicated that Pt #1 was again to be discharged home with the same home health agency (which did not conduct home health visits for COVID-19 positive patients.)

-Discharge planning notes did not include that any alternative home health agencies (agencies that accepted COVID-19 positive patients) were offered to or arranged for Pt #1, to ensure that Pt #1 received home health services.

- Pt #1's clinical record did not indicate that another COVID-19 test (last done on 11/28/2021) was completed prior to discharge with a negative result.

- Pt #1 was discharged on 12/7/2020, to her home with home health. However, without a negative COVID-19 test result, home health survices would not be provided as ordered.

3. On 5/24/2021 at 1:34 PM, an interview was conducted with a Case Manager (E#2) who worked with Pt #1 during her stay, from 11/3/2020 - 11/18/2020. E#2 stated that Pt #1 was tested for COVID-19. E#2 stated that Pt #1 was discharged to her home with home health. Pt #1 chose the home health agency she preferred, and E#2 stated that Pt #1 was aware that the home health agency required a negative COVID-19 result prior to visiting the Pt #1.

4. On 5/25/2021 at 3:39 PM, an interview was conducted with the Director of Case Management (E #6). E #6 stated that patients will not be discharged home with an order for home health if home health cannot make an initial visit within 48 hours of discharge. E #6 stated that the Case Managers must offer and document alternative home health agencies to meet the patients discharge needs.