HospitalInspections.org

Based on record review, staff interview, and facility policy review, it was determined that the facility failed to develop and arrange a discharge plan per the request of a physician for one patient (P) (P#1) of 4 four patients reviewed for discharge plans. This failure resulted in P#1 being discharged unsafely and inappropriately.


Findings included:


A facility policy titled "Hospital Wide Discharge Plan," last revised on 06/04/2024, revealed, "1. Discharge planning begins upon admission with a discharge planning screening by Care Management Staff. All patients that are screened as high risk are referred to a care coordinator for assessment. Any unique patient needs are identified and addressed as part of the D/C [discharge] planning process. 2. Care Management will review the medical record and meet with patients and families as needed to provide appropriate services. The assessment of each patient will involve reviewing the documentation by providers and other disciplines. 3. Patients with identified discharge needs are referred to Case Management through the C.M. [Care Management] screenings and referrals by direct contact with patient/family or by a physician order. See attached table for disposition of patients. 4. Social workers, providers, patient, family, support person and the interdisciplinary team confer regarding the discharge needs of the patient, including: DME [durable medical equipment], Home Health, Rehabilitation Services and Nursing Home Placement. The information is shared through EPIC [electronic health record software] documentation and direct communication to provide timely and appropriate discharge plans. (Refer to Case Management Policy regarding discharge planning) 5. Insurance coverage and demographics are considered within the discharge planning process. Education and supportive services are provided to the patient, family, or support person to assist them in accepting the illness and discharge plan. 6. A provider order is required for certain services such as Home Health, Hospice and DME. 7. Social Workers provide information to patients/families for their use in making informed decisions regarding post-hospital care."
A facility policy titled "Evaluations and Referrals for Discharge Planning Policy," last revised on 06/20/2023, revealed, "All inpatients of [facility name] shall be evaluated for discharge planning needs. Care Managers and social workers shall conduct the evaluative process. Additionally, the Care Management Department has an open referral policy. Referrals may be accepted from patients, their families, physicians, hospital staff and community agencies and outside agencies as needs are identified. Referrals may be received electronically through EPIC as physician orders, or via interdisciplinary rounds followed by EPIC orders. Identified discharge needs may include: 1. A need for community resources. 2. Orthopedic rehabilitation. 3. Rehabilitation after CVA [cerebrovascular accident] or other debilitating illness. 4. Readmission 5. Patient advocacy, such as in cases of abuse or neglect or patient/family conflict. 6. Patient with little or no support systems. 7. Frequent re-hospitalizations. 8. Significant personal care or nursing care needs identified. 9. Maintenance of a chronic illness. 10. Placement in a skilled nursing facility or rehab placement. 11. End of life needs. 12. NICU [neonatal intensive care unit] admission. 13. DFACS [Division of Family & Children Services/APS [Adult Protective Services] referral."


"ED [Emergency Department] Provider Notes," dated 02/19/2025 at 12:49 a.m., revealed P#1 presented to the emergency room with a chief complaint of generalized weakness. A "Review of Systems" section revealed the patient was positive for weakness.


"ED Notes," dated 02/19/2025 at 2:37 a.m., and documented by Licensed Practical Nurse (LPN) #3, revealed P#1 ambulated from their bed to the door of their room with assistance from LPN #3.


"ED Notes," dated 02/19/2025 at 3:00 a.m., and documented by LPN #3, revealed P#1 reported having no place to live, including no longer living with their spouse.


A "Nursing Note," dated 02/19/2025 at 3:13 a.m., and documented by Registered Nurse (RN) #13, revealed RN #13 spoke with P#1's family member, who identified that P#1 could not return to the family member's home, and the family member could not care for P#1.


An order dated 02/19/2025 at 3:28 a.m., revealed Doctor of Osteopathy (DO) #12 placed an order for "Case Management - Referral to post-acute care."


An "ED Re-evaluation Note," filed on 02/19/2025 at 1:19 p.m., by Medical Doctor (MD) #14, revealed "CM [Case Management] is arranging [a ride-hailing service]" to P#1's ex-family member's home.
A "Discharge Information" note revealed P#1 was discharged with a disposition of "Home Or Self Care" to a discharge destination of "None" on 02/19/2025 at 1:49 p.m.


P#1's medical record failed to indicate that DO #12's order for case management was executed. There were no case management notes or evidence of case management assessments conducted prior to the patient's discharge.


During an interview on 05/06/2025 at 2:31 p.m., a Case Manager Director (CMD) stated that, during P#1's visit on 02/19/2025, a referral was placed by a provider for a case management consultation, but case management never followed up on the consultation. The CMD noted case management was expected to follow up on referrals made by providers first thing in the morning when they arrived to work.