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Based on record review and interview the facility failed to reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan for 1 of 12 sampled patient ( SP #1).

The findings:

Review of the physician History and Physical note dated 06/17/16 of sampled patient (SP# 1) showed that the pt. was admitted at the facility on 06/16/16 with diagnoses which includes but not limited to multiple ulceration in lower extremities, sacral decubitus, peripheral neuropathy, peripheral vascular disease, legs DVTs (deep vein thrombosis), COPD (Chronic Obstructive Lung Disease). Has sacral decubitus (ulcer) stage 4 and he was admitted to the hospital few weeks ago and discharged to [name of Skilled Nursing Facility (SNF)].

Record review of Orthopedic progress note dated 6/22/2016 showed Impression and Plan:
Diagnosis ( Dx): Chronic ulcer of left leg with fath layer exposed(fat layer exposure); Chronic ulcer of right leg with fath layer exposed; venous insufficiency (chronic) peripheral. Item # 5. Rehab facility highly recommended.


Review of the Case Manager (CM - A) Discharge Planning notes dated 7/18/2016 showed the pt. was discharged to the ALF ( Assisted Living Facility) . Wheelchair and walker delivery will be made to the ALF by (Name) DME (Durable Medical Equipment provider). Contacted (Name) HHC (Home Health Care) and they received the updated orders that were sent to include sacral ulcer wound care and physical therapy.

The Discharge Summary showed sampled patient (SP #1) was discharged on 07/18/2016. The physical skin assessment showed on the sacrum, the patient has stage 4 (four) sacral decubitus (ulcer). On the lower extremity, the patient has multiple ulcerations in lower extremities stage 3 (three) and 4 (four). No redness. No discharge at this time. The assessment includes multiple ulceration in the lower extremities, different stages. Sacral decubitus stage IV(four). Peripheral neuropathy, and a history of depression and anxiety. After case manager coordination, patient was discharge to ALF.

Review of SP #1 " Resident Health Assessment for Assisted Living Facility " AHCA form 1823 completed by the physician on 07/15/2016 showed that Section 1 and Section 2 was incomplete. The form states to indicate in the appropriate column below, the extent to which the individuals are able to perform each of the listed self-care tasks. If " needs supervision " or " needs assistance " is indicated, please explain the extent and type of supervision or assistance necessary in the comments column. SP # 1 had an "A" = needs assistance marked for all activities of daily living, ability to perform self-care tasks, but no comments were provided. The "General Oversight" was also left blank which indicate the extent to which the individual needs general oversight.

Review of SP #1 discharge summary for the readmission showed that he was admitted on 07/20/2016 and discharged on 07/29/2016. The summary then note that he was admitted to the hospital from 06/16/2016 to 07/18/2016 and discharge to an ALF in less than 24 hours he returned to the ER (Emergency Room) because he was unable to stay in the ALF, then readmitted on 07/20/2016 to 07/29/2016 and discharged back to another ALF. The Assessment: Sacral decubitus (ulcer) stage IV (four).

Record review of SP #1 wound assessment performed on 7/20/2016 (on the readmission) the Enterostomal Therapy (ET) Nurse Progress Note showed: Patient seen and assessed. Leg and foot wounds to be followed by Podiatry. Sacral wound assessed. Photo taken. Length 0.8 cm, width 1.6 cm, depth 0.3 cm; healing stage III (three).


Review of the physician notes dated 07/28/2016 showed that patient was seen and evaluated at bedside. IV vancomycin as per ID (Infectious Disease); will continue with local wound care on outpatient basis; Pt has a Chemo Port, if SNF (Skilled Nursing Facility) will comply, patient may be sent out on IV (intravenous) antibiotics as planned. If IV antibiotics arrangements can be made with SNF facility pt may be cleared for discharge tomorrow with home health care instructions and to follow up in wound care center with named doctor on a weekly basis.

Review of the Case Manager (CM) Notes dated 07/29/2016 at 15:32 PM showed that HHC (Home Health Care) will start care tomorrow and IV (intravenous) antibiotics will be delivered tonight to the ALF (Assisted Living Facility). The address and named provider is an "Adult Family Care Home" facility. Another Case Manager notes showed transportation will be arranged after Home Health Agency confirms that they can provide the IV Vanco (Vancomycin/antibiotic) dose later today.

Interview with Case Manager CM - A on 11/28/2016 at 2:00 PM revealed that the day prior to SP #1 admission on 7/20/2016, she received a call from the ALF administrator asking for the facility's assistance. The ALF said that they do not have enough staff to meet his needs. The CM also state that his wound care needs was arranged with a Home Health Care visit, and Physical Therapy three times a week.

The policy subject: Discharge Planning (date:07/2013) state for placement: Assisted Living Facility: The Resident Health Assessment for Assisted Living Facilities and Adult family- Care Homes AHCA form 1823 (April 2010) is required to be completed for all patients that meet criteria for assisted living facilities.

The policy subject: Discharge Planning (date:07/2013) state that throughout the patient ' s hospitalization the multidisciplinary team will monitor, coordinate and reassess the patient progress towards treatment goals and review the discharge plan to determine if the plan is meeting the needs of the patient.