HospitalInspections.org

Based on policy and procedure review, document review, medical record review, and staff interviews, it was determined the facility failed to provide and ensure a safe discharge as evidenced by the following:

1. Failed to ensure delivery and receipt of durable medical equipment for patients requiring a wheelchair at home. (Refer to A820)
2. Failed to honor patient/family choice of discharge facility. (Refer to A823)
3. Failed to follow physician orders for patient discharges. (Refer to A820)
4. Failed to notify patient's family/representative of the patient's discharge. (Refer to A820)
5. Failed to analyze facility readmissions related to the discharge process. (Refer to A843)


See Tags A820, A823, A843

Based on policy and procedure review, medical record review, and staff interviews, it was determined the facility failed to implement and keep the family/legal representative informed of the discharge plan for three (#2, #3, #5) of five medical records sampled

Findings included:

A review of the policy entitled, Discharge Plan, # PC 402.917, reviewed 04/18, showed Case Manager (CM) is accountable for a prompt, orderly, systematic, and interdisciplinary effort among clinical services, the patient, family, and appropriate community resources and continuity of care post discharge...discharge (DC) planning process is initiated upon admission ...the planning process encourages participation by the patient/family or legal representative including patient/family education post discharge care ... ensure that the necessary services are available at the appropriate level of care...reassessment DC planning is an evolving process that reflects the patient's changing status until the time of DC in order to provide for continuity of care post DC ...patients are DC or transferred from the hospital based on documented physician order... discussion with the patient/family and their understanding of the DC plan and DC instruction is recorded.

1. A review of Patient #2's physician discharge (DC) summary dated 11/27/18 at 7:36 PM showed a DC diagnosis of shortness of breath, chronic obstructive pulmonary disease (COPD) exacerbation, and pneumonia. The physician summary showed the patient was to be DC'd home with an order for a wheelchair.

A review of Patient #2's CM notes dated 11/24/18 at 3:22 PM showed a physician order for a wheelchair had been received and a referral was sent to a durable medical equipment (DME) provider for a wheelchair. The note showed the CM called the DME provider call center and was told the local representative would call the CM back. Continued review of the CM notes failed to reveal the CM followed up to ensure the wheelchair was ordered or received.

An interview on 1/17/19 at 2:45 PM with the Director of CM confirmed the CM failed to document if the wheelchair was ordered or received by Patient #2. The Director stated she would have to call the DME Company to know for sure if the patient received the wheelchair once she got home.

2. A review of Patient #3's physician discharge summary (DC) documentation dated 12/04/18 at 3:56 PM showed a DC diagnosis of acute respiratory failure and pneumonia. The note showed the patient was discharged to a rehabilitation facility with a sleep study ordered so she could obtain home CPAP/BIPAP prior to returning home. The patient was noted to be awake, alert and oriented.

A review of CM documentation dated 11/30/18 at 4:34 AM, showed Patient #3's daughter told CM that she wanted her mother to go to a specific skilled nursing facility (SNF) and she would call back with a second choice.

A review of Patient #3's patient choice letter, dated 12/03/18, showed the patient's signature consenting to be transferred to a SNF other than the one specified by the daughter. A complete review of the medical record failed to reveal the presence of any other facility choice letters signed by the patient or patient's representative.

A review of the CM notes dated 12/04/18 at 3:31 PM showed the Patient #3 was discharged a SNF other than the one specified by the daughter.

On 01/17/19 at 11:15 AM an interview performed with the Director of CM confirmed the only facility Patient #3 and the patient's representative agreed to the original SNF. The CM confirmed the facility failed to implement Patient #3's DC plan and ensure the family/legal representative was informed of the SNF change. The CM Director also confirmed CM failed to document the patient's daughter/legal representative was made aware the patient was DC'd from the facility.

3. A review of Patient #5's physician DC summary dated 12/05/18 at 11:40 AM showed the patient had been admitted for complaints of weakness, lethargy, and mild shortness of breath for 2-3 days. The note showed the patient stated he had chronic anemia for the past 2 years resulting in falls, fainting spells, and chronic dizziness. The note showed the last time the patient reported he fainted and lost consciousness was 2 month ago. The note showed the patient was DC'd to a SNF.

A review of Patient #5's physician orders dated 12/05/18 at 6:27 PM confirmed there was an order for the patient to be DC'd to a SNF.

A review of Patient #5's facility choice letter dated 11/04/18 at 1:00 PM showed three SNF's chosen by the patient.

A review of the CM and RN notes showed the following documentation:
11/30/18 at 3:20 PM - CM note showed the patient stated he lived alone and requested he needed a wheelchair. The note showed the patient transportation home would be a taxicab.
12/05/18 at 11:22 AM - CM noted showed the patient stated he refused rehab and home health and wanted to go home. The note showed the physician and nurse were made aware.
12/05/18 at 1145 AM - CM note showed that approximately 23 minutes after the the last CM note, the unit charge nurse told CM that the patient might go to rehab after all. CM Working on authorization for rehab facility.
12/05/18 at 2:15 PM - CM note showed rehab facility was called and voicemail left to expedite authorization
12/05/18 at 3:08 PM - CM note showed insurance company was faxed to request an authorization for the rehab facility.
No date and No time - CM note showed the patient refused HH and SNF at last minute.
12/05/18 at 6:17 PM - nursing note the physician was called to inform him the patient was refusing the SNF. The note showed the physician agreed to DC home.
12/05/18 at 6:27 PM - physician order showed the patient was to be DC'd to a SNF. A review of the physician orders failed to reveal the presence of an order for the patient to be DC'd home.
12/06/18 and no time - CM note the day after the patient was DC'd showed the patient had been booked to go to a SNF.

An interview with the Director of CM on 01/18/19 at 2:00 PM revealed that Patient #5 decided he wanted to go to rehab on 12/05/18 at 3:08 PM. The Director confirmed the CM notes on 12/05/18 showed the patient went home. The CM confirmed the notes on 12/05/18 were not dated or timed. She confirmed the CM note on 12/06/18 showed the patient was DC'd to SNF. The Director confirmed the notes were conflicting, but the patient actually went home. The Director confirmed the patient had requested a wheelchair for home, but there was no documentation of CM follow-up for the wheelchair or evaluation of a safe DC home instead of a SNF.

Based on policy and procedure review, medical record review, and staff interviews, it was determined the facility failed to honor the patient or patient's representatives choice of facilities for one (#3) of five medical records sampled.

Findings included:

A review of the policy entitled, Discharge Plan, # PC 402.917, reviewed 04/18, showed the DC planning assessment/evaluation is discussed and confirmed with patient/family/guardian in order to facilitate timely development of a DC plan prior to discharge ...this can include patient/family rejection of the DC plan ...The patient choice form is completed when referral to a skilled nursing facility (SNF) or home health (HH) agency is required post DC. Selection of resources is decided by patient/family with physician recommendation and payer source consideration ...plans will include the participation of family as appropriate and consultation with the physician ....discussion with the patient/family and their understanding of the DC plan and DC instruction is recorded.

A review of Patient #3's physician discharge summary (DC) documentation dated 12/04/18 at 3:56 PM showed a DC diagnosis of acute respiratory failure and pneumonia. The note showed the patient was discharged to a rehabilitation facility with a sleep study ordered so she could obtain home continuous positive airway pressure (CPAP) therapy, a common treatment for obstructive sleep apnea. The patient was noted to be awake, alert and oriented.

A review of Patient #3's physician orders dated 12/03/18 at 11:00 PM showed an order for the patient to be discharged to a skilled nursing facility (SNF) when a bed is available and for a sleep study while at rehab to assess the need for continuous positive airway pressure (CPAP) therapy.

A review of Patient #3's face page showed the healthcare surrogate/durable power of attorney was the patient's daughter.

A review of Patient #3's CM documentation dated 11/30/18 at 11:34 AM, showed that physical therapy (PT) recommended a skill nursing facility (SNF).

A review of CM documentation dated 11/30/18 at 4:34 AM, showed the patient's daughter told CM that she wanted her mother to go to a specific skilled nursing facility (SNF) and she would call back with a second choice.

A review of CM documentation dated 11/30/18 at 11:35 AM, showed CM made a referral to a different SNF.

A review of Patient #3's choice letter, dated 12/03/18, showed the patient's signature consenting to be transferred to the SNF other than the one specified by the daughter. A complete review of the medical record failed to reveal the presence of any other facility choice letters signed by the patient or patient's representative.

A review of Patient #3's CM notes dated 12/04/18 at 3:31 PM showed the patient was discharged to a SNF other than the one specified by the daughter.

On 01/17/19 at 11:15 AM, an interview performed with the Director of CM confirmed the only facility Patient #3 and Patient #3's representative agreed to was the original SNF. The CM confirmed that the SNF where Patient #3 was discharged was not listed as one of the patient's or patient's representative SNF choices. The Director confirmed the CM notes failed to show the patient's representative was notified of the change in SNF's or that the patient had been discharged to that facility.

Based on document review and staff interviews, it was determined the facility failed to track and analyze readmissions related to the discharge process in order to identify preventable readmissions.

Findings included:

On 01/18/19 at 1:00 PM a review of the facility patient readmission data showed the facility patient readmission rate within 7 days from skilled nursing facilities (SNF) was 36.6% and from home health (HH) was 45.9%.

On 01/18/19 at 1:05 PM an interview with the CM Director confirmed the facility did not track readmission data to see if the DC planning process contributed to the readmission rate.

An interview on 01/18/19 at 1:10 PM with the VP of QM & Safety confirmed the above facility patient readmission rate from SNF/HH. She confirmed further analysis to see if the readmission were related to the DC process had not occurred. The VP stated she thought the data collection and analysis had started last month, however, she was made aware by the CM Director that it had not been started.