HospitalInspections.org

Based on review of hospital policy, medical record review and patient and staff interviews, the hospital failed to provide a safe discharge plan for 1 of 5 patients (Patient #8) discharged from the hospital.

Findings included:

Review of the hospital policy titled "Discharge Planning" with a revised date: May 2018, revealed the "PURPOSE: To ensure a comprehensive, systematic, and coordinated method of discharge planning which meets the assessed needs of patients and their significant others.... 9) The individualized patient's plan of care is utilized by the appropriate discipline in documenting the patient's/significant other's understanding of the discharge plan and their ability to manage self-care needs after discharge. 10) Education and instruction to meet ongoing health care needs of the patient is presented using the Teach Back method and other ways understandable by patient/family and includes but I not limited to the following: ..b) the safe and effective use of medical equipment ...f) instruction in techniques to facilitate adaption to/functional independence... 14) ...Patient's/significant other's understanding of ability to implement discharge instructions and manage continuing care needs are determined during the review by use of Teach Back...."

Closed medical record review on 01/07/2020, revealed Patient #8 was a 45- year-old female admitted to the hospital on 07/08/2019 through 09/17/2019 for a stage III pressure injury of the sacral region with infection. Record review revealed Patient #8 had a list of co-morbidities which included super obesity. Record review of the patient demographics included a home address for Patient #8 with an "Emergency Contact 1" and "Emergency Contact 2" with the same address as the Patient #8. Record review of the "History and Physical" completed by MD #1 on 07/08/2019 at 2326, revealed " ...As per patient she was discharged last time from hospital to the skilled nursing facility and from skilled nursing facility she was discharged on June 18. She was supposed to get the home health and due to her body size, she could not get the appropriate wound care/home care. She lives with mom and her mom has been trying to help her. ..." Record review revealed on 07/09/2019 at 1241, CM #1 completed the "Care Coordination Screening" whereby Patient #8 was documented as "Risk Level: Patient meets high risk criteria for post hospital services." Review revealed on 07/09/2020 at 1530, CM #2 documented the information with regards to the previous admission in May 2019 that resulted in Patient #8 having been refused acceptance of a Home Health Agency (HHA) due to "an unsafe environment that her mother could not provide adequate care. Pt stated that her mother could not turn and clean her on her own, that they would sometimes wait 1 and ½ days for someone to help so I could be cleaned." Record review revealed an initial evaluation and treatment of Occupational Therapy, Physical Therapy and Wound Care was conducted on 07/09/2019 at 1628, revealed PT (Physical Therapist) #2 documented " ...Patient with significant fear of pain and self-limitation to perform bed mobility .... Patient required increased encouragement and Max A (assistance) X 3 (of three people) to facilitate R (rolling). ...Pt (Patient) will need to participate regularly for any benefit to be seen with mobility. Recommending Pt (Patient) DC (discharge) to SNF (Skilled Nursing Facility) for continue rehabilitation. ... Plan Interventions ...Patient/caregiver education ...PT Frequency: 2-3X/week ... Patient has 24/7 supervision however patient reports her mother has been having a difficult time caring for her. Patient reports she also has several family members that come in and assist when able as patient requires 2 person assist for bed mobility. ... Patient has been bedbound for quite some time and has not ambulated in approximately a year and a half." Medical record review revealed reports of pain in bilateral legs and left hip. Record revealed x-rays completed on 07/12/2019 for bilateral lower extremities and left hip without dislocation, no acute fracture. Record review revealed Patient #8 had expressed resistance to participate in physical therapy with some refusal of therapy during her admission. However, review revealed Patient #8 made progress with therapy from required maximal assistance to a minimal assistance needed for side to side roll for bed mobility. On 07/19/2019 at 1454, CM #2 had discussed with Patient #8 the importance of participation with the ordered therapy. Record review of "Care Coordination Update" on 07/26/2019 at 1532, CM #3 documented "...Pt participated w/PT (with Physical Therapy) today but refused to stand w/assistance. Pt was informed per SW (Social Worker) that this can also increase difficulty locating placement if Pt unwilling to participate w/therapy goals. ..." Record review revealed on 07/30/2019 at 1224, CM #3 documented " ...Pt was able to stand w/PT yesterday for 60 seconds. ..." Record review revealed CM #2 documented on 08/21/2019 at 1641, " ...Pt met with [named staff person from named Skilled Nursing Facility (SNF)], [named staff person] advised SW after meeting that they will accept with a LOG (Letter of Guarantee), a bariatric bed with air mattress, wheelchair, hoyer lift (as the facility hoyer only goes up to 475lbs and PT. They are willing to give Pt a private room at no extra cost for 30 days. SW met with Pt and her mother/father at bedside. ...Pt refused [named facility], advised that the hospital cannot force her to go and she has checked reviews online and they 'are below my standards'. ... SW advised that the hospital has a safe dc plan for her with a SNF that is licensed by the state and if she refuses then the hospital will advise that she can be dc'd (discharged) home due to does not have a medical need to remain. ... Pt's mother advised she cannot take care of her at home. ..." Record review revealed CM #2 documented on 09/02/2019 at 1630, " ...Physician feels it will be beneficial to have a meeting with pt. and family to discuss future options. ...Per rn, [named nurse], pt. now able to roll in bed independently to be cleaned. ..." Record review failed to display evidence of instruction in techniques to facilitate management of continuing care needs by use of Teach Back method by Patient #8's primary caregiver (mother). Record review of noted CM #4 "Care Coordination Update" on 09/12/2019 at 1549, revealed "SW stated we only had one (named facility) after a statewide search with a 30-day LOG and they withdrew offer. ...Her mother and father were present. ... her mother continued to state there is no way she can provide the care she needs at home and her dghtr (daughter) will just end up back at hospital with an infection. ..." Record review of noted "Therapy Plan of Care" on 09/12/2019 at 1505, PT (Physical therapist) #1 " ...Discharge Recommendation Update: While SNF remains optimal d/c plan, patient has continued to make progress with bed mobility goals allowing her to return home with the assistance of one person, specifically for rolling to her R (right) side. ..." Record review of noted CM #5 "Care Coordination Update" on 09/13/2019 at 1421, revealed "Social worker met with patient, mother and father in pt.'s room today with physician present. ...Social worker informed pt. and parents of the numerous SNF denials (more than 100 denials) ...Several SNFs denied pt. since pt. has declined physical therapy on several occasions and felt pt.'s refusal would prevent pt. from achieving goals. ...Social worker informed pt., mother and father that pt.'s only current option is to return home. Pt's mother states that pt. cannot return home since mother is not able to care for pt. ..." Record review of the Wound Consultant Note on 09/17/2019 at 0900, revealed "Pt able to turn to right side with minimal assistance. ... No alterations in skin noted. ..." Record review of "Care Coordination Update" on 09/17/2019 at 1935, CM #6 documented the involvement of the Medical Director of Hospitalists, Risk Management, Hospital Security, City Police and the Magistrate to facilitate on 09/17/2019 the discharge of Patient #8 home with Home Health services. "[Patient's Name] confirmed she understands she is medically ready to go home. [Patient's name] confirmed receipt of private duty caregiver list provided. ...Patient's mother provided consent for delivery of DME (Durable Medical Equipment) equipment this evening. ..." Medical record revealed Patient #8 was discharged on 09/17/2019 to home with intended Home Health Agency services for Home Health Skilled Nurse evaluate and treat, Physical Therapy evaluate and treat, DME services and Social Services orders.

Record review revealed Patient #8 was evaluated by the HHA's Registered Nurse's initial assessment on 09/19/2019 at 1409 which deemed the patient "...not appropriate for home health care due to no physically able cg (care giver). ..." Medical record revealed, on 09/26/2019 at 0225, Patient #8 had returned to the Emergency Department (ED) with a complaint of leg pain. Patient #8 was placed into a Skilled Nursing Facility within 24 hours of ED visit.

Interview with PT #1 on 01/08/2020 at 1045, revealed PT #1 had recalled working with Patient #8 several times during the admission period. Interview revealed, Patient #8 was difficult to work with due to her refusal to participate at times. "Patient did not meet her goals, but our biggest barrier was her willingness to participate. ...Patient was able to stand during the hospitalization, which was something she was unable to do prior to admission so that was really positive progress. We recommended rehabilitation although ... discharge with the appropriate equipment discharge to home was the best option. ...There was no significant education provided to her mother due to patient frequently refusing treatment." Interview revealed, the patient's caregiver did not participate in physical therapy sessions nor was the caregiver taught any maneuvers or techniques in preparation for discharge to home.

Telephone interview with the non-hospital staff person, Sales Manager of the HHA on 01/09/2020 at 1030, revealed the technician for the HHA equipment provided education to the patient's caregiver on 09/17/2019 in the patient's home. The caregiver signed consent on 09/17/2019 for receipt of the equipment and the training provided. Interview revealed, on the date of the RN visit 09/19/2019 to Patient #8's home, the caregiver informed the RN that she was unable to provide the needed assistance to care for Patient #8 in the home. It was at that time the HHA declined to accept Patient #8 for services. Interview revealed the Care Manager of HHA then notified the hospital SW department.

Telephone interview with the non-hospital staff person, Sales Manager of the HHA on 01/09/2020 at 1120, revealed a return demonstration was part of the education provided to the caregiver on 09/17/2019 at the time of equipment delivery.

Telephone interview with MD #3 on 01/09/2020 at 1130, revealed Patient #8 was noncompliant with some clinical aspects of care while in the hospital. " ...Staff informed me of so many issues of care that the patient refused. ...I was involved with the discussion with the patient about the importance of her participation with orders. If this patient had followed our recommendations this patient could have done much better with her progression."

Telephone interview with CNA #1 on 01/09/2020 at 1220, revealed CNA #1 provided care for Patient #8 on several occasions, specifically 09/12/2019, 09/13/2019, 09/14/2019, and 09/15/2019. Interview revealed Patient #8 was non-compliant with some clinical aspects of care while in the hospital such as turn and repositioning scheduled every two hours. Interview revealed, "Her mother did mention she did not think she could handle [Patient #8] at home. The hoyer lift is taught in orientation as a two-person assist device."

Interview with SS #1 on 01/09/2020 at 1530, revealed " ...Security Services were asked by clinical staff CM #6 to assure that someone was home on the day of discharge on 09/17/2019. I don't know if the clinical side told the parents or the patient, we were going to do that. Security Services went to the house to make sure someone was home to receive the equipment. Security Services knocked at the door in uniform and marked vehicle to ensure someone was at the home to accept the equipment. ..."

Interview with CM #6 on 01/09/2020 at 1620, revealed Risk Management team alerted CM #6 on 09/26/2019 of an Emergency Department visit by Patient #8. Interview revealed the HHA conducted an "Initial Evaluate and Treat" visit on 09/19/2019 for Patient #8. Interview revealed on 09/19/2019 the RN for the HHA declined to accept the Patient #8 for services. Telephone interview with the non-hospital staff person [Sales Manager of the HHA], revealed it was reported to CM #6 on 09/20/2019 the HHA was unable to accept the Patient #8 for services. Interview revealed, CM #6 was under the impression that Patient #8 refused care. CM #6 did not recall the notification of the HHA's decline to provide outpatient services from the HHA due to the unwilling and uncapable caregiver. During interview CM #6 was made aware the explanations did not correlate regarding the HHA's decline to accept the patient as a client. Interview revealed, on 09/23/2019 the HHA made an Adult Protective Services referral regarding the care of Patient #8. Interview revealed Patient #8 was not admitted to the HHA due to no available caregiver and did not meet criteria for admission.

Interview with the non-hospital staff person, Administrator of the HHA on 01/09/2020 at 1620, revealed the Patient #8 was not admitted to the HHA due to no available caregiver and did not meet criteria for admission.

NC00155961; NC154666; and NC156027