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Based on interview, record review, and review of the facility policy it was determined the facility failed to establish an appropriate discharge plan for one (1) of ten (10) sampled patients (Patient #8). Patient #8's physician ordered a Case Management Consultation on 08/05/2020, for home health services post-discharge, related to a decubitus ulcer. However, interviews with staff revealed the consultation did not occur as ordered, and the patient was discharged home with no home health services.

The findings include:

Review of the facility policy titled "Discharge Planning," dated January 2017, revealed the discharge planning process should be initiated at the time of admission and was utilized to determine and identify the appropriate post-hospital discharge needs of each patient. The policy also stated that a Registered Nurse (RN), Social Worker, or other qualified personnel must coordinate the discharge needs evaluation and development of the discharge plan.

Review of Patient #8's medical record revealed he/she was admitted to the facility on 08/02/2020 with diagnoses that included Chronic Paraplegia, Altered Mental Status, and Complicated Urinary Tract Infection. Further review of Patient #8's medical record also revealed on 08/03/2020 staff identified a decubitus ulcer on his/her perineal area.

Patient #8's record also indicated his/her physician ordered a Case Management Consultation on 08/05/2020, for the patient to receive home health services post-discharge, related to a decubitus ulcer on his/her coccyx.

Review of Patient #8's record revealed Registered Nurse (RN) #1 (Case Manager) consulted with the patient and his/her caregiver on 08/06/2020 and no discharge needs were identified. Patient #8 was discharged home with no home health services on 08/07/2020.

Interview with Patient #8 and his/her caregiver on 09/23/2020 at 1:40 PM revealed the patient was discharged home on 08/07/2020 with no home health services for ongoing care and treatment for the patient's decubitus ulcer. The caregiver stated she received a call on 08/06/2020 from a Case Manager related to home health needs post-discharge but was not informed by the Case Manager that the patient had a decubitus ulcer. The caregiver also stated she would have requested home health services if staff had informed her that Patient #8 had a decubitus ulcer at the time of discharge.

Interview with RN #1 (Case Manager) for Patient #8 on 09/23/2020 at 3:00 PM revealed she spoke to Patient #8 and his/her caregiver on 08/06/2020 and no discharge needs were identified. However, she acknowledged she was not aware that Patient #8 had a decubitus ulcer when the consultation occurred. Therefore, she had not discussed care and treatment post-hospital discharge related to his/her decubitus ulcer with the patient or his/her caregiver, to ensure home health services were not needed. She stated staff were required to have a care meeting related to potential post-discharge needs of each patient; however, no meeting occurred related to the needs of Patient #8 and that was why she was not aware he/she had a decubitus ulcer. She also stated a meeting should have occurred to ensure Patient #8's discharge needs were identified and met before he/she left the facility.

Interview with Risk Manager (RM) #1 on 09/23/2020 at 2:30 PM revealed staff were required to conduct care meetings for each patient to ensure any discharge needs were identified and home health services provided post-discharge as required. She stated Case Management should have been aware that Patient #8 had a decubitus ulcer when the consultation occurred on 08/06/2020, so the ongoing care/treatment could have been discussed with the patient and his/her caregiver to ensure home health services were provided if needed. The RM also stated the caregiver contacted the facility three (3) days post-discharge and requested assistance with obtaining home health services for care and treatment of Patient #8's decubitus ulcer. Further interview with the RM revealed the facility assisted with setting up home health services for Patient #8 on 08/10/2020.