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Based on medical record review and interviews the facility failed to ensure a reassessment of the patient's post-discharge needs was completed after a change was made to the discharge plan and reflected in the discharge documentation provided to the patient. This failure was identified in 1 of 1 patients who had a change in discharge plans upon discharge (Patient #2).

Findings include:

Facility policy:

The Discharge Planning policy read, the purpose was to identify patients with additional needs after discharge in order to provide patients and caregivers adequate time to ensure the patient and family were aware of the continued needs and support for discharge. Reassessment of the discharge plan was to occur throughout the hospitalization as needs were identified or with change in condition. The nurse was responsible for documentation of the discharge plan within the medical record. For the patient to return home, the home care needs would be identified through assessment by nursing or other disciplines. The case manager was to communicate with the home care agency and coordinate the delivery of services and provide referral information.

1. The facility failed to ensure the patients discharge needs were reassessed and reflected within the discharge packet given to the patient, after a change to the discharge plan was identified.

a. Review of the discharge packet provided to Patient #2 at the time of discharge, on 1/10/20 at 2:12 p.m. revealed the documentation provided to the patient did not reflect the change in the discharge plan. Specifically, the patient received a document, at discharge, which specified the discharge plan was to go to a nursing facility. Patient #2 was discharged home with home health services and was not provided with the contact information for the home health agency selected to provide services. Additionally, there was no evidence in the discharge packet the patient was provided any medical equipment, or resources to obtain equipment had it been recommended.

The facility was not able to provide evidence the contact information for the home health agency was provided at the time of discharge and reviewed in the discharge packet.

b. Medical record review for Patient #2 was conducted. Patient #2 was admitted to the facility on 12/28/19 with altered mental status (AMS) and a past medical history to include pulmonary embolism (PE) (blood clot in the lungs), hypertension (high blood pressure), sleep apnea (decreased oxygenation with sleep) and type II diabetes (a condition which required medications to control blood sugar levels).

i. The medical record review revealed the patient was evaluated by Physical Therapy (PT) and Occupational Therapy (OT), on 12/29/19, to determine his functional status and therapy services needed in the hospital as well as potential needs at discharge. Both the OT and PT evaluations revealed recommendations for discharge to a rehabilitation center when ready. The OT evaluation revealed the equipment needed for discharge would continue to be assessed throughout the hospitalization and would be obtained as needed. Similarly, the PT evaluation specified equipment needed for discharge was "to be determined" and it was unknown if Patient #2 had equipment available for use at home.

On 1/9/20 at 2:37 p.m., the medical record revealed a PT note which identified concerns about safety related to altered cognition, but Patient #2 was safe to discharge home with family. Additionally, the patient ambulated with a walker with PT. No equipment was obtained for the patient at discharge and it was unknown what equipment the patient owned.

The OT note on 1/9/20 at 4:39 p.m. revealed the recommendation for discharge continued to be to a rehabilitation facility and equipment recommended would continue to be assessed and obtained as needed.

ii. Review of the Case Management (CM) Discharge Planning Evaluation on 12/29/19 at 6:02 p.m. revealed Patient #2 lived at home with his spouse and had limitations in his ability to toilet himself. Additionally, the patient had home health services prior to admission and had barriers to discharge related to a significant medical condition. CM noted they would continue to follow the patient for discharge needs.

The CM notes revealed on 1/6/20 at 11:46, Patient #2, continued to have barriers to discharge and recommendations were to be determined and discussed with the family as needed.

On 1/10/20 at 10:41 a.m., a note from CM revealed the anticipated discharge was home with home health care and there were no additional recommendations from other members of the care team (PT or OT).

On 1/10/20 at 1:58 p.m. a note from CM revealed PT recommended Patient #2 be discharged to a rehabilitation facility, however, Patient #2 refused and requested to be discharged home with home health care. Per the note, the family agreed with the new discharge plan. The CM note revealed the patient was accepted to receive home health services upon discharge, but no follow up was noted for Patient #2's post discharge needs due to the new discharge plan.

iii. The Discharge Summary completed by the physician on 1/10/20 at 5:12 p.m. revealed the disposition plan was for Patient #2 to go home with home health services which was discussed with the patient and his family. The Discharge Summary noted CM was to arrange the home health as well as medical equipment needed.

Throughout the duration of the hospitalization, and upon discharge, there was no evidence of assessment for the need of medical equipment completed by OT, PT, CM or nursing staff. Furthermore, there was no evidence the patient or family was provided resources in order to obtain medical equipment for use at home.

c. An interview was conducted with Registered Nurse (RN) #1 on 2/18/20 at 8:59 a.m. She stated the information provided to the patient upon discharge differed based on where the patient was discharged to. RN #1 said if a patient was discharged home they would receive a packet which included information about the reason they were hospitalized, the follow up recommendations and plan, recommended diet and activity level, medications and possible side effects as well as general information about stroke and safety after discharge. She stated the discharge packet was her responsibility to compile and review with the patient and families.

Upon review of the discharge packet and information provided to Patient #2, RN #1 identified a discrepancy in the discharge plan. She revealed the discharge packet noted the patient went to a nursing facility, but the note she entered into the record reflected Patient #2 went home with home health. RN #1 was unable to recall if she provided the patient the contact information for the home health agency upon discharge and was unable to provide evidence of the updated information within the discharge packet provided to the patient. Furthermore, RN #1 stated she thought CM provided patients with home health agency contact information.

d. An interview was conducted with CM #2 on 2/18/20 at 9:40 a.m. She stated her role was to assist and coordinate the discharge process to ensure the patients were discharged to a safe environment. She said the discharge planning process included a review of the medical record and conversations with the medical team (OT, PT, nursing and physicians) to determine a patient's post discharge needs. She stated medical equipment needed for discharge was determined by OT and PT recommendations which was then reviewed with the patient and family by CM.

Upon review of Patient #2's record, CM #2 stated she recalled the decision for the patient to return home with home health occurred the same day of discharge. CM #2 said she thought there was an assessment which reflected what the patient needed at home, however was unable to provide evidence of the assessment. CM #2 stated Patient #2's medical equipment needs were identified by OT and PT, however, she was unable to identify any specific recommendations. Furthermore, she was unable to provide evidence this information was reviewed or reassessed with the patient and family after the discharge plan was changed to go home with home health services versus a skilled nursing facility.

CM #2 stated upon selection of an agency prior to discharge, the patient would receive a yellow sheet with the name of the agency the patient was referred to for follow-up. The document was not found in the medical record. CM #2 stated she was unsure if the contact information for the selected agency was included in the discharge packet provided by the RN.

e. An interview was conducted with PT #3 on 2/18/20 at 11:00 a.m. She stated the role of the OT and PT was to make an initial discharge recommendation based on the patient's functional status and needs. She said an evaluation of possible medical equipment needs or equipment a patient had available was completed during the initial evaluation. PT #3 stated recommendations were then relayed to the CM for further coordination.

Upon review of Patient #2's medical record, PT #3 was unable to identify medical equipment recommendations for discharge, nor an assessment of equipment the patient had access to. PT #3 was unable to identify a reassessment of medical equipment needs upon change of the discharge plan. PT #3 stated there was no evidence as to what the patient needed or resources provided to the family. PT #3 stated the risk of discharging a patient without appropriate medical equipment was an unsafe discharge which could ultimately result in a fall.