HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to provide patients with an effective discharge planning process, including discharge planning throughout admission, an evaluation of the discharge plan, an accurate, patient-specific discharge summary, and an effective process to communicate the patient's post-discharge treatment needs and referrals.

Failure to provide patients with a discharge planning process that focuses on the patient's goals, treatment needs, and ensure an effective transition to post-discharge care, places the patients at risk for inappropriate, inadequate care, readmissions, and poor outcomes.

Findings included:

1. Failure to ensure that staff provide all patients with discharge planning and the evaluation of the discharge plan, places the patients at risk for an ineffective transition to post-discharge care and increases the risk for patient harm.

2. Failure to ensure the initiation of an accurate, patient-specific discharge summary places the patients at risk for inappropriate post-discharge treatment and increases the potential for re-admission.

Cross Reference: A0802

3. Failure to ensure that a discharge summary is included in the patient's medical record puts the patient at risk for poor continuiuty of care and potential patient harm.

4. Failure to ensure that patient-specific medical information and post-discharge treatment needs are included in the patient's discharge plan and discharge summary puts the patient at risk for inappropriate post-discharge services and inadequate continuity of care.

Cross Reference: A0813

Due to the scope and severity of deficiencies cited under 42 CFR 482.43, the Condition of Participation for Discharge Planning was NOT MET

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Item #1 - Evidence of Discharge Planning/Evaluation

Based on interviews, policy review, and medical record review, the hospital failed to ensure that staff documented evidence of discharge planning and the ongoing evaluation of the patient's discharge plan throughout the patient's admission, as demonstrated by 5 of 10 records reviewed (Patients #2, #3, #4, #5, and #6).

Failure to ensure that staff documented evidence of discharge planning and the evaluation of the discharge plan, places the patient at risk for an ineffective transition to post-discharge care, creates barriers to continuity of care, and increases the risk of patient harm and potential for readmission.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Discharge and Transition Planning - Inpatient," Policy Stat ID #14647604, last revised 11/23, showed the following:

a. The purpose of the policy is to ensure patients are allowed to transition to another level of clinical care or treatment at the time of discharge, when necessary.

b. It is very important that all steps of the discharge are documented. Information that will be documented in the chart includes:

i. Initial conversation with the patient regarding discharge.

ii. Weekly discharge discussions.

iii. Discharge conversations within 24 hours of discharge.

Document review of the hospital's policy and procedure titled, "Inpatient Discharge Process," Policy Stat ID #13484606, effective 04/23, showed the following:

a. The purpose of this policy is to note that patients discharged from inpatient services will undergo a coordinated and compliant discharge process. The goal is to identify risk factors that may result in further treatment recommendations, when possible, and continuity in the patient's care through coordination with the patient's aftercare provider.

b. For all discharges, planned, unplanned, and AMA - The facility engages in ongoing transition planning at the start of services, throughout the course of treatment, and at the time of discharge. The therapist will be responsible for completing the Discharge Planning Progress Note in its entirety. The form will be initiated at admission and indicate when and where all information is documented in the chart. Information that will be documented in the chart minimally includes:

i. Initial conversation with the patient regarding discharge.

ii. Weekly discharge discussions.

iii. Discharge conversation within 24 hours of discharge.

iv. Information on family sessions, living arrangements, and transportation information and needs.

v. Safety concerns addressed before discharge.

vi. Aftercare plans to include provider and therapy appointments.

2. The Investigator reviewed the medical records of 10 patients who had been discharged from the hospital within the last 6 months. The medical record review showed the following:

a. Patient #2 was admitted on 03/17/24 and discharged on 03/22/24 when the Patient's behavior became increasingly sexually aggressive and assaultive. The hospital staff contacted law enforcement and the Patient was taken into police custody and transported to jail. A review of the Patient's medical record, including treatment planning documents and clinical progress notes, found that staff failed to document evidence of discharge planning or attempts of discharge planning during the Patient's admission before the Patient was taken into custody.

b. Patient #3 was admitted on 11/26/23 and discharged on 12/01/23 as a planned discharge. On 12/01/23, the nursing staff documented that the Patient was discharged on 12/01/23 at 6:00 PM. The Patient reported to the nurse that she was struggling with loneliness, apathy, and panic. The provider was notified and advised the staff to continue with the discharge. A review of the Patient's medical record, including treatment planning documents and clinical progress notes, found that staff failed to document evidence of discharge planning or attempts of discharge planning during the Patient's admission for the planned discharge.

c. Patient #4 was admitted on 09/30/23 and discharged on 10/04/23 as a planned discharge. On 10/04/23 at 12:00 PM, nursing staff documented that at discharge, the Patient endorsed suicidal ideation. The provider was notified and advised staff to continue with the discharge. A review of the Patient's medical record, including treatment planning documents and clinical progress notes, found that staff failed to document evidence of discharge planning or attempts of discharge planning during the Patient's admission for the planned discharge.

d. Patient #5 was admitted on 01/18/24 and discharged on 01/21/24 when the Patient's behavior escalated. On 01/21/24 at 7:00 AM, the nursing staff documented that the Patient became disruptive and demanding, attempting to get into the nurse's station. The provider was notified, and an order was given for emergency intramuscular medication. The hospital staff contacted law enforcement and the Patient was taken into police custody and transported to jail. A review of the Patient's medical record, including treatment planning documents and clinical progress notes, found that staff failed to document evidence of discharge planning or attempts of discharge planning during the Patient's admission for the planned discharge.

e. Patient #6 was admitted on 02/13/24 and discharged on 02/25/24 when the Patient became aggressive and assaultive, fashioning a weapon from a piece of plastic. The hospital staff contacted law enforcement and Patient #6 was taken into police custody and transported to jail. On 02/25/24 the provider placed an order to discharge the Patient AMA due to aggressive behavior. A review of the Patient's medical record, including treatment planning documents and clinical progress notes, found that staff failed to document evidence of discharge planning or attempts of discharge planning during the Patient's admission for the planned discharge.

3. On 04/03/24 at 1:00 PM, during an interview with the Investigator, the Discharge Planner (Staff #5) stated that all their documentation is through the hospital's electronic system called Fluency and is included in the copy of the medical record provided to the Investigator. When the Investigator asked Staff #5 about the missing discharge planning documentation in the medical record, the Discharge Planner verified that it was missing and stated that sometimes patients are unwilling or unable to participate in discussions about discharge planning. Staff need to make sure that they attempt to meet with the patient at least three different times and document the attempts.

4. On 04/09/24 at 2:40 PM, during an interview with the Investigator, the Director of Clinical Services (Staff #8) stated that the therapists are responsible for documenting discharge planning on the "discharge planning progress note." Staff #8 stated that the therapists will meet with the patients on the 2nd or 3rd day of their admission to discuss discharge planning. Staff #8 was not aware that 5 of 10 medical records reviewed did not contain evidence of discharge planning. Staff #8 stated that often this is discussed with the treatment team and the discharge planner and staff should document these discussions.


Item #2 - Missing or Incongruent Information - Discharge Summary

Based on interviews, policy review, and medical record review, the hospital failed to ensure that staff initiated a patient-specific, individualized discharge summary, that contained accurate documentation of the patient's admission and relevant, patient-specific requirements for post-discharge, as demonstrated by 3 of 5 records reviewed (Patients #1, #2, and #9).

Failure to ensure the initiation of an accurate, patient-specific discharge summary places the patient at risk for an ineffective transition to post-discharge care, creates barriers to continuity of care and increases the risk of patient harm and potential for readmission.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Inpatient Discharge Process," Policy Stat ID #13484606, effective 04/23, showed the following:

a. The facility's Medical Provider will complete the Inpatient Discharge Summary as soon as possible, but no later than 30 days after the patient's discharge.

b. The following information is to be documented in the patient's discharge summary:

i. Date of discharge.

ii. Identifying information and reason for hospitalization.

iii. Hospital course.

iv. Laboratory findings.

v. Discharge diagnosis.

vi. Follow-up appointments.

vii. Discharge medications.

viii. Diet and activities.

ix. Disposition.

x. Prognosis.

2. The Investigator reviewed the medical records of 5 patients who had been discharged from the hospital within the last 6 months and whose medical records contained the required discharge summaries. The medical record review showed the following:

a. Patient #1 was admitted on 10/10/23 for treatment of an exacerbation of schizophrenia and discharged on 01/26/24 to an adult family home (AFH). On the Patient's Discharge Summary dated 01/31/24, the provider documented that over the course of the Patient's hospitalization, she achieved her targeted goals, which were identified as a baseline of psychosis. The provider stated that during admission the Patient participated in CBT (Cognitive Behavioral Therapy) and Process Groups that focused on reducing stress, addiction, and mental health. The Patient also participated in Activity/Leisure Groups that focused on music, art, and health relationships. However, a review of the Patient's medical records found that Patient #1 had refused to attend 326 of 369 therapy/activity groups offered during her admission.

b. Patient #2 was admitted on 03/17/24 and discharged on 03/22/24 when the Patient's behavior became increasingly sexually aggressive and assaultive. The hospital staff contacted law enforcement and the Patient was taken into police custody and transported to jail. On the Patient's Discharge Summary dated 04/02/24, the provider documented that the Patient did not complete psychiatric stabilization and was discharged into police custody after assaulting another patient and staff member. The Discharge Summary also contained documentation from the provider stating, "the patient was no longer considered suicidal, homicidal, or unsafe outside of a structured setting," which was inconsistent with the Patient's documented aggressive/assaultive behavior which led to his transfer to jail.

c. Patient #9 was admitted on 01/10/24 and discharged on 01/17/24. On 01/17/24, the nursing staff documented that the Patient began destroying the computer station and the juice machine. The nursing staff called for assistance from staff (Code 100) and contacted the provider for an order for emergency medication. The medication was administered; however, the Patient continued the destructive aggressive behavior. The nursing staff documented that when the provider was updated, the provider decided to discharge the Patient as an AMA discharge. The provider directed staff to escort the Patient to the front door of the facility, returned his belongings to him, and had him leave the facility. A review of the Discharge Summary dated 01/17/24 found that the provider documented that the Patient was discharged back into the community due to his request leave leave the hospital against medical advice. The provider documented the Patient's mental status on discharge as follows: Appearance: Neat and clean; Behavior: Cooperative; Mood: "I'm fine"; Affect: Mood congruent; Attention: Intact; Thought Process: Logical, Linear, Organized; Associations: Intact; Judgement/Insight: Poor. The Investigator found that the information contained in the Discharge Summary was incongruent with the description of the incident by the nursing staff which had ultimately led to the Patient's request to leave against medical advice.

3. On 04/03/24 at 1:00 PM, during an interview with the Investigator, the Discharge Planner (Staff #5) stated that when there is a patient incident, and law enforcement is contacted, often the Quality Department will take over the documentation of the incident. The discharge planner's role is minimal. The provider will always write the discharge summary. The provider is typically involved in the incident if they are on-site at the facility, and they would have access to all of the documentation regarding the incidents. The staff are told to document the incident in the progress notes of the medical record.

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Item #1 - Discharge Summary

Based on interviews, policy review, and medical record review, the hospital failed to ensure that the patient's medical record included a discharge summary, as demonstrated by 5 of 10 records reviewed (Patients #5, #6, #7, #8, and #10).

Failure to ensure that a discharge summary is included in the patient's medical record puts the patient at risk for poor continuity of care and potential patient harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Inpatient Discharge Process," Policy Stat ID #13484606, last revised 04/23, showed the following:

a. Definitions include:

i. Planned Discharge - The patient was discharged as projected and planned.

ii. AMA (Against Medical Advice) Discharge - Discharges where a patient chooses to leave the hospital before the treating provider recommends discharge.

iii. Unplanned Discharge - The patient was discharged after discharges were reviewed in the daily Flash meeting and occurred outside of the treatment team and the established daily discharge list. For example, if the patient wasn't projected by the treatment team for discharge before the patient's discharge and the provider has not classified the discharge as an AMA, the discharge is unplanned.

b. The Medical Provider will complete the patient's Discharge Summary as soon as possible, but no later than 30 days after the patient's discharge.

Document review of the hospital's policy and procedure titled, "Unplanned Discharge," Policy Stat ID #13083795, effective 02/23, showed the following:

a. All discharge paperwork completed for a planned discharge should be completed for an unplanned discharge and AMA discharge.

b. This includes a Discharge Plan and Discharge Summary.

2. The Investigator reviewed the medical records of 10 patients who had been discharged from the hospital within the last 6 months. The records review showed that medical staff failed to document a discharge summary for the following patients:

a. Patient #5 was admitted on 01/18/24 and discharged on 01/21/24 when the Patient's behavior escalated. The hospital staff contacted law enforcement and the Patient was taken into police custody and transported to jail.

b. Patient #6 was admitted on 02/13/24 and discharged on 02/25/24 when the Patient became aggressive and assaultive, fashioning a weapon from a piece of plastic. The hospital staff contacted law enforcement and Patient #6 was taken into police custody and transported to jail.

c. Patient #7 was admitted on 01/26/24 and discharged on 02/10/24 when the Patient became combative, threatening staff. The hospital staff contacted law enforcement and Patient #7 was taken into police custody and transported to jail.

d. Patient #8 was admitted on 01/03/24 and discharged on the same day (01/03/24) when the Patient requested to leave the facility against medical advice (AMA).

e. Patient #10 was admitted on 01/22/24 and discharged on 01/22/24 when the Patient requested to leave the facility against medical advice (AMA).

3. On 04/03/24 at 11:00 AM, during an interview with the Investigator, the Director of Quality (Staff #1) stated that the electronic copies of the patient's medical records provided to the Investigator were each patient's record in its entirety and should contain all the documents from the original paper chart, including the discharge summary. Staff #1 verified that some of the medical records reviewed were missing documents, including the discharge summary. During the investigation, after multiple requests, the facility was unable to provide the missing documents to the Investigator.

4. On 04/03/24 at 1:00 PM, during an interview with the Investigator, the Discharge Planner (Staff #5) stated that when a patient discharges AMA, the Discharge Planner's role is minimal. The therapist will write the Discharge Plan and the provider, who is already aware of the patient's request to discharge AMA, will write the Discharge Summary.


Item #2 - Transfer of Medical Information and Referrals (CMS)

Based on interviews, policy review, and medical record review, the hospital failed to ensure that the patient's medical information, including referrals for post-discharge care, is included in the discharge plan and discharge summary, as demonstrated by 3 of 10 records reviewed (Patients #1, #6, and #10).

Failure to ensure that patient-specific medical information and the need for post-discharge care are included in the patient's discharge plan and discharge summary puts the patient at risk for poor continuity of care and potential patient harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Discharge and Transition Planning - Inpatient," Policy Stat ID #14647604, last revised 11/23, showed the following:

a. The purpose of the policy is to ensure patients are allowed to transition to another level of clinical care or treatment at the time of discharge, when necessary.

b. It is very important that all steps of the discharge are documented. Information that will be documented in the chart includes aftercare plans, such as provider and therapy appointments.

c. Patients discharged from inpatient services should have a provider appointment set within 7 days of discharge. If it is not possible, it should be documented thoroughly.

d. The discharge plan should include the following information:

i. Next provider of care to include contact information and appointment time.

ii. Continued treatment needs.

iii. Medical appointment information, if needed.

Document review of the hospital's policy and procedure titled, "Unplanned Discharge," Policy Stat ID #13083795, effective 02/23, showed the following:

a. All discharge paperwork completed for a planned discharge should be completed for an unplanned discharge and AMA discharge.

b. This includes a Discharge Summary and a Discharge Plan completed in full, including the next provider of care and/or resources recommended for the patient to follow up with at discharge.

Document review of the hospital's policy and procedure titled, "Inpatient Discharge Process," Policy Stat ID #13484606, effective 04/23, showed the following:

a. Discharge is based on the assessed needs of an individual, specifically any physical or psychosocial needs.

b. Regardless of planned, unplanned, or AMA discharge status, facility staff members are to determine with the patients when possible whether further services are needed and provide referrals to needed services.

2. The Investigator reviewed the medical records of 10 patients who had been discharged from the hospital within the last 6 months. The medical record review showed the following:

a. Patient #1 was admitted on 10/10/23 and discharged on 01/26/24 to an adult family home (AFH). A review found that the Patient had an appointment set up for medication management on 03/01/24 (35 days after discharge) and an additional appointment on 04/04/24 (69 days after discharge) to meet with her primary care provider (PCP). The provider wrote orders for a 30-day supply of medications, that were electronically sent over to the Patient's pharmacy of choice. These medications, if taken as prescribed, would run out before the Patient's medication management appointment on 03/01/24. The staff failed to document why the aftercare appointments were set up more than 7 days after the Patient's discharge, as directed by hospital policy.

b. Patient #6 was admitted on 02/13/24 and discharged on 02/25/24 into police custody. During the Patient's admission, he was sent to the acute care medical hospital for the evaluation and treatment of frostbite on his fingers on both hands, after it was assessed that the skin on his fingers was blackened, peeling, scabbed, and purulent discharge (thick, milky discharge) from the left fifth digit (little finger). The instruction from the acute care medical hospital included pain medication, and the recommendation to schedule a follow-up appointment with the orthopedic and neurosurgical center upon discharge. A review of the Discharge Plan dated 02/25/24 found that staff documented that the Patient did not have any medical follow-up appointments. The hospital staff failed to document the recommendation for the Patient to follow up with the orthopedic and neurosurgical center upon discharge for the continued evaluation and treatment of his frostbite.

c. Patient #10 was admitted on 01/25/24 and discharged on 01/31/24 when he was discharged AMA. During the Patient's admission, he was prescribed Suboxone (buprenorphine/naloxone) which is used to treat narcotic dependence. A review of the discharge plan and discharge summary found that staff failed to document a referral to an aftercare facility to manage the Patient's Suboxone medication.

3. On 04/03/24 at 11:15 AM, during an interview with the Investigator, a Registered Nurse (RN) (Staff #3) stated that when there is a discharge, the RN will go over the medication with the patient. Staff #3 stated that the therapist is responsible for completing the discharge plan.

4. On 04/03/24 at 1:00 PM, during an interview with the Investigator, the Discharge Planner (Staff #5) stated that they would meet with each patient on the 3rd or 4th day of their admission to discuss the discharge plan. The therapist will also meet with the patients and is responsible for establishing the details of the discharge plan. The discharge planner then implements the plan set up by the therapist, by setting up the follow-up appointments and arranging transportation and housing (when needed).

5. On 04/09/24 at 2:40 PM, during an interview with the Investigator, the Director of Clinical Services (Staff #8) stated that the therapists meet with the patients on the 2nd or 3rd day of their admission to discuss discharge planning. During treatment team meetings, the provider will project the patient's anticipated discharge date and any patient-specific aftercare recommendations. Then, the discharge planner will work on setting up the patient's post-discharge appointments. Staff try to set these appointments up within 7 days of discharge, but often in rural areas it's difficult to schedule appointments, so they will document the attempt and find a walk-in clinic within the community. Staff #8 stated that in the case of Patient #1's medication management appointment that was scheduled 35 days after discharge, the Patient should have been discharged with a prescription for her medication to account for the delay in seeing a provider.

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