HospitalInspections.org

Based on review of the hospital's policy and procedures, medical record review, and staff interviews, the hospital failed to implement a safe discharge plan by failing to reassess the appropriateneess of the discharge plan for 1 of 1 (Patient #1) discharged patients who was readmitted to the hospital within 6 days of discharge

The findings include

Review of the current hospital policy and procedure (P&P) "Discharge Planning" dated 03/08/11 revealed "the case manager is responsible for assessing discharge planning needs and coordinating referrals for needs in the home....when a patient/significant other/guardian chooses a plan for care after discharge that is considered by a health team member to be inappropriate, documentation must show that the patient/significant other/guardian and any other involved health team members have been informed... General Information and Desired Outcome... 2. Discharge planning includes assessment, intervention, information and referral regarding but not limited to: Home care, Homemaker services, Home health aides, Rehabilitation, Nursing home....; 3. Assessment: interview patient and or family for their perception of problems, feelings, wishes, attitudes, etc.; Determine functional status/ability to perform activities of daily living;... Assess ability of family significant other/guardian to help;... 5. Assess the effectiveness of the ongoing discharge plan to coordinate the component parts and to intervene as necessary, with the patient, family or community agency to resolve problems and reduce obstacles to continued care... Home Care.... 4. Ensure home health care referral is completed and accurate; 5. Notify home care and verify that services can be provided".

Review of the current hospital policy "Continuum of Care Plan", dated 6/2010, states "leaders have developed processes for the provision of services to provide care in a continuous manner utilizing the care settings appropriate to the patient needs. Central to these processes are the assessment and reassessment of patients in order to match patient needs with the appropriate level and type of setting and the coordination and collaboration among health care professionals, other health care facilities and patient and/or families. ...13. Decisions regarding provision of care are always based on the patient's needs for care and never on ability to pay or on the recommendation of an external review agency".

Closed medical record review of Patient #1 revealed a 73 year old male admitted on 09/16/2012 with repeated falls and rapid decline in cognitive function and aggressive behavior. Review of the dictated physician's (Physician #1) History and Physical (H&P) exam, dated 09/16/2013, revealed for Patient #1 a Chief Complaint (CC) of "falls" and History of Present Illness (HPI) of "repeated falls, rapid decline in cognitive function, and aggressive behavior, wife has been caring for him for the last 2 years ...and now too much to handle, since she also uses walker to get around since recent surgery". Further review of the H&P revealed the Assessment/Plan to be " falls secondary to Ataxia PT (physical therapy)/OT (occupational therapy), Alzheimer's dementia advance...family requesting placement". Continued record review revealed Patient #1 was discharged back to home on 10/03/2012.

Record review revealed a Case Manager's (CM #1) note dated 09/25/2012 at 1530. Review of the notes revealed "sitter noted with patient per MD (medical doctor) order for safety. Spoke with staff nurse who stated patient has not actively fallen during hospital stay but sitter provided per MD order for safety. Called physician and discussed the need for sitter for patient and per LTAC (long term acute care) representative patient needs to be evaluated for LTAC placement sitter-free for 48 hours. MD agreed to attempt allowing patient to be on falls protocol without sitter present". Continued review revealed CM #1 documentation on 10/01/2012 at 1258 "no offer for bed placement with LTAC".... Requested patient information go out to...ALF's (assisted living facility) with memory care unit "with a locked unit due to patient walking > (greater than) 150 feet with PT (physical therapy) here and has dementia". Further record review revealed on 10/01/2012 at 1308 the CM #1 notes revealed "informed her (the spouse) that ALF (assisted living facility) with locked unit may be the best option for patient since he is now able to walk 300 feet with PT. Family in agreement..."

Continued review of the CM #1 notes on 10/02/2012 at 10:01 revealed "Discussed case with CM director. Asked CMA (case management assistant) to send patient information state-wide for bed offers. Called patient family member ... and made her aware we were seeking a bed offer state-wide and if no bed offer available, and patient is ambulating 300 feet at this point, then patient will have to be discharge home with family, as all means have been exhausted in attempting placement for patient ....."

Record review revealed a Social Worker (SW #1) note on 10/2/2012 at 1126. Review of the notes revealed "it will likely be harder to obtain a LTC bed but at least it secures a payer source as home does not seem to be an option especially with diagnosis of ES (end stage) Alzheimer's dementia with psychotic features LTC in SNF (skilled nursing facility) would be an appropriate option.

Continued record review of the CM #1 notes on 10/02/2012 at 1314 revealed "spoke with patient's Primary Physician (PCP) extensively about patient case. Informed him that we are seeking LTC (long term care) SNF (skilled nursing facility) placement for patient state-wide but if no bed offers return, then the patient will need to be discharged home tomorrow with family and that family is aware that this is a possibility for patient. PCP concerned about patient safety at home. Informed patient is walking 300 feet with PT. Safety issue involved is patient going outside at home and wife is unable to follow patient due to her own recent hip surgery ....PCP wanted APS (adult protective services) to evaluate patient safety prior to the patient leaving hospital, APS requires patient be at home in order to determine if patient is safe or not."

Further review of CM#1 notes on 10/03/2012 at 0945 revealed "informed wife that DSS (department of social services) would evaluate patient safety at home and any concerns that she has regarding patient's safety at home should be shared with DSS worker. Voiced understanding. Wife stated she could not transport patient home as she is unable to drive due to her recent surgery and her sister, is traveling back home today from TN (Tennessee) and is unable to pick patient up today if patient is discharged home." Further record review revealed on 10/03/2012 at 10:05 the CM #1 notes revealed "discharge plan (DCP) home with APS referral and need for transport home since no family available to transport patient home today".

Further record review of SW #1 notes on 10/03/2012 at 1039 revealed "patient will likely be discharged home due to no bed offers after a state wide search....spouse can not come pick patient up as she is not driving yet since she is recovering from surgery...W/C (wheelchair) van will pick patient up at 11:30 am (to transport home)... spoke with patient's spouse confirmed there is a w/c ramp...patient has a walker and w/c...spouse verbalized understanding that no bed offers for placement... states she will continue to try and care for patient at home until other options are available...confirms someone will be with patient 24/7 for supervision." Continued review of the chart revealed on 10/04/2012 at 1427 SW #1 notes revealed "APS has been out to see patient feels SNF placement is needed to maintain patient safety and meet care need ... efforts continue to locate a SNF bed for patient however he (the patient) no longer met medical necessity to remain inpatient (in the hospital) and was d/c (discharged from hospital) yesterday with spouse in agreement."

Further review reveals no documentation of Home Health (HH) or other in home care agency referral.

Review of the record revealed Patient #1 returned to the Emergency Department (ED) on 10/09/2012 at 1046, 6 days after discharge of 10/03/2012, with chief complaint of " fall" and subsequently admitted as an inpatient on 10/09/2012 at 1400. Record review of the ED summary report revealed on 10/09/2012 at 1048 the patient's chief complaint "per family" was "fall, slid out of recliner, and not acting right". Review of the physician's (Physician #2) H&P dated 10/09/2012 at 1634 revealed the CC as "altered mental status" with HPI of "the patient has end-stage Alzheimer's... the last several days this gentleman has had a change in mental status from his baseline. He has been more agitated and then occasionally more somnolent". Review of the physician's Assessment/Plan revealed diagnosis of Sepsis (infection throughout the whole body-systemic), toxic encephalopathy (disorder of the brain) secondary to sepsis, UTI (urinary tract infection), pneumonia left lower lobe,...end-stage dementia with behavioral abnormalities, ...functional quadriplegia (patient is unable to feed self; do ADL's (activity of daily living); walk; is total care". Record review revealed Patient #1 was discharged on 10/11/2012 to a SNF.

An interview on 01/30/2013 at 0930 with the assigned SW (SW #1) revealed "if home can provide 24/7 care that is required for a patient then we may send them home pending placement, if family is in agreement. We can also make referral to APS but they can not go into the home to determine safety until the patient is discharged and at home". Review of the chart by SW #1 revealed the patient was admitted on 09/16/2012 and discharged home via wheelchair (w/c) van service on 10/03/2012 at 1130. SW #1 stated the patient had "dementia and was not competent to make decisions and wife was the decision maker". Continued interview revealed "patient was feeding him self with verbal cueing (from staff), patient was ambulating with PT and required someone to be with him 24/7 for his safety... the wife had recent surgery but understood patient had to go home pending SNF placement since he (the patient) did not meet admission criteria to stay in the hospital and we had a state wide search for placement pending". Continued interview with SW #1 revealed "I knew the attending physician had concerns about patient safety at home and I knew there was an issue of safe discharge so we made the referral to APS but they couldn't go in to evaluate if the home was safe until after the patient went home....the patient no longer met medical necessity for admission to the hospital and we didn't know how long it would take to get a SNF placement...so he was discharged home pending SNF placement & the wife was in agreement with discharge plan". Interview with SW #1 revealed she knew the spouse wanted the patient placed and that she couldn't meet his needs at home, however, "the spouse's sister (patient's sister-n-law) would be at home to help 24/7 through the weekend". Interview revealed SW #1 s"did not know" who would take care of the patient and provide for his needs and safety after the sister-n-law left the home on Sunday, four (4) days after discharge.

An interview on 01/30/2013 at 1015 with the CM director revealed there are 3 things that should be considered when looking at a safe discharge plan for the patient 1) what level of care the patient will need? 2) Can these needs be met at home? 3) What are the risks (to the patient)? The interview further revealed "the patient needed 24/7 care and supervision for safety and personal care needs for all ADL's (bathing, grooming, dressing, toiletry); the wife due to recent hip surgery could not provide for his care however she stated her sister could provide this service through the weekend but no one would be there to help after that and there was risk for the patient's safety and significant risk to the patient for readmission (to the hospital). APS agreed the patient needed to be placed for his safety and yes we could have done better and should have waited until he was placed in a facility rather than discharge home. He was readmitted on 10/09/2012 for falls and change in behavior."

An interview on 01/30/2013 at 11:30 with the RN (RN #1) who discharged Patient #1 revealed the patient care needs as "the patient needed assistance with bathing and dressing, he was oriented to self but had dementia and Alzheimer's... he was incontinent (involuntary excretion of urine) and wore briefs that required someone to change him ...he could not be left home alone ... he is unable to perform ADL's and IADL's (instrumental activities of daily living i.e. housework, cooking, shopping) these needs would have to be provided by others. The doctor emphasized the patient needed home health and couldn't take care of himself; review of my discharge forms shows no home health referral was set for this patient." Review of the chart by RN #1 during interview revealed the patient was transported home by an ambulance service via wheelchair; the nurse reviewed the d/c instructions over the phone with the wife and informed her "the patient is at very high risk for falls". RN #1 revealed "I remember putting on his shoes. He was wearing a brief (diaper) because he was incontinent of urine but I can't recall if he went home in a hospital gown. The family couldn't come get him so we may not have had clothes for his discharge in that case we would have put two gowns on him for transport home."

An interview via telephone on 01-30-2013 at 1130 with the patient's attending physician (Physician #3) revealed his concern for a safe discharge was "the patient was incompetent and my concern with his dementia was that I worried he would just walk out of the house with no one there to safely care for him; his wife had recent hip surgery and she wasn't able to provide for his care. I requested APS and thought they would be at the home when he arrived to investigate the safety of his home environment; at least that's what I understood from the CM or I would not have discharged him (the patient) if APS couldn't evaluate and provide for his safety when he arrived home". Further interview revealed the physician stated "it would not have been safe if no one from APS was at the home to evaluate the safety when the patient arrived home."

The assigned CM #1 was no longer employed by the hospital and was not available for interview.