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Based on review of medical records, policy and procedure, and staff interviews, the facility failed to ensure an appropriate discharge plan was established and discussed with the patient's representative for one (#1) of three patient's sampled.

Findings included:

Review of the facility policy, "Discharge Planning," #GUID-4934-3002, states (III) Department Guideline, (G) upon receipt of discharge order the Care Management team member will finalize plans with the patient/family, community resources and healthcare team.

Review of the medical record for Patient #1 revealed the patient was admitted to the facility on 08/03/2023. Review of the record revealed the patient had a recent admission from 07/19/2023 through 07/30/2023, and was discharged to a SNF (Skilled Nursing Facility)/ Rehabilitation Facility. On 08/03/2023 at 11:22 AM, a discharge planning assessment was conducted by a case manager. The assessment documented the patient was admitted for anemia, but did not identify the patient as a recent readmission. The Case Manager (CM) documented the patient's representative (daughter) was called to verify information and she confirmed the patient's plan was to be discharged from the SNF/Rehab to home with home health on the afternoon of 08/03/2023. She confirmed the patient used a walker while at the SNF/Rehab and the patient would need transportation at the time of discharge.

Review of CM Progress Note, dated 08/04/2023 at 3:31 PM, stated the CM spoke with the physician who stated a psychiatric consult was ordered to evaluate the patient's capacity. Review of the record revealed a psychiatric consult was conducted on 08/05/2023 at 12:34 PM. The consultation stated the patient had an extensive medical history and a reported history of dementia. The social history stated the patient had a daughter (patient's representative) that wanted to be involved. Following a comprehensive exam the psychiatric assessment/diagnosis was unspecified dementia without behavioral disturbance and delirium. The documentation stated he discussed his findings with the ordering physician. His professional opinion and recommendation stated the patient's medical situation had rendered her unable to make educated choices; he recommended case management contact the patient's daughter to act as the decision maker; and upon medical stabilization the patient may regain capacity to make decision and re-evaluation was recommended.

Review of CM notes, dated 08/08/2023 at 5:36 PM, stated the patient was discussed during multidisciplinary rounds. The case manager stated the patient's daughter would be making all decisions for the patient.

Review of the APRN (Advanced Practice Registered Nurse) note, dated 08/09/2023 at 4:26 PM, stated the patient has been inconsistent in her communication. She was seen by psychology with recommendations that her daughter act as decision maker until the patient regains capacity to make educated choices. Palliative care was consulted to discuss goals of care. They spoke to the patient and daughter to discuss the goals of care. Documentation stated the patient's daughter understands that she is the patient's decision maker at this time. She stated her goal is to respect her mother's wishes but stated her mother has been inconsistent.

Review of CM notes, dated 08/11/2023 at 1:44 PM, stated the patient will be discharging home with home health care. Documentation stated the patient reported she lived alone and she was able to manage her needs. The patient requested a walker and reported she would need transport at discharge. She requested a cab for transport home.

Review of the record revealed no evidence the patient was re-evaluated by the psychiatrist to determine capacity to make decisions.

Review of the nursing notes, dated 08/11/2023 at 6:00 PM, stated discharge instructions were provided to the patient and a cab called for transport. At 6:32 PM nursing documented a call was received from the cab company that they are here. The nurse documented upon arrival to patient's room with a wheelchair the patient stated EMS had her shoes and she demanded the nurse call the EMS company to have her shoes delivered before she goes home. She also stated she needed a walker to go home since her walker won't be delivered tonight. At 6:40 PM the nurse documented the cab driver left and the company was called again to reorder a cab.

Review of the nursing notes, at 7:00 PM, stated the nurse called the cab company for an ETA (Estimated Time of Arrival) and was told they are still searching for a driver. At 8:07 PM the nurse documented the cab company was called again for ETA and was told "hopefully in 30 minutes." Review of the record revealed no further documentation of the time the patient left the facility. The medical record stated the patient was removed from the system at 9:33 PM.

Review of the medical record revealed the patient presented to the facility ED (Emergency Department) on 08/13/2023. Review of the physician medical screening exam at 7:00 AM revealed the patient was recently discharged from the facility on 08/11/2023. Documentation stated the patient received a cab ride home from the facility and had spent the last two nights outside. The patient had fallen down and was unable to get up. The patient presented with generalized weakness and had spent the last night outside. The patient was unable to get up and into her house.

An interview was conducted with the Clinical Quality Specialist on 09/27/2023 at 1:45 PM. She reviewed the medical record and confirmed the above findings. An interview was conducted with the Risk Manager on 09/27/23 at 2:45 PM. She confirmed the daughter's concerns regarding the patient's discharge was reviewed by the nurse leader. It was determined the patient stated she was not speaking to her daughter therefore the daughter was not contacted when the patient was discharged.