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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING, was out of compliance.

A-0800 DISCHARGE PLANNING- EARLY IDENTIFICATION The hospital's discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient's representative, or patient's physician. Based on observations, interview and document review, the facility failed to ensure staff complete an admission assessment in order to identify patients with discharge planning needs according to facility policies and protocols, in 2 of 2 current patients interviewed (Patients #2 and #10) and 2 of 10 closed inpatient medical records reviewed (Patients #6 and #7).

A-0808 DISCHARGE PLANNING- EVALUATION The discharge planning evaluation must be included in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient's representative). Based on interviews and document review the facility failed to ensure discharge plans and post-discharge care needs were reassessed, evaluated and discussed with the patient. The failure was identified in three of six patients who were seen by a care management staff member. (Patient #4, Patient #12 and Patient #13)

Based on observations, interview and document review, the facility failed to ensure staff complete an admission assessment in order to identify patients with discharge planning needs according to facility policies and protocols, in 2 of 2 current patients interviewed (Patients #2 and #10) and 2 of 10 closed inpatient medical records reviewed (Patients #6 and #7).

Findings include:

Facility policies:

The Patient Discharge policy read, all hospitalized patients will be screened and a discharge plan will be developed and implemented. Patients with complex discharge needs are coordinated by the Clinical Social Worker, patient/ family, physician and registered nurse with input from pharmacy, respiratory therapy, rehabilitation services, clinical nutrition and pastoral care as needed. The final decision rests with the patient and/or patient representative. A discharge plan will be developed as indicated by the evaluation. The final plan will reflect the patient's physical, behavioral and psychosocial needs. Implementation of the discharge plan will be initiated throughout the hospitalization and prior to the patient's discharge.

Discharge planning begins upon admission when assessment data is obtained from the medical record, patient/ family and health care professionals. The complexity of the plan will vary based on the assessed needs of the patient and the barriers identified.

Care Management: The Care Management Hospital Admission Assessment flowsheet will be completed to assist in identifying potential needs and barriers for discharge planning. A subset of the patients screened and determined to be at risk for adverse health consequences will receive a discharge planning evaluation conducted by the clinical social worker within the hospital Care Management department. The patient or members of the multidisciplinary team may also request an evaluation at any time. The Care Management team will involve the patient, family or patient representative in the development of the discharge plan at the time of admission. The discharge plan will be tailored to the unique goals, preferences and needs of the patient.

References:

The Hospital Care Management Restructure: Roles and Responsibilities document read, RN Care Coordinator Responsibilities include: complete assessments with patients and/or surrogate. Complete the 24 hour Case Manager Hospital Admission Assessment. Include documentation of social determinants of health and interventions. Meet with the patient/ or next of kin regarding resumption of care. Develop and document a plan to avert future risk of readmission. Communicate with the bedside nurse and ancillary services to mitigate internal hospital barriers to discharge. Utilize tools in the electronic health record to document progression of care coordination, such as expected discharge date.

1. The facility failed to ensure care management staff completed an admission assessment for admitted patients to identify discharge planning needs or barriers which required further evaluation or interventions to facilitate a safe discharge.

a. Patient interviews revealed patients who were admitted for several days were unaware of their plan for discharge, including their planned disposition and follow-up care, and had not met with hospital staff to discuss planning for discharge.

i. On 5/9/22 at 2:20 p.m., Patient #2 was interviewed. Patient #2 stated he had been in the hospital for six days due to a motor vehicle accident. He stated he had sustained multiple injuries including a leg injury and a broken collarbone.

Patient #2 stated he did not know the plan for his discharge, to include when he was anticipated to discharge or where he would go following his hospitalization. He stated he was not certain how he would get into or around his home if he was discharged home. Patient #2 stated he had not spoken with a case manager or social worker regarding his discharge plan, and he did not believe anybody had offered to involve family or friends in the discharge planning process.

ii. On 5/11/22 at 3:38 p.m., Patient #10 and his significant other at bedside were interviewed. Patient #10 stated he had been in the hospital for several days due to a broken pelvis. He stated he was not aware of when he was anticipated to be discharged from the hospital.

Patient #10 stated he wished to discharge home but did not know whether this was realistic because he lived in an RV. He stated he had concerns regarding returning to his home following his hospitalization. Patient #10's significant other stated the patient was expected to discharge with a wheelchair and they would have to get him in and out of the RV in a wheelchair, and she was not sure where they were going to park the RV. Patient #10 stated he did not believe anybody had spoken with him regarding plans for discharge or concerns with returning to his home upon discharge.

b. Staff interviews revealed care management staff were to complete a care management admission assessment in order to identify discharge planning needs, barriers and concerns requiring further evaluation and planning.

i. On 5/11/22 at 2:51 p.m., Social Worker (Social Worker) #17 was interviewed. Social Worker #17 stated she was covering the Surgical Intensive Care Unit and the Progressive Care Unit. She stated when a patient admitted to the facility an initial assessment was conducted to identify the patient's previous level of care, the patient's supports and what the team anticipated the patient would need when they discharged. She stated although the social worker sometimes assisted with completing the initial assessment it was typically the responsibility of the RN care coordinator to complete the assessment. Social Worker #17 stated the initial assessment was to be completed within 24 hours of the patient's admission.

ii. On 5/10/22 at 4:23 p.m., Licensed Clinical Social Worker (LCSW) #15 was interviewed. LCSW #15 stated in order to evaluate a patient's discharge needs the social worker or the RN Care Coordinator would conduct a chart review to understand the patient's medical or psychiatric condition, meet with the interdisciplinary team to discuss the patient's admission, and collaborate with the team to understand the patient's current needs. She stated the social worker or RN Care Coordinator would also meet with the patient to assess their stability, cognition, and discuss any recommendations for the next level of care following their hospitalization.

LCSW #15 stated when she worked on the inpatient units there was a standardized process to facilitate discharge planning in which the RN care coordinator completed an admission screening to identify discharge needs as early as possible in the patient's hospitalization. She stated the admission screening was to be completed within 24 hours of admission. LCSW #15 stated sometimes the social worker assisted to complete the admission screening but the expectation was for the RN care coordinator to complete the screening, and this was typically care management's first point of involvement in the patient's care.

LCSW #15 stated the admission screening was intended to collect data about the patient's prior level of care. She stated this included their living situation, level of function, whether the patient had established care with a primary care provider, or whether the patient required use of an assistive device. She stated it was important to collect this psychosocial data in order to better inform the team's recommendations for a discharge plan.

iii. On 5/11/22 at 10:32 a.m., the Director of Hospital Care Management (Director) #16 was interviewed. Director #16 stated she oversaw a team of RN care coordinators and social workers who were responsible to assist patients and the interdisciplinary team with discharge planning. She stated care management staff were responsible to complete a care management initial assessment on all new admissions within 24 hours of the patient's admission. Director #16 stated this assessment was documented in a specific flowsheet and included assessment of the patient's living arrangements, support systems, and goals.

Director #16 stated the care management department was significantly understaffed, specifically for the role of RN care coordinator. She stated ideally a RN care coordinator and a social worker would be assigned to cover specific units or services together, and the RN care coordinator would attend interdisciplinary rounds and complete the care management 24 hour admission assessments in order to identify discharge needs. However, she stated due to short staffing the RN care coordinators were all covering several units and were responsible for high patient caseloads, and therefore the RN care coordinators and other care management staff often struggled to perform these tasks.

Director #16 reviewed the medical record for Patient #2. She stated it appeared the care management staff had not completed an admission assessment for Patient #2. She stated there was a care management note entered for 5/10/22, which was seven days after Patient #2 admitted; however, she stated the note only documented information regarding the patient's health insurance. Director #16 stated Patient #2's medical record did not include an assessment of Patient #2's discharge needs or identification of an anticipated discharge plan, and she stated this should happen before a patient had been in the hospital for seven days. Director #16 reiterated the lack of care management assessments was likely due to high patient to RN care coordinator ratios.

Director #16 stated if discharge needs were not identified early in a patient's hospitalization it could cause delays in the patient's discharge. She stated the risks of delayed discharge included increased risk of contracting a Hospital-Acquired Infection, and also involved emotional distress to the patient due to not being in their home environment with their supports.

c. Medical records reviews revealed staff did not complete the care management admission assessment according to facility policies and processes for multiple patients, including patients who had documented discharge needs and barriers.

i. Patient #2's medical record was reviewed. Patient #2 admitted to the facility on 5/3/22 with fractures of the ribs, leg and clavicle. Patient #2's leg fracture required surgery and application of an external fixation device on 5/4/22.

Patient #2 was evaluated by physical therapy on 5/6/22 and 5/9/22. On both evaluations the physical therapist noted Patient #2 was limited by pain and weight-bearing restrictions and would need a wheelchair until the restrictions were liberalized. The therapist documented the patient's home was inaccessible to a wheelchair and problem solving would be required to ensure the patient had entry to his home. According to the therapy notes, Patient #2 would require one to two weeks of continued therapy to be "modified independent."

There was no evidence the care management admission assessment was completed in the six days since Patient #2 admitted in order to identify potential discharge planning needs, and there was no evidence in the medical record a discharge plan had been identified or facilitated for Patient #2.

ii. Patient #10's medical record was reviewed. Patient #10 was admitted on 5/4/22 for multiple traumatic injuries due to a motor vehicle accident, including a pelvic fracture which required surgery.

Patient #10 was evaluated by a physical therapist on 5/10/22. According to the physical therapist Patient #10's multiple injuries limited him to wheelchair mobility until he was permitted to bear weight. The therapist noted Patient #10 had significant mobility challenges and an unclear disposition due to his inaccessible home.

On 5/10/22 at 5:13 p.m., a Physical Medicine and Rehabilitation physician entered a note which read Patient #10 had suspicion for a mild traumatic brain injury and significant mobility deficits due to pelvic surgery. The note read, Patient #10 required maximum assistance to move in bed and sit at the edge of the bed. The physician documented barriers for discharge included homelessness, right-sided weight bearing restrictions, and the need to be in a wheelchair for several weeks. According to the note the patient would need to find an alternative home living situation or stay in the hospital until weight-bearing restrictions were lifted, and although a shelter could be considered the patient would need to be independent of activities of daily living and due to his injuries was not independent. The note read, continue to work with social work and therapy teams to find a safe disposition.

On 5/11/22, the date Patient #10 was interviewed, a Care Management Admission Assessment was entered which identified limitations in mobility and activities of daily living and homelessness as potential barriers to discharge. This assessment was completed seven days after the patient admitted. There was no evidence of care management or social work involvement prior to 5/11/22 to identify or address the patient's discharge needs.

iii. Patient #7's medical record was reviewed. Patient #7 admitted on 5/8/22 for a NSTEMI (a type of heart attack) which required cardiac catheterization (insertion of a small catheter into a chamber or vessel of the heart) in the hospital. Patient #7 discharged to home on 5/10/22.

There was no evidence in Patient #7's medical record a care management admission assessment was completed to identify discharge needs. There was no evidence a RN care coordinator or social worker from the care management team were involved to ensure a safe disposition was in place for Patient #7 prior to the patient's discharge.

iv. Patient #6's medical record was reviewed. Patient #6 was admitted on 5/5/22 for a fracture of the orbital wall (the eye socket) which required surgery on 5/6/22. Patient #6 was discharged to home on 5/7/22.

There was no evidence in Patient #6's medical record a care management admission assessment was completed to identify discharge needs, nor was there evidence of care management evaluation or involvement to ensure a safe disposition was in place prior to discharge.

v. The medical records reviewed were in contrast to facility policy and protocol, which read all hospitalized patients were to be screened and a discharge plan to be developed and implemented; discharge planning was to begin upon assessment with the complexity of the plan depending on the assessed needs and barriers of the patient; the Care Management Hospital Admission Assessment was to be completed to identify potential needs and barriers for discharge planning; and the RN care coordinator was to complete the 24 hour Care Manager Hospital Admission Assessment to include documentation of determinants of health and interventions warranted.

d. Observations revealed multiple patients were currently admitted had not received an admission assessment to identify discharge barriers and needs.

i. During the interview with Social Worker #17 on 5/11/22, the patient census for Social Worker #17's two units was reviewed. Social Worker #17 explained when the census was viewed in the facility's Electronic Health Records system, there was a system to identify whether a patient's 24 hour admission assessment had been completed. She stated if the admission assessment was complete the patient's name had a green dot next to it, and if the assessment had not been completed the patient's name had a red dot next to it.

Social Worker #17 reviewed the patient census for the Surgical Intensive Care Unit. Of the 13 patients on the census for the day, five patients who had been admitted to the hospital for greater than 48 hours had a red dot next to their names. This included a patient who had been admitted to the hospital for five days and another patient who had been admitted for eight days. Social Worker #17 confirmed the 24 hour admission assessment had not been completed for these patients.

Social Worker #17 reviewed the census for the Progressive Care Unit. Of the 20 patients on the census for the day, four patients who had been admitted to the hospital for greater than 48 hours had a red dot next to their names. This included two patients who had been admitted for five days and one patient who had been admitted for seven days. Social Worker #17 confirmed the 24 hour admission assessment had not completed for these patients.

Social Worker #17 stated due to short staffing in the care management department and the need to prioritize patients with more acute or complex needs, she had observed the initial assessment for discharge planning needs was not consistently completed within 24 hours of the patient's admission.

Based on interviews and document review, the facility failed to ensure discharge plans and post-discharge care needs were reassessed, evaluated and discussed with the patient. The failure was identified in three of six patients who were seen by a care management staff member. (Patient #4, Patient #12 and Patient #13) (Cross Reference A0800)

Findings include:

Facility policy:

The Patient Discharge policy read, the purpose of the policy is to ensure the development of a safe, individualized patient discharge plan. Individualized discharge plans shall take into account the goals and preferences of the patient and family, and prepare patients and their caregivers or support persons to be active participants in the patient's self-care.

All hospitalized patients will be screened and a discharge plan will be developed and implemented for the patient. Upon admission patient information is obtained from the medical record, the patient, the patient's family and the health care professionals caring for the patient. The discharge plan will be based on the assessed discharge needs of the patient and the discharge barriers identified.

The Care Management (CM) Hospital Admission Assessment flowsheet will be completed to assist in identifying potential needs and barriers for discharge planning. At the time of admission the CM team involves the patient, the patient's family or the patient's representative in the development of the discharge plan. Discharge plans are tailored to the goals, preferences and needs of the patient. CM teams participate in multidisciplinary team rounds where the patient's discharge needs and discharge barriers are discussed. Patient discharge plans are continuously assessed by the CM team and the discharge plan revised as necessary throughout the inpatient stay. Available community resources to meet the patient's post discharge needs are identified by the CM teams and referrals are established when needed.

The Registered Nurse Care Coordinator (RNCC) conducts the CM Hospital Admission Assessment and collaborates with the Clinical Social Worker to identify any resources available for the post-discharge care of the patient.

1. The facility failed to ensure staff performed continual discharge reassessments and evaluations of post-discharge needs with the patient.

A. Medical record review revealed patients were not reassessed or evaluated by care management staff before the patient was discharged from the facility. Examples include:

a. On 2/7/22 at 2:22 p.m., emergency medical services (EMS) arrived on scene at an outpatient clinic waiting room to assist Patient #4. According to the EMS Patient Care report, Patient #4 had been physically assaulted and repeatedly struck in the face. Patient #4's jaw was swollen and he had several broken and missing teeth. EMS transported Patient #4 to the Emergency Department (ED).

At 6:51 p.m., Patient #4 was diagnosed with bilateral mandibular fractures (fractures on the left and right side of the lower jaw bone) and malocclusion (misaligned upper and lower teeth).

i. On 2/8/22 at 11:20 a.m., Registered Nurse Care Coordinator (RNCC) #18 performed a Case Management (CM) Hospital Admission Assessment with Patient #4 at his bedside. According to the CM Hospital Admission Assessment, Patient #4 was homeless, slept in a homeless shelter, and did not have a patient caregiver or representative. RNCC #18 documented surgery was planned for Patient #4 and he was "not medically ready" for inpatient discharge.

ii. On 2/9/2022 at 1:00 p.m., Patient #4 had surgery performed. According to the Oral Maxillofacial Surgery Operative Report for Patient #4, an open reduction internal fixation of the jaw fractures (surgery to repair the fractured jaw bones) and intra-operative maxillomandibular fixation (the upper and lower jaw bones were wired together) were performed.

At 4:23 p.m., an order for a pureed diet (dietary order for physically soft foods to reduce or eliminate the need to chew) was placed for Patient #4. One day later on 2/10/22 at 2:33 p.m., Patient #4 was discharged from the facility.

There was no evidence of continued discharge planning evaluations in Patient #4's medical record. Furthermore, there was no evidence in the medical record documenting where Patient #4 was discharged to and what post-discharge follow up care was initiated for the patient.

b. On 4/14/22 at 3:38 a.m., Patient #13 was admitted to the facility for an upper respiratory infection and alcohol withdrawal.

i. On 4/20/22 at 2:06 p.m., six days after Patient #13 was admitted, a Care Management Social Work Progress Note documented discharge planning needs for Patient #13. According to the Care Management Social Work Progress Note, Patient #13's behavioral and mental health had remained unsteady after he physically withdrew from alcohol.

ii. On 4/22/22 at 12:16 p.m., a physician consultation note documented Patient #13 had a long history of alcohol use, alcohol withdrawal related delirium, acute alcoholic hepatitis and jaundice. The note read, Patient #13 required continued help and support to remain sober. Additionally, the note documented Care Management assistance was needed to help Patient #13 establish continued outpatient care. Five days later on 4/27/22 Patient #13 was discharged.

The medical record for Patient #13 lacked evidence continued discharge evaluations were performed and the post-discharge care needs of the patient were assessed by care management staff prior to when Patient #13 was discharged from the facility.

c. On 5/1/2022 at 1:13 p.m., Patient #12 was diagnosed with an upper gastrointestinal bleed and admitted to the facility.

i. On 5/4/22 at 2:56 p.m., three days after Patient #12 was admitted to the facility, a Care Management Social Work Progress Note documented on-going discharge planning needs for Patient #12.

According to the Care Management Social Work Progress Note, Patient #12 requested to speak with Care Management staff. Patient #12 expressed she had discharge planning concerns and requested transportation to the location where she parked her vehicle. The Care Management staff documented Patient #12 had hallucinations and required a cab voucher at the time of discharge. Three days later on 5/7/22 at 12:31 p.m., Patient #12 was discharged from the facility.

The medical record for Patient #12 lacked evidence continued discharge evaluations were performed by care management staff. Furthermore, the post-discharge needs of Patient #12 were not reviewed or assessed prior to being discharged from the facility.

The above examples of Patient #4, Patient #13 and Patient #12were in contrast to the Patient Discharge policy which stated, patient discharge plans will be continuously assessed and evaluated by the Care Management team and the discharge plan will be revised throughout the inpatient stay. The policy continued by stating the post discharge needs of the patient are identified and referrals established for the patient prior to the patients discharge.

B. Staff interviews revealed care management staff failed to perform continual discharge planning evaluations and assessments for post-discharge patient care needs.

a. On 5/10/22 at 12:10 p.m., an interview was conducted with RNCC #18. RNCC #18 stated she performed the CM Hospital Admission Assessment with patients admitted to the facility. RNCC #18 stated the CM Hospital Admission Assessment reviewed care services needed for the patient and anticipated the potential discharge needs of the patient. RNCC #18 stated the CM Hospital Admission Assessment was expected to be performed within 24 to 48 hours after patients were admitted to the facility.

RNCC #18 stated generally care management assessments and communication with the patient were documented in the patient's medical record. RNCC #18 stated the care management staff were required to review the reason the patient was admitted, the patient's current mental status, patient demographic information, emergency contacts, living arrangements and if any healthcare and or social services were needed for the patient. RNCC #18 stated continual care management assessments would be performed for all inpatients at the facility. RNCC #18 stated care management staff was expected to re-evaluate patient discharge needs and the post-discharge care needed before patients were discharged.

b. On 5/11/22 at 10:33 a.m., an interview was conducted with Care Management Director (CM Director) #16. CM Director #16 stated the CM Hospital Admission Assessment identified the initial discharge needs of the patient and was completed with the patient within 24 hours of when the patient was admitted to the facility. CM Director #16 stated interdisciplinary rounds were conducted daily and patient discharge needs and concerns were addressed at that time. CM Director #16 stated discharge barriers and post-discharge needs were re-evaluated by care management staff and updated in the patient medical record.

CM Director #16 then stated the Care Management staff were extremely short staffed and were unable to maintain continued discharge planning assessments. CM Director #16 stated patient discharge needs were not addressed when care management staff were unable to provide continued discharge planning evaluations. CM Director #16 stated discharge planning re-evaluations were required to be performed before patients were discharges from the facility.