HospitalInspections.org

Based on hospital policy review, medical record and interview, the hospital failed to ensure post-hospital care needs were secured with the home health agency (HHA) and infusion agency prior to discharge, regarding new tube feeding orders and education for 1 patient (Patient #11) of 2 patients reviewed for discharge planning.

The findings include:

Review of the facility's policy titled, "Care Management/Interdisciplinary Discharge Planning," revised 1/2029, revealed "...The Care Management Department, in conjunction with the medical...multidisciplinary patient care staff, will coordinate and provide...services for the patient...family...Post-acute care needs...identified...to meet the identified needs, preferences...goals to ensure...appropriate, safe...smooth transition of care..."

Review of Patient #11's medical record revealed the patient presented to the facility's Emergency Department on 5/8/2023, with complaints of cough and shortness of breath. The patient was admitted from 5/9/2023-5/14/2023 with Aspiration Pneumonia, Dysphagia, Myasthenia Gravis (a neuromuscular disorder that leads to weakness of skeletal muscles) and Myotonic Dystrophy (a complex, inherited condition that causes progressive muscle atrophy and weakness).

Review of Patient #11's Gastroenterology Daily Progress Note dated 5/10/2023, revealed the patient was tolerating liquids. After a discussion with the patient's wife and Neurology, it was agreed to proceed with gastrostomy tube placement. The procedure was discussed in detail. The patient and wife were aware "...as...daughter has a gastrostomy tube with the same neurological condition..."

Review of Patient #11's Hospitalist Daily Progress Note dated 5/11/2023 at 2:43 PM, revealed a plan for PEG (Percutaneous Endoscopic Gastrostomy-a tube inserted into the stomach for nutritional feedings and mediation administration) insertion; "...Discussed with Case Management to arrange for home tube feedings...orders will depend on nutritionist recommendation...Likely discharge either on Friday or Saturday depending on how patient tolerates...tube feeds..."

Review of Patient #11's Case Management Narrative Note dated 5/12/2023 at 9:00 AM, revealed the discharge summary was faxed to the home health agency to notify of pending discharge to home on 5/14/2023. Review revealed the discharge summary did not include the planned home bolus tube feedings (bolus is the amount of tube feeding given at one feeding interval, approximately equal to a meal) or family educational needs.

Review of Patient #11's Nutrition Note dated 5/12/2023 at 1:14 PM, revealed "...For home bolus TF [tube feeding] regimen after d/c [discharge], recommend 7 total cartons Jevity 1.2...daily over 4 bolus feedings/day (mealtimes & before bed) w [with]/80 mL[milliliters] H2O [water] flush before & after each bolus feeding. First 3 bolus feedings - 2 cartons each & last feeding - 1 carton..." Review revealed this order did not get faxed to the infusion agency when Patient #11 was discharged.

Review of Patient #11's Case Management Narrative Note dated 5/17/2023 at 10:22 AM, revealed the infusion agency notified the Case Manager the wife of Patient #11 had called about the patient's tube feedings and supplies, "...as this was not arranged prior to the patient's DC [discharge] 5/14 [5/14/2023]..." The Case Manager faxed the documentation to the infusion agency with confirmation of receipt to, "...assist with securing TF [tube feeding] arrangement post DC..."

During an interview on 12/3/2024 at 9:18 AM, Hospitalist A stated he relied on the nursing team to ensure the patient and family are educated on discharge care and instructions.

During an interview on 12/3/2024 at 9:48 AM, Discharge Care Coordinator B stated on Friday 5/12/2023, home health had been arranged for Patient #11 and they were waiting on the home dietary orders for tube feedings from the RD (registered dietician). Discharge Care Coordinator B stated she did not get the dietary orders on 5/12/2024, before she left for the day. She stated she was unaware the orders had been written, and the orders did not get faxed to the infusion agency to set up in-home tube feedings or family education.

During an interview on 12/3/2024 at 9:53 AM, Case Manager (CM) C stated when she saw Patient #11 on 5/12/2023 (Friday) the RD had not seen the patient or made dietary recommendations. CM C stated the RD, after seeing Patient #11 and writing recommendations for in-home tube feedings, should have notified nursing or case management, but that did not happen. No order was placed in the electronic medical record (EMR) for the recommended tube feedings. Patient #11 was discharged on a Sunday and there was no Case Manager available to ensure the aftercare, for home discharge had been arranged and the patient had everything needed to go home. The CM stated typically, before a patient is discharged home with skilled nursing services, and tube feeding is considered a skilled service, the infusion agency will send a nurse to the hospital to start education with the patient and family. After bedside education is completed, the infusion nurse will notify the Case Manager involved with the patient to let them know the education is completed. CM C stated this did not happen because the infusion agency was not made aware of the pending discharge with tube feeding recommendations.

During an interview on 12/3/2024 at 1:28 PM, the RD stated she was consulted on Patient #11 for new tube feeding recommendations and the patient would be going home on bolus tube feeding at discharge on 5/12/2023. The RD stated she spoke with the family on 5/12/2023, went over tube feedings and provided them with a pamphlet titled, "Your Guide to Home Tube Feeding." She was unable to recall the patient's or wife's knowledge of tube feeding. The RD stated she places her recommendations in the patient's EMR, she does not notify anyone after she places her recommendations. The RD stated she is unaware of how case management or nursing are aware of her recommendation, but there had never been a problem that she was aware of, "...I put the note in and then case management takes care of it..." She was unaware of any process changes.

During an interview on 12/3/2024 at 10:15 AM, Unit Manager E stated if Patient #11 and the wife had not received discharge education about the tube feeding and the staff were not sure if everything had been arranged for discharge, then she expected there to be a discussion among the discharge nurse, unit shift leader, house supervisor, case management, and/or the provider of home services to ensure the patient and the family were ready for discharge and had what they needed to go home.