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Based on medical record review, staff interviews, and policies and procedures, it was determined that the facility failed to ensure that discharge plans and post-acute care was discussed with patient and patient's family when one (P#2) out of seven (P#1, P#3, P#4, P#5, P#6, P#7) sampled patients was discharged to home via non-emergency transportation without notification being made to the patients spouse. P#2 was discharged to home and spouse had not received discharge teaching and instructions to care for an intravenous catheter.

Findings:
A review of patient (P)#2's medical record revealed that she was seen in the Emergency Department (ED) on 4/20/22 at 9:26 a.m. with a diagnosis of cough with sputum (mixture of saliva and mucus coughed up from the respiratory tract) and empyema (collection of pus in a cavity in the body). P#2 was admitted for further evaluation and management of her infection and recurrent empyema.

A review of ED nursing note dated 4/20/22 at 10:23 a.m. revealed patient had been coughing up green and yellow sputum for three months. P#2 had a bronchoscopy (procedure allows doctors to look at lungs) done last Thursday and was told to come to the hospital due to an infection. Review of Bedside PICC (Peripherally Inserted Central Catheter) Line Insertion by IV Therapy RN dated 4/25/22 at 4:51 p.m. revealed patient tolerated PICC insertion procedure without complaints or signs of discomfort.

Review of nursing note dated 4/29/23 at 4:45 p.m. revealed this nurse spoke with MD via telephone communication with an update on patient more alert and that she continues to respond to commands and asking more question. Requested order for cath flo due to patient proximal PICC line is not returning blood flow. Verbal order was received to hold dose of Lovenox (blood thinner) at this time since MRI pending.

A review of a physician note dated 5/3/22 at 2:08 p.m. revealed that P#2 had decreased movement of LUE (left upper extremity) during mobility today. Patient reported increased pain due to PICC line placement and hesitance to move. Review of physician note dated 5/4/23 at 2:07 p.m. revealed patient had LUE swelling. Continued review of physician note dated 5/5/23 at 2:07 p.m. revealed that P#2 did not appear to have a thrombus (blood clot) in the left upper arm. A review of physician note dated 5/6/22 at 10:01 a.m. revealed that patient continued to have pain in LUE and was hesitant for range of motion due to the pain.

Review of hospital course dated 5/6/22 at 8:22 a.m. revealed that IV antibiotics will be given via HH (home health) Services. P#2 has PICC line for prolonged IV antibiotic administration. Discharge Instructions: the patient was educated on warning signs regarding the current medical conditions. If any of these issues were to arise or worsen, the patient was instructed to contact their PCP or seek further medical evaluation in the emergency room. Disposition: discharge to home with HH Services and prolonged IV Abx.

An interview was conducted with Executive Director of Care Coordination (DCC) on 7/25/23 at 10:15 a.m. DCC BB confirmed that Care Coordinator (CC) CC no longer works for the hospital. She continued to explain that the responsibilities of a Care Coordinator is to identify patients from the screening tool that may have additional medical needs after discharge. She continued to explain that her staff will collaborate with the patient's care team regarding the most appropriate discharge planning and the progression of care. She continued to explain that her team will facilitate anything that has to do with discharge or the discharge planning process. DCC BB continued to explain that it is the responsibility of the CC to work closely with the patient and their family to communicate and ensure understanding of what their needs will be, if any, after the patient discharges from the facility. DCC BB confirmed that Care Coordinator CC was assigned to P#2 and initiated the proper discharge planning process during her stay at the facility. She confirmed that Care Coordinator CC did not document in P#2's medical record, and she did not communicate with P#2's family about scheduling the non-emergent transportation to pick up P#2 on the day of discharge. She confirmed that Care Coordinator CC did not provide the patient or her family the discharge instructions for caring for her PICC line. DCC BB confirmed that Care Coordinator CC did not ensure that P#2 or her family received the needed counseling to prepare them for post-hospital care.

A telephone interview was conducted with P#2's spouse (SP) on 7/25/23 at 5:00 p.m. SP stated that he received a call from P#2's nurse on the day she was discharged, and she asked how long it will take him to arrive to the hospital. He continued to say that he told the nurse that he was on the way and would arrive in approximately 30-45 minutes. SP stated that when he arrive to the hospital and went to P#2's room she was not there. He stated he asked the nurse on duty where is P#2 and the nurse stated that she was discharged home by non-emergent ambulance. SP stated he asked why because he was not prepared to care for her at home and needed some additional information on what to do and how to care for P#2. SP continued to explain that the discharge papers were sent with P#2 however, he received no direction or instruction on how to care for his wife and the PICC (peripherally inserted central catheter) (long, thin, tube inserted through a vein in the arm) line that was placed in her arm during her hospital stay. SP stated that he had no idea what to do for P#2 at home and he expressed his concerns to the nursing staff, and they did not provide him with any instructions. SP continued to explain that the Home Health Agency put in place by the facility did not have an opportunity to start because P#2 was home for one day and had to be rushed to another emergency department the next day because of a complication with the PICC placement.

An interview was conducted with Care Coordinator (CC) GG on 7/26/23 at 9:45 a.m. in the administration conference room. CC GG stated that she is a travel nurse and has worked at the facility since February 2023. She stated that the responsibility of a CC is to help with discharge planning, communicate with patients and/or their families or representatives to do the initial assessment and to establish the patients at home baseline to determine what, if any, equipment the patient has at home. She continued to explain that they work closely with the patient and their physician care team to formulate the best discharge plan for the patient. CC GG continued to say that as a CC we are expected to work closely with the nursing staff to keep all lines of communication open between Care Coordination and nursing. CC GG continued to explain that in many cases the patient will express signs and symptoms to the CC and not to the nurse and often times it's the other way around as well. She continued to explain if the patient expressed being in any kind of pain she would gather as much information from the patient as possible and relay the information to his/her nurse on duty. She continued to explain that it is the responsibility of the CC to ensure that all necessary Home Health Agencies (HHA) are scheduled, the patient and their families are educated on what to do at home, and all discharge instructions are provided to the family. She continued to explain that if non-emergent transportation is being provided it is the responsibility of the CC to communicate the name of the company, the phone number, and the date and time of the pickup to the family as well as the approximate time of arrival.

A telephone interview was conducted with Registered Nurse (RN) LL on 7/26/23 at 10:05 a.m. RN LL stated that she has worked at the facility as a full-time employee since April 2023 and currently works on the Cardiac Unit located in the Blue Tower, 6th floor, West Side (B6W). She stated that the standard of care for nursing when a patient complains of pain, specifically pain due to swelling in the arm from a PICC line, is to assess the site to ensure the dressing is clean and intact. She continued to explain that as a nurse we do not perform PICC line dressings therefore, the nurse on duty would notify the IV (intravenous) team of the patient's complaints of pain and they would come to the patient's room to assess for placement and make any necessary adjustments needed. RN LL continued to explain that the IV team would order an x-ray to make sure the line is in place and if it is not then they usually take it off. She continued to explain that if the pain is from the initial insertion, then the nurse on duty would monitor the patient and manage the pain with medication. RN LL stated that patients and their caregivers receive instructions on how to care for the PICC before being discharged. She continued to explain that they will receive general instructions at bedside on how to care for the line at home.

A telephone interview was conducted with Post Acute Navigator (PAN) MM on 7/26/23 at 11:00 a.m. PAN MM stated that her responsibility as a PAN is to coordinate with the Care Coordination Department all medical services needed once a patient is discharged from the hospital. She continued to explain that the difference between a PAN and CC is that she is has no contact verbally or face-to-face with the patient or their caregivers. She continued to explain that CCs maintain verbal and/or face-to-face communications with the patient and their representatives. PAN MM continued to explain it is her responsibility to process home health referrals, medical equipment referrals, home infusion referrals, skilled nursing facility placements, long term acute care placements, and Hospice referrals for the patients assigned to her. She stated that after reviewing P#2's medical record she could recall working on home health referral for her. PAN MM stated that the initial referral for P#2 included home health, skilled nursing, and physical therapy. She continued to explain that nursing identified that they were looking at disease process teaching and management, medication management, teaching, and medication administration. She continued to say for physical therapy the referral included monitoring and educating them on pain management, gait strengthening, strengthening exercises, and range of motion exercises. PAN MM stated that per her documentation she was able to confirm that P#2 was accepted by a company willing to service her needs with a start date of 5/6/22. She continued to explain that the servicing company will educate the patient and their caregiver at home, however the Care Coordinator and/or nursing staff will ensure that education takes place at bedside.

A review of the Care Coordination Transition Standard Work - Home Health process, effective 6/29/22, version 2, revealed the objective: want a collaborative patient-centered approach to achieve the best outcomes and to prepare for timely and safe discharges for patients requiring home Health disposition. Purpose: to facilitate home Health transitions timely and safely. Step One. Complete Initial Assessment. Introduction to patient/family. Obtain point person for communication surrounding discharge planning and document. Step Two. Have discussion of post-hospital needs. Develop transition plan with patient/family participation. Develop Plan A and Plan B. Evaluate Plan throughout hospitalization with revisions as needed. Document evaluation of transition plan at least every three days or when revision of plan is necessary. Step Three. Obtain 4 Home Health Choices. Discuss transportation to home with pt/family. Document conversation in EPIC with all interactions. Step Four. Follow up with Attending/Nursing/Ancillary. Identify other necessary skilled need. Step Five. Accepted Home Health Choices. Step Six. Inform Attending to enter discharge order (if patient is medically stable for transition). Ensure transportation is set-up. Complete EMS packet if transport is needed (document in EPIC) face sheet, ticket to ride, PCS. Step Seven. Discharge patient. Document patient's disposition (level of care) and destination (name of agency). Enter discharge disposition and destination under the case management module. Complete discharge note in EPIC. Summary of discharge planning along with transportation.

A review of the "Disposition Planning" policy, Policy #CC-15-01, last revised January 2017 revised 1. Assessment. All patients will be screened at the time of initial contact and at regular intervals during the hospitalization, treatment, or service to identify continuing health care needs. The Physician will direct the Disposition Planning efforts, provide orders, and approve plans for continuity of care. 1.1 Assess patient for potential post-hospital care needs. 2. Implementation. An individualized plan of care will be developed from information obtained in the assessment and needs identification processes. This plan will include input from the interdisciplinary health care team; patient and family will be implemented in a timely, effective manner to ensure that the patient's health care needs are met. Disposition Planning is an integral part of the patient care process. The health care team's on-going responsibility is to assess a patient's potential health care needs and to educate the patient/family in the management of the care required. The health care team members' responsibility is to coordinate and to initiate early referrals to appropriate disciplines when needs are identified. 3. Coordination. The Disposition Planning process is the coordination of services/resources to ensure that the patient's health care needs will be met as the patient transitions to the next level of care. 4. Documentation. All aspects of the Disposition Planning process will be documents and communicated in a timely manner. 5. Evaluation. The disposition plan will be continually evaluated during the delivery of health care services. The adequacy of Disposition Planning is monitored by a variety of methods including but not limited to monitoring.

A review of the "Assessment of the Patient" policy, Policy # PE-05-01, last revised 11/1/22 revealed 1. Patient Assessment. Upon entry into the system (within 12 hours of arrival to the inpatient unit). Initial assessment included health history and physical assessment. LPN may collect nursing history and physical assessment data, but RN must review and cosign. 2. Patient Reassessment. After an invasive procedure. After a non-invasive procedure. When there is a significant change in condition or diagnosis. Upon transfer to a different level of care or specialty unit. At specified times based on discipline and patient location. 3. Discharge Planning Assessment. Assessment the patient for discharge planning needs. Process begins upon patient entry into the system. Requires input from all disciplines involved in the patient's care. Plan is continually evaluated during hospitalization.