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Based on interview and review of medical records, it was determined that the hospital failed to develop an appropriate discharge plan for 1 of 10 patients, when patient 4 was discharged home to a caregiver who could not care for the patient and placed the responsibility of finding placement in a skilled nursing facility on the home health agency. (Patient identifier: 4)

Findings include:

1. Patient 4 was admitted to the hospital on 8/10/2023 with a diagnosis of cough, confusion, and fatigue. A review of Patient 4's medical record revealed that the patient was admitted to the hospital following 3-4 days of worsening dementia. The patient presented at the hospital with mild to moderate dementia and was diagnosed with COVID-19.

2. A review of the caseworker notes and Patient Safety Analysis documentation was completed and included the following information:

On 8/10/2023, the patient was assessed as requiring discharge to a SNF due to dementia, disorientation, frequent falls at home, ADL (activity of daily living) needs, safety, and mobility deficits. Patient 4's wife stated they wanted him to go to a nearby Veteran Administration (VA) facility for skilled nursing placement and then long-term care placement.

On 8/11/2023, the VA facility reported they were not able to take the patient until he was ten days post-positive for COVID-19.

On 8/12/2023, a local SNF declined patient 4's admission, indicating the patient "Does not meet admission criteria." According to patient 4's wife, the case manager (CM) called her on her landline to inform her of being declined by the SNF. Patient 4's wife gave the case manager her cell phone number for future communication.

On 8/13/2023, the discharge plan remained the same, recommending a discharge to a SNF after a 10-day waiting period from when patient 4 admitted to the hospital.

On 8/14/2023, the CM and physician attempted to call Patient 4's wife to discuss discharge plans, but they were unable to reach her. [Note: An internal investigation was completed related to Patient 4's discharge. It was determined that the alternate phone number provided by Patient 4's wife had been erased from the whiteboard in Patient 4's room. The phone number used to reach her was not the updated number.]

A physician's order, dated 8/15/2024, was received to have a social worker assist patient 4's wife with long-term placement. [Note: No documentation was provided that a social worker assisted patient 4's wife with long-term placement.]

On 8/15/2023, the CM and physician were unable to contact the patient's wife and decided to call the local police department for a wellness check, as she was also reported to have COVID-19. The police told patient 4's wife that patient 4 was being discharged on 8/15/2023.

The patient was discharged home with his wife on 8/15/2023 with the resource of a home health agency, including contact information and instructions that the home health agency would "get the ball rolling on long term care placement."

It was documented in the physician's discharge note that patient 4's discharge plan was changed from a skilled nursing rehabilitation discharge to a plan for him to return home with his wife as he was "doing much better he does not really qualify for SNF". The physician documented that the patient's wife expressed concerns about him returning home, that the patient was the cause of her health problems, and that she wanted him to be discharged to a SNF. [Note: Patient 4's wife was diagnosed with COVID-19 at the time Patient 4 was discharged home.]

3. On 7/15/2024, a request was made to the Executive Director (ED) for the hospital's discharge policy specific to assisting patients with post-acute care services, including skilled nursing facilities. The ED stated the hospital did not have a policy related to this and knew one needed to be developed.

4. The CM was interviewed on 7/15/2024 at approximately 1:40 PM related to patient 4's discharge to home. The CM was asked why patient 4 was discharged home. The CM stated that patient 4 met the hospital's criteria to be discharged home. The CM was asked if a social worker met with patient 4's wife to assist in long-term care placement. The CM stated that patient 4 was discharged home with home health, who was to assist patient 4's wife with long-term care placement. The CM stated the hospital does not arrange for nursing facility placement.