HospitalInspections.org

Based on interviews and record review, the facility failed to ensure the discharge planning process included the regular re-evaluation to identify changes that required modification to the discharge plan ensuring a safe discharge. (Patient ID #1).

Findings Included:

Record Review of facility policy titled "Care Coordination Discharge Planning" dated November 21, 2022, showed the following information:

POLICY:
Discharge planning is a collaborative process that includes the patient, family/caregiver or other patient identified support person(s), attending physician, nursing and other member(s) of the multidisciplinary care team in the post-acute transition. The discharge plan needs to be consistent with the patients' goals of care and treatment preferences as appropriate and is completed by the RN care coordinator or a social worker when discharge needs are identified during the first stage screening or at the request of the patient, family, or representative or physician/healthcare team member. All activities related to discharge planning, patient's choice, and referrals are documented in the medical record, including screenings, assessments/reassessments, evaluations, and arrangements made for implementation of the discharge plan, refinement or changes to the discharge plan, as well as education/training and materials provided to the patient or caregiver.

Development of the Discharge Plan
...The hospitals discharge planning process must require regular re-evaluation of the patient's condition to a identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.


Record Review of Patient ID #1 Medical Record showed the following information:

Patient ID# 1 was admitted 4/30/2024 and discharged 5/14/2024.

Case management note dated 5/3/24: Discharge Planning Arrangements
Patient identified by name and date of birth. Care management responded to inpatient consult for post-acute levels of care: skilled nursing facility(SNF).

Case Management note dated 5/3/24: Discharge Planning Evaluation.
Transition Needs
Home or Post Acute Services- Post Acute facilities (Rehab/SNF/ect).

Case Management Note dated 5/13/24:
CM called SNF and spoke with DON .... she stated that they cannot take this patient due to history. CM will have to find another facility. CM called patient's mother and she was given list for SNF and chose facility (named).
Addendum:
CM called facility to talk to Admission Coordinator but was told she was gone for the day. CM to follow-up tomorrow.
CM received call from patient's mother saying that after talking to family members, they would like to change to facility (named).

Case Management note dated 5/14/24:
CM called facility (named) and spoke to Admission Coordinator. She stated that they are not able to take this patient. CM notified MD who said patient is medically cleared to discharge. CM called the patient's mother to let her know the situation. She is willing to accept patient at her house.

Physical Therapy note dated 5/14/24:
PT Recommendations for Discharge: therapy discharge recommendations, patient would benefit from three hours of intensive multidisciplinary therapy per day to maximize functional outcomes and address functional limitations to return to the highest level of functioning.

Occupational Therapy Note dated 5/14/2024:
OT recommendations for Discharge: Based on today's therapy session, pt would benefit from low to moderate intensity therapies post-acute care prior to his discharge home.
Requires a wheelchair and hoyer lift.

Interview with Manager of Social Work staff (M) and Division Director of Care Coordination staff (N) on 7/25/24 at 1:0f PM confirmed the above findings that no post-acute services were provided including DME, stating that if SNF was the plan but unable to obtain a facility that would accept the patient, home health services should have at least been offered.