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Based on interviews and document review, the facility failed to ensure the discharge plan was updated and follow up had occurred after an incident of injury was reported in one of one medical record reviewed of a patient who reported an injury at the facility. (Patient #1)

Findings include:

Facility policy:

According to the Discharge Planning policy, this plan of care is utilized in forming the discharge plan of care. Evaluation of needs is performed upon admission and throughout hospitalization so that post hospital care needs are identified before discharge.

1. The facility failed to ensure follow-up discharge planning was completed following Patient #1's reported injury to her leg.

a. According to a medical record review, on 12/1/21 at 7:54 a.m., Patient #1 was admitted to the facility for surgery with a diagnosis of a chronic infection of the right prosthetic (artificial) knee. Further review of the medical record noted Patient #1 was admitted to the inpatient unit at 6:21 p.m. following surgery.

i. On 12/7/21 at 3:03 p.m., a summary of a physical therapy visit note documented Patient #1 was perseverating on an incident which had occurred the day prior. Patient #1 reported to Physical Therapist #5 that she was concerned the incident had led to a further injury to her right knee. Patient #1 was discharged shortly after the physical therapy note was documented.

There was no evidence of any follow up evaluation or assessment occurring due to Patient #1's report of injury. Furthermore, the discharge plan was not updated to reflect the injury reported by Patient #1 to determine if additional care was needed prior to discharge.

This was in contrast to the Discharge Planning policy which read, evaluation of needs is performed upon admission and throughout hospitalization to ensure post hospital care needs were identified before discharge.

b. An interview with the surgeon (Surgeon #1) who provided care for Patient #1 was conducted on 5/25/22 at 2:30 p.m. Surgeon #1 stated he recalled the physician assistant (PA #2) informed him that Patient #1 had experienced a fall during her hospital stay. Surgeon #1 stated Patient #1 required an additional surgery on her right leg after she was discharged. Surgeon #1 stated the need for further surgery was potentially expedited by the fall reported to him by PA #2.

c. An interview with physician assistant (PA) #2 was conducted on 5/26/22 at 8:15 a.m. PA #2 stated he recalled Patient #1 had experienced a fall while she was in the facility. PA #2 stated he recalled Patient #1 had reported this fall to him during hospital rounds. PA #2 stated Patient #1 required an additional surgery following the fall in the facility. However, PA #2 stated Patient #2 reported an additional fall following discharge and that there was no way of knowing which fall contributed to her need for the additional surgery.

Based on interviews and record review, the facility failed to provide all necessary medical information prior to a planned discharge and transfer to a skilled nursing facility (SNF) in one of four patient's medical record reviewed of a patient transferring to a SNF (Patient #2).

Findings include:

Facility policy:

The Discharge Planning policy read, it provides information regarding the discharge planning process that involves determining the appropriate hospital post-discharge destination of a patient; identifying what the patient requires for a smooth and safe transition from the hospital to the discharge destination, and beginning the process of meeting the patient's post discharge needs.

The discharge planning process disciplines involved in the patient's care participate in discharge planning. Care Manager Staff initiates risk assessment screening through various methods including clinical chart review, patient interviews, interdisciplinary team rounds and tool found in the Electronic Health Record (EHR). Will inform the patient or the patient's designated caregiver of the results of the evaluation.

1. The facility failed at the time of discharge to transmit necessary information to the receiving SNF.

a. Review of Patient #2's medical record revealed Patient #2 was admitted on 12/21/21 with a sepsis (potentially life-threatening condition when the body's response to an infection damages its own tissue) diagnosis. Patient #2's medical record revealed the patient was transferred to the Intensive Care Unit (ICU) where a Peripheral Inserted Central Line (PICC) line (a form of intravenous access used for a prolonged period of time) was inserted and used to stabilize patient #2's blood pressure with the administration of vasopressors (medications used to treat severely low blood pressure and administered via a central line). Patient #2 was then stabilized and transferred to medical surgical unit (a lower acuity unit).

Patient #2's medical record revealed there was no evidence for the need of a PICC line because the patient was not receiving IV medications, antibiotics or treatments for post discharge care. Furthermore, there was no evidence the receiving facility had documentation to continue the PICC line and provide care to the PICC line at the time of discharge.

b. On 5/24/22 at 4:56 p.m., an interview with Case Manager (CM) #3 was conducted. CM #3 stated daily rounds, with a multi-disciplinary team composed of doctors, nurses, physical therapists (PT), speech therapists (ST), occupational therapists (OT) and CMs, were conducted for all inpatient units. CM #3 further stated all participants provided recommendations on patient care, including post discharge needs.

CM #3 stated a PICC line was used post discharge for antibiotic and/or intravenous (IV) treatments use. CM #3 stated the provider would document a reason for the continuation a PICC line after discharge. CM #3 further stated that this information should be communicated to the receiving facility to ensure the facility had the ability to provide PICC line care. CM #3 explained there was an increased risk of infection to the patient if the PICC line was not cared for appropriately.

CM #3 verified Patient #2's medical record revealed no evidence of physician documentation for the continuation of the PICC line at the time of discharge. CM #3 further verified Patient #2 had oral medications ordered and no orders for IV medications were found in the medical record. CM #3 stated there should have been a documented reason to continue a PICC line in the After Visit Summary (AVS) note in the medical record. CM #3 further stated a CM should have been aware of any intravenous lines on the patient and should have made sure the receiving facility was aware of the patient's PICC line.

c. On 5/25/22 at 1:56 p.m., an interview with Medical Doctor (MD) #4 was conducted. MD #4 stated the discharge planning process consisted of an overview of patients' medications, specialty diets, post discharge care needs such as PT, OT, ST and continuation of lab draws. MD #4 stated the need of IV lines was also part of the discharge order set and that it would read whether to continue or discontinue peripheral or central lines. MD #4 explained peripheral IV lines were temporary lines removed at time of discharge and central lines were similar to PICC lines but were used as long term use IV lines that needed a physician order to be discontinued. MD #4 stated discharge planning was summarized in the AVS which was provided to the receiving facility prior to patient's discharge from the hospital.

MD #4 stated Patient #2's medical record did not reveal a need for a PICC line post discharge. MD #4 reviewed Patient #2's medication list and verified that there was no continuation of IV medications, antibiotics, or treatments. MD #4 stated he was unable to find in Patient's #2 medical record an order to discontinue the PICC line or a reason documented to continue the PICC line for post discharge care. MD #4 stated the SNF must be made aware if PICC line was in place as the SNF may not have the appropriate staff to access the IV line.