HospitalInspections.org

Based on interview and record review the facility failed to reassess the patient's discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan in 2 (SP#6 and SP#8) out of 8 sampled patients (SP).

Findings include:

1. Review of SP#8 Podiatry Consultation Report dated 03/22/2018 revealed patient has a history of a stroke with right-sided right arm hemiparesis, mostly wheelchair bound. Reflexes are diminished at the ankle joint. The patient's right arm and hand are contracted and edematous.

Review of SP#8 Psychiatric Evaluation Notes dated 03/23/2018 revealed that patient requires assistance for activities of daily living (ADLs).

Review of SP#8 Occupational Therapy (OT)/Behavioral Health (BH): Initial Evaluation Patient Assessment dated 03/23/2018 revealed that patient needs assistance with food preparation, driving and community mobility. Requires maximal assistance for toileting and moderate assistance with transfer bed/chair/wheelchair/toilet. Patient needs supervision/set-up with eating, moderate assistance with grooming and maximal assistance with bathing, upper body dressing and lower body dressing. Problem list: decreased with activities of daily living (ADLs). Treatment diagnosis: Functional decline. Discharge recommendations: Inpatient facility.

Review of SP#8 Physical Therapy (PT)/Rehab: Initial Evaluation Patient Assessment dated 03/23/2018 revealed Transfer segments: bed mobility with maximal assist, supine to sit with maximal assist, sit to stand with moderate assist. Transfer comment: slow, unsteady transition, assistance for safety. Maximal assistance for gait with human support or assistive device. Gait deviations and safety: uneven step length, decreased cadence, decreased stride length. Discharge recommendations: Inpatient rehab.

Review of SP#8 Social Work Discharge Planning Note dated 03/23/2018 revealed that patient is currently homeless. Patient reported she was going to a motel upon discharge, patient has not reported source of income or means to pay for motel.

Review of SP#8 Social Work Discharge Planning Update dated 04/02/2018 revealed that an individual met with patient in person and deemed her a fall risk. Stated that she is only providing transitional housing and does not have the capability of an Assisted Living Facility to help with Activities of Daily Living.

Review of SP#8 Social Work Discharge Planning Update Notes dated 04/18/2018 revealed that per staff, patient requires assistance with attending to her activities of daily living (ADLs). Other option of Independent Living Facility (ILF) with home health was discussed.

Review of SP#8 Social Work Discharge Planning Notes dated 04/24/2018 revealed writer inquired about home health possibilities for placement in an independent living facility due to funding. Home Health Agency related that home health services are not covered if patient was to go to an independent living. It would need to be medically necessary and not in an independent living facility.


Review of SP#8 Social Work Discharge Note dated 07/25/2018 revealed that patient has been accepted into supportive housing.

Review of SP#8 Social Work Discharge Planning Notes Addendum dated 07/28/2018 revealed that writer met with representative from supportive housing and confirmed patient's bed at the location.


Review of SP#8 Behavioral Health (BH): Discharge Instructions Home dated 07/30/2018 revealed that patient was discharged to supportive housing location.

Interview with Licensed Clinical Social Worker on 10/25/2018 at 10:20AM revealed the criteria to determine placement for Independent Living Facility include that the patient is able to function on their own by taking medications, preparing basic meals for self, and conducting activities of daily living (ADLs) independently.

2. Review of SP#6 History and Physical dated 10/19/2018 revealed that patient presented to emergency department for evaluation of syncope. Past medical history includes syncope, functional decline.

Review of SP#6 Admission Health History dated 10/19/2018 revealed that patient designated spouse as the caregiver. Patient identified as unable to function independently or live independently. Present with decrease in activities of daily living function/upper limb mobility and recent decline in mobility or ambulation past 7 days. Falls within the past 3 months with a history of musculoskeletal chronic conditions: generalized weakness to bilateral lower extremities. Assistive device used: wheelchair. Current living situation in assisted living.

Review of SP#6 Case Manager Notes dated 10/21/2018 revealed that case manager (CM) acknowledged an order for discharge planning to skilled nursing facility (SNF). The Case Manager spoke with the patient's spouse who is refusing SNF placement. Patient to return to Assisted Living Facility. Patient needs assistance with all activities of daily living (ADLs). Discharge risk: bedbound. Current mental status/cognition: alert and disoriented.

Review of SP#6 Admission/Shift Assessment dated 10/23/2018 revealed patient oriented to person and place, weak motor strength to left and right leg and foot, non-ambulatory, not continent of urine for developmental age without catheter, does not have full range of motion, bedbound.

Review of SP#6 Discharge Summary dated 10/23/2018 revealed that patient was discharged to Assisted Living Facility.

Interview with Case Manager B on 10/23/2018 at 1:30PM revealed that for an Assisted Living Facility placement patient does not have support at home, cannot live alone, or does not have family support to receive care at home. Patient should not be bed bound.
The policy "Discharge Planning Process" (revision date: 09/17) states in accordance with the utilization review plan, the case manager will identify and implement a realistic; coordinated plan for continuity of post-hospital care for patient of all ages. The policy further states discharge planning involves the evaluation of the patient and family needs, strengths, limitations and resources. The discharge plan must take into account all realities of both the patient's condition and existing laws, rules, regulations and regulated agency requirements, along with availability of community resources.