HospitalInspections.org

Based on interview and a review of facility documentqation, the facility failed to discharge the patient with home health services for 1 of 3 sampled patients (#1).

Findings:

Patient #1's Case Management note of 12/20/20 at 10:48 AM indicated discussions with the patient regarding the possibility of having a home health aide at discharge. Attending physician orders of 12/20/20 at 9:42 AM read, "Home Health - Care Coordination - Nursing to Assess and Evaluate." Orders were written for Home Health services. These orders for home health at discharge were not cancelled.

A resident physician note of 12/21/20 at 11:15 AM read, "Dispo (disposition): Possible DC (discharge) pending PT (physical therapy) recommendations. Orders for HH (home health) are in.

A physical therapy note of 12/21/20 at 3:28 PM read, "Other discharge recommendation: safe for home discharge with family to A (assist) and HH (home health)."

A Case Management note of 12/21/20 at 3:18 PM read, "PT recommending HHC (home health care) and aide for DC." A Case Management note of 12/21/20 at 3:29 PM read, "No accepting agency for HHC due to either insurance or COVID (Coronavirus) status. Per PT, patient is safe to go home with family. MD (medical doctor) notified of barriers to staffing HHC. DC plan is to DC home with family assistance. Case closed."

Discharge orders of 12/21/20 at 3:33 PM read, "This order is intended as final authorization to d/c the patient." This order makes no mention of a destination; it simply authorizes discharge.

A nurse's note of 12/21/20 at 6:45 PM read, "Additional notes: Pt stable. D/C home with taxi." Thus, the physician's order for home health to be arranged for the patient's discharge were not followed.

During an interview of the Operations Manager - Risk on 4/14/21 at 1:25 PM, she confirmed the findings.