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Based on interview and record review, the facility failed to provide proof of a discharge planning evaluation that included a documented assessment of the patient's capacity for self-care prior to discharge to home alone without verification of acceptance and authorization by a home health agency (HHA) for nursing and therapy services for 1 of 10 sampled residents, resulting in an unsafe discharge and subsequent re-hospitalization three days later (#1).

Findings:

Patient #1, a 69 year old patient, was admitted to the hospital on 3/14/16 and discharged back to home where he lived alone on 3/17/16. On 3/14/16, he was seen in the emergency department (ED) and then admitted to the hospital with diagnoses which included lower back pain due to a fall at home, generalized weakness, and dehydration per the emergency physician record. Other diagnoses included cerebral palsy, coronary artery disease, and hypertension. The emergency physician record read, "Pt (patient) states he was walking and both legs has been weak & they gave out & he fell backwards....Pt landed on 'rear end'. Pt called landlord who came & was picked up & placed on couch until his friend arrived....Pt states that he ran out of cardiac meds & high blood pressure meds for past couple of months."

The ED discharge planning case manager's notes on 3/14/16 read, "Will need to assess for safe DCP (discharge care plan)."

On 3/14/16, a chest x-ray was also ordered and done. The results revealed that patient #1 had bibasilar interstitial infiltrates. According to his medication administration record (MAR), he received two days of the intravenous antibiotic, Zosyn 3/375 grams every 6 hours, which was initiated on 3/15/16. The MAR also revealed that the patient was later started on the antibiotic Levaquin 500 milligrams (mg.) on 3/17/16 just prior to his discharge home.

Per the admission history and physical (H&P) dated 3/15/16, patient #1's primary mode of mobility was the use an electric wheelchair and four wheeled walker. The H&P read, "In the emergency department the patient was noted to be....hypertensive....The resident is admitted for further management." At the time of the H&P the patient's blood pressure remained high at 177/91 and his pulse remained high at 91 beats per minute.

A physical therapy note dated 3/15/16 at 11:48 AM, the day after admission, read "Physical therapy eval (evaluation) refused by patient." The patient had stated "I don't feel like doing anything but staying in bed....Please reorder when patient compliant for eval." There was no documentation provided that the therapist had conducted an evaluation of the patient, including physical abilities for self-care, before discharge home.

A nurse's note, dated 3/16/16 at 3 PM, one day before patient #1's discharge, read, "Maximum 2 assist when getting to bsc (bedside commode) pt shaking a lot unsteady on both feet."

A nurse's note dated 3/17/16 at 8 AM, the day of the resident's discharge home alone, read, "feed pt."

The inpatient case manager (CM)/registered nurse's (RN) discharge care planning notes for patient #1 from admission to discharge did not reveal any assessment of the patient's physical abilities at discharge for self-care at home alone which would include toileting, bathing, and eating.

The inpatient case manager discharge plan assessment, dated 3/15/16 at 1:06 PM, included that no living environment information was available. Per patient information, the case manager documented that the patient lived at home alone, used an electric scooter and a 4 wheel walker, did not receive any professional skilled/community services, and had a friend of 40 years for contact who could transport the patient home if not working. The case manger's notes also revealed that the patient was interested in therapy, would qualify for home health services, and the plan was to discharge him home with home health services.

The CM's narrative note, dated 3/16/16, the day before discharge read, "Spoke with patient regarding home health care (HHC) RN and physical therapist (PT) and he is in agreement. Also gave patient the Lynx Application. Pending PT re-eval."

The CM's note dated 3/17/16 at 3:01 PM, the anticipated discharge date home was 3/17/16, the same day and read, "Order received for HHC RN and PT....Offered HHC choice list and he would like to use....He stated that his friend...will provide transport home....Barriers to Discharge unresolved: None identified....HHC referral sent to PACAT (post acute care arrangement team)."

On 3/17/16 at 3:21 PM, a request was sent from patient #1's CM to the hospital's PACAT, "Please send HHC referral to (home health agency's name)...."

The PACAT staff notes, dated 3/17/16 at 3:31 PM revealed that he had faxed the patient referral and hospital information to the home health agency for RN and PT services and would follow up. At 4:37 PM, the HHA called and stated that they have the referral from the hospital and would work to get PCP (primary care physician) authorization.

On 3/17/16, about one and 1/2 hours later, at 6:04 PM, per the nurse's note, patient #1 was discharged home and read, "d/c (discharge) instructions done to pt., told pt to pick up meds from...pharmacy. pt understood. d/c." The resident was taken home by his friend.

On 3/18/16 at 11:30 AM, the day following the patient's discharge, per a PACAT staff note, the HHA was called and stated they were still trying to contact the PCP for authorization. At 1:38 PM, the HHA called the hospital's PACAT staff and informed them that the PCP wanted the patient to come to the doctor's office to get authorization for HHA services. The patient was called and notified of what the PCP wanted him to do. The patient stated that he did not want to go to that doctor anymore. At 1:41 PM, the PACAT staff note read, "Agency/Resource Comment: (HHA) Canceled as PCP wants patient to visit before providing authorization."

On 4/24/16 at about 8:30 AM via phone interview, patient #1's friend stated that he had gone to check on patient #1 on 3/20/16, three days after his discharge home. The friend stated that the patient was sitting in soiled clothing and unable to care for himself. The friend indicated that home health services had not come to the home, that the patient had to be sent to the emergency department the same day, had been re-hospitalized, and was awaiting placement in a long-term care facility.

On 5/11/16 from about 3:45 PM-4:15 PM, the director of case management was asked to see the physical therapy re-eval done by the hospital, and stated that a re-evaluation had not been done. When asked if there was an assessment by the patient's RN case manager that evaluated the patient's abilities to perform self-care activities, she stated that there was not that kind of assessment.

Based on interview and record review, the facility failed to reassess the patient's discharge plan home alone with a home health agency when learning prior to discharge that the home health agency had not accepted the patient because they had yet received authorization from the patient's PCP (primary care physician) for 1 of 10 sampled patients (#1). This resulted in the patient not receiving nursing and therapy services and a subsequent re-hospitalized three days after discharge.

Findings:

Review of the hospital's PACAT (post acute care arrangement team for discharges) notes dated 3/17/16 at 3:31 PM revealed that hospital referral and patient hospital information had been faxed to the home health agency (HHA). The HHA order, dated 3/17/16, was for RN (registered nurse) and PT (physical therapy services). On 3/17/16 at 4:37 PM, the HHA called and stated that they had received the referral from the hospital and would work to get the PCP's (primary care physician) authorization for home health services.

On 3/17/16, about one and 1/2 hours later, at 6:04 PM, per a nurse's note, patient #1 was discharged home. The nurse's note read, "d/c (discharge) instructions done to pt., told pt to pick up meds from...pharmacy. pt understood. d/c." The patient was taken home by his friend. The patient did not yet have authorization for HHA services from the PCP.

On 3/18/16 at 11:30 AM, the day following the patient's discharge, per a PACAT note, the HHA was called. The HHA stated they were still trying to contact the patient's PCP for authorization.

On 3/18/16 at 1:38 PM, the HHA called the hospital's PACAT staff and informed them that the PCP wanted the patient to come to the doctor's office to get authorization for HHA services. The patient was called by a PACAT team member and notified of what the PCP wanted. This was a Friday afternoon and the doctor's office was not open again until after the weekend on Monday. The patient did not have his own transportation. He relied on a friend who worked. At 1:41 PM, the PACAT staff note read, "Agency/Resource Comment: ( HHA) Canceled as PCP wants patient to visit before providing authorization."

On 4/24/16 at about 8:30 AM, via phone, patient #1's friend stated that he had gone to check on patient #1 on 3/20/16, three days after his discharge home. The friend stated that the patient was sitting in soiled clothing and unable to care for himself. The friend indicated that home health services had not come to the home, that the patient had to be sent to the emergency department the same day, had been re-hospitalized, and was awaiting placement in a long-term care facility.

On 5/11/16 from about 3:45 PM - 4:15 PM, the director of case management was asked if anyone from the hospital's PACAT or case management team had notified her that the patient had been discharged to home and that the HHA did not accept the patient because they could not get PCP authorization. She stated that they had not, but wished that they had notified her for some type of follow-up. When asked if she was the appropriate person that the case management team or PACAT would have reported to regarding such, she validated that she was the person to notify.

On 5/11/16 at about 4:30 PM via phone, the senior director of case management indicated that there would have been the possibility of the hospital having sent one of their contracted home health agencies to conduct at least the initial assessment on the patient, free of charge until further arrangements could be made.