HospitalInspections.org

Based on interview, record review, and policy review, the provided failed to ensure discharge planning had been a part of the comprehensive care plan upon admission for twenty of twenty-seven sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20) to ensure their goals for a successful discharge had been met. Findings include:

1. Interview on 2/4/25 at 10:45 a.m. with patient 1 regarding her discharge plans revealed:
*She had been admitted for pneumonia on 2/1/25.
*She was living at a warming house (shelter for homeless people).
*Her goal was to fill out general assistance paperwork to get financial help from the local Native American tribe.
*She would have been able to pay for her own apartment.

Review of patient 1's electronic medical record (EMR) revealed:
*Her admission questions completed upon admission noted her discharge plan was to return to the warming house.
*A nurse's discharge plan note stated she wanted to fill out paperwork with the tribe for general assistance.
*She had a care plan initiated for impaired gas exchange and risk for infection.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospital stay.
-Implemented by the nursing staff and social service designee/case manager (SSD/CM) C to ensure a plan had been developed to help determine what her discharge goal would have been or interventions to meet that goal.

2. Record review of patient 8's EMR regarding discharge planning revealed:
*She had been admitted on 1/22/25 and discharged from the facility on 1/25/25.
*Her diagnoses included: acute pelvic inflammatory disease (PID) and chronic idiopathic constipation.
*She had a care plan initiated for pain management and at risk for falls.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what her discharge goal would have been or interventions to meet that goal.

3. Record review of patient 9's EMR regarding discharge planning revealed:
*She had been admitted on 12/29/24 and discharged from the facility on 1/1/25.
*Her diagnoses included: acute/chronic congestive heart failure (CHF) and pneumonia.
*She had a care plan initiated for activity intolerance, risk for falls, and pain management.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what her discharge goal would have been or interventions to meet that goal.

4. Record review of patient 11's EMR regarding discharge planning revealed:
*She had been admitted on 9/28/24 and discharged from the facility on 10/1/24.
*Her diagnoses included: pneumonia and chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe).
*She had a care plan initiated for impaired gas exchange and pain management.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what her discharge goal would have been or interventions to meet that goal.


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5. Review of patient 3's EMR revealed:
*He had been admitted on 12/14/24 and discharged from the facility on 12/17/24.
*He had been admitted with a diagnosis of an upper gastrointestinal (GI) bleed.
*His care plan that had been initiated upon admission included physical comfort and nausea.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what his discharge goal would have been or interventions to meet that goal.

6. Review of patient 4's EMR revealed:
*She had been admitted on 1/23/25 and discharged from the facility on 1/25/25.
*She had been admitted with a diagnosis of left lower quadrant pain and alcoholic intoxication with complication.
*Her care plan that had been initiated upon admission included risk for falls and risk for impaired skin integrity.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what her discharge goal would have been or interventions to meet that goal.

7. Review of patient 10's EMR revealed:
*He had been admitted on 9/25/24 and discharged from the facility on 9/27/24.
*He had been admitted with a diagnosis of pyelonephritis (kidney infection) and sepsis.
*His care plan that had been initiated upon admission included risk for infection, physical comfort, risk for decreased cardiac tissue perfusion (adequacy of blood volume ejected from the ventricles in exchange for carbon dioxide and oxygen at the alveolar level) and impaired gas exchange.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what his discharge goal would have been or interventions to meet that goal.

8. Review of patient 12's EMR revealed:
*She had been admitted on 9/17/24 and discharged from the facility on 9/19/24.
*She had been admitted with a diagnosis of low hemoglobin, soft tissue infection, rectal mass and leukocytosis (high white blood cell count).
*Her care plan that had been initiated upon admission included physical comfort and risk for infection.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what her discharge goal would have been or interventions to meet that goal.



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9. Review of patient 13's EMR revealed:
*He had been admitted on 9/8/24 through 9/12/24 with a diagnosis of pneumonia (an infection that inflames air sacs in one or both lungs, which may be filled with fluid).
*His care plans that had been initiated upon admission included physical comfort and impaired gas exchange.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure his goals to return home.

10. Review of patient 14's EMR revealed:
*She had been admitted on 9/1/24 through 9/5/24 with a diagnosis of acute exacerbation (the process of making a problem, bad situation or negative feeling worse) COPD.
*Her care plan that had been initiated upon admission included impaired gas exchange.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure her goals to return home.

11. Review of patient 15's EMR revealed:
*She had been admitted on 7/23/24 through 7/26/24 with a diagnosis of hepatorenal failure (a complication of severe liver disease that leads to kidney dysfunction) and altered mental status (a change in a person's awareness and alertness).
*Her care plans that had been initiated upon admission included risk for shock (an acute medical condition associated with a fall in blood pressure), physical comfort, excess fluid volume, impaired memory, and cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses).
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure her goals to return home.

12. Review of patient 16's EMR revealed:
*She had been admitted on 6/28/24 through 7/2/24 for a left rib fracture (an injury that occurs when one of the bones in the rib cage cracks).
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure her goals to be admitted to a long-term care facility.

13. Review of patient 17's EMR revealed:
*He had been admitted on 6/18/24 through 6/21/24 with a diagnosis of pyelonephritis (a kidney infection).
*His care plans that had been initiated upon admission included physical comfort and risk for infection.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure his goals to be admitted returning home.

14. Review of patient 18's EMR revealed:
*She had been admitted on 6/4/24 through 6/7/24 with a diagnosis of pneumonia.
*Her care plan that had been initiated upon admission included impaired gas exchange.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure her goals to be admitted returning home.

15. Review of patient 19's EMR revealed:
*She had been admitted on 5/14/24 through 5/16/24 with a diagnosis of an asthma (a condition in which a person's airway becomes inflamed, narrow and swell, and produces extra mucous, which makes it difficult to breathe) exacerbation.
*Her care plan that had been initiated upon admission included impaired air exchange.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure her goals to be admitted returning home.

16. Review of patient 20's EMR revealed:
*She had been admitted on 3/29/24 through 4/1/24 with a diagnosis of pyelonephritis while pregnant.
*Her care plans that had been initiated upon admission included fluid volume deficient, falls, and nutrition.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during her hospitalization stay.
-Implementation by the nursing staff and SSD/CM C to ensure interventions and goals had been put in place to ensure her goals to be admitted returning home.





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17. Review of patient 2's EMR revealed:
*He had been admitted to swing bed on 1/31/25 with diagnoses of COVID-19, urinary tract infection, and CHF.
*His goal had been to return to his prior level of care at the assisted living center (ALC).
*His care plan was initiated upon admission by the nursing staff and had included the following focus areas:
-High risk for falls.
-Mobility.
-Risk for impaired skin integrity.
-Impaired gas exchange.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospital stay.
-Implemented by the nursing staff and social service designee/case manager (SSD/CM) C to ensure interventions and goals had been put in place to ensure he reached his goal to return to the ALC.

18. Review of patient 5's EMR revealed:
*He had been admitted to swing bed on 7/30/24 and was discharged from the facility on 9/20/24.
*His discharge plans had been undetermined at the time of admission.
*He had been admitted with the diagnoses of a rib fracture, atrial fibrillation (irregular heartbeat), and a removal of a mass located by his neck and shoulder area.
*His care plan was initiated upon admission by the nursing staff and had included:
-Impaired physical mobility.
-Risk for decreased cardiac tissue perfusion.
-Risk for falls.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospital stay.
-Implemented by the nursing staff and SSD/CM C to ensure a plan had been developed to help determine what his discharge goal would have been or interventions to meet that goal.

19. Review of patient 6's EMR revealed:
*He had been admitted to swing bed on 12/23/24 and discharged from the facility on 1/27/25.
*He had been admitted with the diagnoses of CHF, acute onset of high blood pressure, and diabetes mellitus.
*His goal was to return the his prior level of functioning at the ALC.
*His care plan was initiated upon admission by the nursing staff and had included:
- Impaired physical mobility.
-Risk for falls.
-Tissue integrity: Skin & mucous membranes.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospital stay.
-Implemented by the nursing staff and the SSD/CM C to ensure interventions and goals had been put in place to ensure he reached his goal to return to the ALC.

20. Review of patient 7's EMR revealed:
*He had been admitted to swing bed on 7/5/24 and discharged under Hospice (end-of-life) care on 7/12/24.
*He had been admitted with the diagnoses of severe side and back pain, and hallucinations.
*His care plan was initiated upon admission by the nursing staff and had included:
-Impaired physical mobility.
-Physical comfort.
*There was no documentation that supported discharge planning had been:
-Initiated upon admission or during his hospital stay.
-Implemented by the nursing staff and the SSD/CM C to ensure interventions and goals had been put in place to ensure he reached his goal to discharge at his prior level of function.

Interview on 2/5/25 at 2:25 p.m. with chief nursing officer (CNO) A, assistant chief nursing officer (ACNO) B, and SSD/CM C revealed:
*They agreed discharge planning should have started at the patient's admission and should have been a part of the patient's initial care plan.
*The nursing staff were to initiate the patient's care plan upon admission and had addressed any focused concerns at that time.
*SSD/CM C:
-Stated she did not have access to the patients' care plans to initiate a focus area or edit them throughout a patient's hospital stay.
-Confirmed she initiated and oversaw the patient's care conference and the care plans had been a crucial part of those meetings.
*CNO A and ACNO B:
-Had not been aware that SSD/CM C did not have access to initiate or update the care plans.
-Agreed she should have access to enter and revise the patients' care plans.
*They had been limited on what to classify SSD/CM C as in the EMR for her access capabilities.
*CNO A stated; "Corporate had us put her as a nursing assistant because of that. So that really limited her capabilities in the system."

Review of the provider's revised 10/28/24 Discharge Planning Swing Bed policy revealed:
*"Social Service/Discharge Planning interventions are to be initiated at the earliest possible time in the patient's hospitalization to optimize positive patient/family outcomes and reduce re-hospitalization rates.
*The Social Service/Discharge Planning process is typically performed by a Social Worker/Social Worker Designee."

Review of the provider's revised March 2024 Documentation by Exception & Care Plan policy revealed:
*Diagnosis/Planning:
-"The care plan is to be initiated within the same shift of admission by the RN [registered nurse]."
-"Determine the interventions which will help the patient progress toward the outcome(s)."