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Based on interview, record review, and document review, the Critical Access Hospital (CAH) failed to ensure a discharge planning process that focused on the patient's specific discharge planning needs to identify treatments that would be unique, patient goal focused, and included the caregiver's involvement to the discharge plan and to update the discharge plan to reflect such changes for one of six records reviewed (Patient 1).

The cumulative effects of the CAH's failure to ensure a discharge process that focused on the patient's specific discharge planning needs to identify treatments that would be unique, patient goal focused, and included the caregiver's involvement to the discharge plan and to update the discharge plan has the potential of resulting in adverse outcomes including injury, infection, or rehospitalization for any patient receiving services at this facility.

Findings Include:

1. The Critical Access Hospital (CAH) failed to ensure the discharge process identified a patient who was likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning. (Refer to C-1404)

2. The Critical Access Hospital (CAH) failed to ensure a discharge plan included an evaluation of a patient's likely need for appropriate post-CAH services, the determination of availability of appropriate services as well as the patient's access to those services. (Refer to C-1408)

3. The Critical Access Hospital (CAH) failed to ensure regular reevaluation of the patient's discharge planning process to identify changes that would require modification to the discharge plan and to update the discharge plan to reflect such changes. (Refer to C-1420)

Based on interview, record review, and document review, the Critical Access Hospital (CAH) failed to ensure the discharge process identified a patient who was likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning for one of six patients reviewed (Patient 1). This deficient practice has the potential to result in adverse health outcomes following discharge including rehospitalization for any patient receiving services at this facility.

Findings Include:

Review of a policy titled, "Discharge Plan - Swing Bed," approved date 10/20/16, showed, "t is the desire and intent of Russell Regional Hospital to ensure that every patient admitted to the hospital has a timely and need driven discharge plan that is realistic and facilitates a sustainable transition to a lesser level of care, including home ...Discharge planning shall begin as part of the initial assessment process. Assessment shall include, but not be limited to: Identification of patients in need of focused discharge planning, who are likely to suffer adverse effects if there is not adequate discharge planning and evaluation of patient's capacity for self-care or the possibility of patient being cared for in the environment from which he/she entered the hospital. All discharge related activity will be noted in the patient's Electronic Health Record ...Details a post-discharge plan of care that has been developed with the participation of the patient and the patient's family, which will assist the patient to adjust appropriately to his/her new living environment ..."


Patient 1

Review of Patient 1's medical record showed that on 08/12/21, patient arrived via EMS to the emergency department with complaints of pain, swelling and redness, and decreased ability to bear weight on the left leg. The patient was evaluated in the emergency room and found to be a morbidly obese male weighing around 523 pounds. Patient 1 was observed to have wounds upon ER assessment. Wounds were described as moisture associated skin damage in all areas of skin folds, with redness and drainage and foul odor, a Stage 2 pressure ulcer (shallow open wound caused by pressure) to coccyx (a small triangular bone at the base of the spine) and three open wounds on the buttocks. Patient was admitted to acute care at 3:30 PM for continued treatment of sepsis and cellulitis. The Initial History and Physical was completed on 08/12/21 at 4:39 PM with medical history including hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), cerebral vascular accident (CVA) (stroke) with left sided weakness, and morbid obesity. He was discharged from acute status and admitted to skilled swing bed (SSB) on 08/16/21 for continued antibiotic administration and wound care that consisted of topical treatments of Calmoseptine ointment (a moisture barrier that protects and helps heal skin irritations) and Nystatin topical cream (a topical medication used to treat fungal or yeast infections of the skin) to reduce moisture contact and a dressing to the buttocks. Patient 1 was placed in a bariatric (obese) bed to help reduce the risk of further pressure ulcer formation. Documentation showed patient to be incontinent of urine and stool and a Foley catheter (tube put into bladder for urine drainage) was placed to prevent further moisture associated skin damage. Upon admittance to swing bed, the patient was evaluated by occupational therapy and physical therapy. Patient 1 received occupational therapy but due to his morbid obesity and body habitus it was determined that he was not a good candidate for physical therapy services. During his hospitalization and upon discharge, the patient was noted to have decreased level of functioning, required maximum assist with bed mobility and transfers x 5-person assistance, and required assistance for wound and catheter care. Social history showed that patient was on disability, uninsured, and lived in a home with his ex-wife and significant other and received no home care services.


Review of a document in Patient 1's medical record titled, "PT (Physical Therapy) Evaluation," dated 08/17/21 at 7:10 AM-7:30 AM showed, "Activity limitations: weakness, dependent care; Participation restrictions: Unable to return home at PLOF (prior level of function.) ...PT Order: Evaluate and treatment ...Home situation: lives with family in a house; DME: walker and cane; Stairs: Outdoor 4 steps ...Patient Reports: Patient admitted via Emergency room on 08/12/1 and transferred to SSB on 08/16/21. He was transferred to bed by hospital staff and first responders and mechanical lift to get to bed. Patient reports that he was living in home with assistance from family. Patient reports that he last stood over a week ago ... ...Patient is supine (laying on back) on arrival of PT. He is not able to roll, sit, or stand. He is total assist via lift, but chairs not rated for patient weight for transfer. He is unsafe to sit at side of bed. Attempted rolling bilaterally unable to roll. He is assisted x 5 (number of people needed for assistance) with in bed cleaning and bed mobility ...Patient is not able to safely perform mobilities this am ...Patient is dependent care."


Patient 1 was discharged to home on 08/25/21 with his and his family's objection, voicing concern that discharge was unsafe due to inability to safely care for him in the home environment.


Review of a document in Patient 1's medical record titled, "Discharge Planner," dated 08/16/21, showed, " ...Present Living Situation: Lives with others; Anticipated Environmental Condition Problems: None; Emotional Concerns Expressed By Patient: Financial; Patient Goal During Hospitalization: Increase ability to complete ADL's independently; Name of Primary Caregiver: Daughter, Son; Concerns Expressed by Caregiver: Financial, Home care; Intended Destination Post Discharge: Home; Anticipated Need for Financial Assistance: Yes; Referrals: Social Services; What services do you have at home? None"


Patient 1's medical record failed to show documented evidence the CAH identified Patient 1's need for focused discharge planning, or that he was likely to suffer adverse effects if there was not adequate discharge planning and evaluation of his capacity for self-care or the possibility of Patient 1 being cared for in the environment from which he entered the hospital. The medical record review showed no discharge planning was performed in order for the patient to be successfully discharged to home.


During a phone interview on 10/12/21 at 11:25 AM, Patient 1's daughter, stated that the discharge paperwork showed that Patient 1 could use his walker and wheelchair although her father was bedridden. When he was discharged home, he was unable to get into the car and he was brought home by ambulance. She stated that she was provided with an application for Medicaid by the case manager but does not know if they ever tried to get him assistance from home health or a nursing home upon discharge. Once he was at home, he was unable to transfer from his wheelchair, sat in feces, and on 08/27/21, she called an ambulance to have him taken to a hospital in the next town, where he was admitted, and is still a patient.


During an interview on 10/13/21 at 10:05 AM, Staff D, Utilization Review/Swing bed Coordinator, stated that discharge planning is the responsibility of social services. Staff D stated that she took over discharge planning responsibilities in December 2020. Staff D stated, " ...I have kind of taken over ... ...Discharge planning starts as soon as they are admitted. ...Documentation of discharge planning is supposed to be done on social services flowsheet ...I'm not a social worker and just trying to hit the hotspots and what we think the patient is going to need ..." Staff D verified Patient 1 was discharged to home while requiring a four-six person assist for mobility/transfers, wound care, and with a Foley catheter. Staff D stated, "I had made the statement to (Staff H, Physician) that I didn't know how we were to get the patient home." When asked why the discharge documentation showed that Patient 1 was able to demonstrate the use of equipment (walker/wheelchair), Staff D stated that Patient 1 told her "I can do that ...He insisted he could use a walker ..." Staff D verified that Patient 1 was not able to demonstrate use of his walker and wheelchair. Staff D was not able to state whether Patient 1 was provided with discharge instructions/education for caring for wounds or Foley catheter care.


During an interview on 10/14/21 at 9:54 AM, Staff H, Physician, stated that patient was immobile from the day of admission through discharge. Staff H stated that Patient 1 was discharged from hospital upon completion of antibiotics for cellulitis. He stated that he spoke to Patient 1's family one time on the day before discharge and that family voiced, they did not want patient to be discharged from the hospital.

Based on interview, record review, and document review, the Critical Access Hospital (CAH) failed to ensure a discharge plan included an evaluation of a patient's likely need for appropriate post-CAH services, the determination of availability of appropriate services as well as the patient's access to those services for one of six charts reviewed (Patient 1). The CAH's failure to include an evaluation of a patient's need for appropriate post-CAH service, the availability of services and the patient's ability to access those services has the potential to result in adverse effects including rehospitalization for any patient receiving services at this facility.

Findings Include:

Review of a policy titled, "Discharge Plan - Swing Bed," approved date 10/20/16, showed, "It is the desire and intent of Russell Regional Hospital to ensure that every patient admitted to the hospital has a timely and need driven discharge plan that is realistic and facilitates a sustainable transition to a lesser level of care, including home ...Discharge planning shall begin as part of the initial assessment process. ...The anticipated discharge plan will be part of every multidisciplinary planning meeting with discussion about the anticipated date of discharge and the patient needs at the time of discharge. The Discharge Planner and the Social Worker will be responsible for the arrangement of any outside services and supportive devices needed at the time of discharge. The goal will be for the discharge services to be in place, so as to not delay discharge once the patient is ready.


Patient 1

Review of Patient 1's medical record showed that on 08/12/21, patient arrived via EMS to the emergency department with complaints of pain, swelling and redness, and decreased ability to bear weight on the left leg. The patient was evaluated in the emergency room and found to be a morbidly obese male weighing around 523 pounds. Patient 1 was observed to have wounds upon ER assessment. Wounds were described as moisture associated skin damage in all areas of skin folds, with redness and drainage and foul odor, a Stage 2 pressure ulcer (shallow open wound caused by pressure) to coccyx (a small triangular bone at the base of the spine) and three open wounds on the buttocks. Patient was admitted to acute care at 3:30 PM for continued treatment of sepsis and cellulitis. The Initial History and Physical was completed on 08/12/21 at 4:39 PM with medical history including hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), cerebral vascular accident (CVA) (stroke) with left sided weakness, and morbid obesity. He was discharged from acute status and admitted to skilled swing bed (SSB) on 08/16/21 for continued antibiotic administration and wound care that consisted of topical treatments of Calmoseptine ointment (a moisture barrier that protects and helps heal skin irritations) and Nystatin topical cream (a topical medication used to treat fungal or yeast infections of the skin) to reduce moisture contact and a dressing to the buttocks. Patient 1 was placed in a bariatric (obese) bed to help reduce the risk of further pressure ulcer formation. Documentation showed patient to be incontinent of urine and stool and a Foley catheter (tube put into bladder for urine drainage) was placed to prevent further moisture associated skin damage. Upon admittance to swing bed, the patient was evaluated by occupational therapy and physical therapy. Patient 1 received occupational therapy but due to his morbid obesity and body habitus it was determined that he was not a good candidate for physical therapy services. During his hospitalization and upon discharge, the patient was noted to have decreased level of functioning, required maximum assist with bed mobility and transfers x 5-person assistance, and required assistance for wound and catheter care. Social history showed that patient was on disability, uninsured, and lived in a home with his ex-wife and significant other and received no home care services.


Review of a document in Patient 1's medical record titled, "PT (Physical Therapy) Evaluation," dated 08/17/21 at 7:10 AM-7:30 AM showed, "Activity limitations: weakness, dependent care; Participation restrictions: Unable to return home at PLOF (prior level of function.) ...PT Order: Evaluate and treatment ...Home situation: lives with family in a house; DME: walker and cane; Stairs: Outdoor 4 steps ... He was transferred to bed by hospital staff and first responders and mechanical lift to get to bed. Patient reports that he was living in home with assistance from family. Patient reports that he last stood over a week ago ... ...Patient is supine (laying on back) on arrival of PT. He is not able to roll, sit, or stand. He is total assist via lift, but chairs not rated for patient weight for transfer. He is unsafe to sit at side of bed. Attempted rolling bilaterally unable to roll. He is assisted x 5 with in bed cleaning and bed mobility ...Patient is not able to safely perform mobilities this am ...Patient is dependent care.

Patient 1 was discharged to home on 08/25/21 with his and his family's objection voicing concern that discharge was unsafe due to inability to safely care for the him in the home environment.


Review of a document in Patient 1's medical record titled, "Discharge Planner," dated 08/16/21, showed, " ...Present Living Situation: Lives with others; Anticipated Environmental Condition Problems: None; Emotional Concerns Expressed By Patient: Financial; Patient Goal During Hospitalization: Increase ability to complete ADL's independently; Name of Primary Caregiver: Daughter, Son; Concerns Expressed by Caregiver: Financial, Home care; Intended Destination Post Discharge: Home; Anticipated Need for Financial Assistance: Yes; Referrals: Social Services; What services do you have at home? "None."


Review of Patient 1's medical record lacked documented evidence of a discharge plan that included an evaluation of Patient 1's likely needs for appropriate post-CAH services, the determination of availability of appropriate services as well as the patient's access to those services. The medical record failed to show arrangements or attempts to arrange any outside services and supportive devices needed at the time of discharge.


During a phone interview on 10/12/21 at 11:25 AM, Patient 1's daughter, stated that the discharge paperwork showed that Patient 1 could use his walker and wheelchair although her father was bedridden. When he was discharged home, he was unable to get into the car and he was brought home by ambulance. She stated that she was provided with an application for Medicaid by the case manager but does not know if they ever tried to get him assistance from home health or a nursing home upon discharge. Once he was at home, he was unable to transfer from his wheelchair, sat in feces, and on 08/27/21, she called an ambulance to have him taken to a hospital in the next town, where he was admitted, and is still a patient.

During an interview on 10/13/21 at 2:00 PM, Patient 1's daughter, stated that the day of discharge, she informed Staff D, she did not feel Patient 1 was ready to be discharged, that it would not be safe, and that he had not moved in bed for two weeks. No education, resources, or recommendations were provided to her at discharge.


During an interview on 10/13/21 at 10:05 AM, Staff D, Utilization Review/Swing bed Coordinator, stated that Patient 1 and his daughter were provided an application for Medicaid and offered assistance in filling it out. Staff D was asked if she had documentation of other interventions for patient assistance other than providing a Medicaid application and Staff D stated, "I'm sorry, I don't. I might have on my scratch sheets but those aren't part of the chart." Staff D stated that the facility made no attempt to transfer Patient 1 to a higher level of care.


During an interview on 10/14/21 at 9:54 AM, Staff H, Physician, stated that he spoke to Patient 1's family one time on the day before discharge and that family voiced, they did not want patient to be discharged from the hospital. Staff H stated that Patient 1 could not be discharged to long term care due to lack of insurance.

Based on observation, interview, and document review, the Critical Access Hospital (CAH) failed to ensure regular reevaluation of the patient's discharge planning process to identify changes that would require modification to the discharge plan and to update the discharge plan to reflect such changes for one of six records reviewed (Patient 1). This deficient practice has the potential of resulting in adverse effects including injury, infection, or rehospitalization for any patient receiving services at this facility.


Findings Include:


Review of a policy titled, "Discharge Plan - Swing Bed," approved date 10/20/16, showed, "It is the desire and intent of Russell Regional Hospital to ensure that every patient admitted to the hospital has a timely and need driven discharge plan that is realistic and facilitates a sustainable transition to a lesser level of care, including home ...Discharge planning shall begin as part of the initial assessment process. Assessment shall include, but not be limited to: Identification of patients in need of focused discharge planning, who are likely to suffer adverse effects if there is not adequate discharge planning and evaluation of patient's capacity for self-care or the possibility of patient being cared for in the environment from which he/she entered the hospital. All discharge related activity will be noted in the patient's Electronic Health Record ...Details a post-discharge plan of care that has been developed with the participation of the patient and the patient's family, which will assist the patient to adjust appropriately to his/her new living environment ..."


Review of a policy titled, "Patient Discharge," approved date 04/24/17, showed, " ...Print education documents, ...Problems should have been addressed and updated prior to discharge ...When they understand the instructions, document they indicate understanding of instructions, and education, give copy of instructions to patient ...Document time of discharge, by who accompanied type of conveyance, and all other pertinent observation ..."


Patient 1

Review of Patient 1's medical record showed that on 08/12/21, patient arrived via EMS to the emergency department with complaints of pain, swelling and redness, and decreased ability to bear weight on the left leg. The patient was evaluated in the emergency room and found to be a morbidly obese male weighing around 523 pounds. Patient 1 was observed to have wounds upon ER assessment. Wounds were described as moisture associated skin damage in all areas of skin folds, with redness and drainage and foul odor, a Stage 2 pressure ulcer (shallow open wound caused by pressure) to coccyx (a small triangular bone at the base of the spine) and three open wounds on the buttocks. Patient was admitted to acute care at 3:30 PM for continued treatment of sepsis and cellulitis. The Initial History and Physical was completed on 08/12/21 at 4:39 PM with medical history including hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), cerebral vascular accident (CVA) (stroke) with left sided weakness, and morbid obesity. He was discharged from acute status and admitted to skilled swing bed (SSB) on 08/16/21 for continued antibiotic administration and wound care that consisted of topical treatments of Calmoseptine ointment (a moisture barrier that protects and helps heal skin irritations) and Nystatin topical cream (a topical medication used to treat fungal or yeast infections of the skin) to reduce moisture contact and a dressing to the buttocks. Patient 1 was placed in a bariatric (obese) bed to help reduce the risk of further pressure ulcer formation. Documentation showed patient to be incontinent of urine and stool and a Foley catheter (tube put into bladder for urine drainage) was placed to prevent further moisture associated skin damage. Upon admittance to swing bed, the patient was evaluated by occupational therapy and physical therapy. Patient 1 received occupational therapy but due to his morbid obesity and body habitus it was determined that he was not a good candidate for physical therapy services. During his hospitalization and upon discharge, the patient was noted to have decreased level of functioning, required maximum assist with bed mobility and transfers x 5-person assistance, and required assistance for wound and catheter care. Social history showed that patient was on disability, uninsured, and lived in a home with his ex-wife and significant other and received no home care services.


Review of a document in Patient 1's medical record titled, "PT (Physical Therapy) Evaluation," dated 08/17/21 at 7:10 AM-7:30 AM showed, "Activity limitations: weakness, dependent care; Participation restrictions: Unable to return home at PLOF (prior level of function.) ...PT Order: Evaluate and treatment ...Home situation: lives with family in a house; DME: walker and cane; Stairs: Outdoor 4 steps ...Patient Reports: Patient admitted via Emergency room on 08/12/1 and transferred to SSB on 08/16/21. He was transferred to bed by hospital staff and first responders and mechanical lift to get to bed. Patient reports that he was living in home with assistance from family. Patient reports that he last stood over a week ago ... ...Patient is supine (laying on back) on arrival of PT. He is not able to roll, sit, or stand. He is total assist via lift, but chairs not rated for patient weight for transfer. He is unsafe to sit at side of bed. Attempted rolling bilaterally unable to roll. He is assisted x 5 [number of people needed to provide assistance] with in bed cleaning and bed mobility ...Patient is not able to safely perform mobilities this am ...Patient is dependent care."


Review of a document in Patient 1's medical record titled, "Discharge Planner," dated 08/16/21, showed, " ...Present Living Situation: Lives with others; Anticipated Environmental Condition Problems: None; Emotional Concerns Expressed By Patient: Financial; Patient Goal During Hospitalization: Increase ability to complete ADL's independently; Name of Primary Caregiver: Daughter, Son; Concerns Expressed by Caregiver: Financial, Home care; Intended Destination Post Discharge: Home; Anticipated Need for Financial Assistance: Yes; Referrals: Social Services; What services do you have at home? None"

Review of a documents in Patient 1's medical record titled, "Patient Progress Notes, showed the following:

1. 08/17/21 at 1:23 PM, "Swing bed Care Plan: Nursing Notes for Swing bed; Patient is disabled and in need of assist. His family states he was walking around the house prior to hospitalization - he is not able to do so at this time ..."

2. 08/18/21 at 3:50 AM, skin assessment with wounds noted to sacrum, left buttock, LLE (left lower extremity), and right lateral abdominal fold.

3. 08/22/21 at 11:20 AM, " ...Pt continues to have a split above the tailbone, a scrotal ...Pt continues to have bleeding areas on sacrum, left buttock and posterior left leg ...Wound, and bleeding about the left thigh. It is noted patient has erythema (redness) to the bulged of skin under axillary (arm pit) areas. No open areas. Possible caused by lift sling material/straps ..."

4. 08/23/21 at 10:27 AM, "Pt alert and oriented X 3, Foley remains in place with hematuria (blood in urine) noted. Open wounds to coccyx, right above coccyx, and left posterior thigh ...He was a x 5 for total cares. Pt is unable to assist with cares."

5. 08/24/21 at 7:00 PM, Occupational Therapy (OT) note showed, " ...Pt demo [demonstrates] to have safety concerns due to decreased functional mobility with ADL's [activities of daily living] and transfers. Pt demo to be using a lift with transfers. Pt will need assistance with ADL's ..."

6. 08/24/21 at 1:34 PM, showed Swing Bed Care Plan Nursing Note, " ... He has a Foley catheter to dependent drainage. He is participating in OT services and PT somewhat. Dr [doctor] plans to discharge tomorrow. Questions of how to get him home since it appears, he has not been walking for a while. He could benefit from a long-term facility but with no insurance will not be possible. Plan to discharge to home with question of how to get him returned to his home..."

7. 08/25/21 at 7:00 AM, " ...States he has his daughter and ex-wife coming up to visit with Dr when rounds are made about discharge. Doesn't feel he should go home because he is bed bound. Discussed options for him are limited due to lack of insurance." A nurse note at 9:03 AM showed, "Dr to visit with patient and family about discharge. Unable to offer PT services and antibiotics are completed today. Plan to discharge to home today around 1300 [1:00 PM] per private vehicle. Family has brought up patient's wheelchair."

8. 08/25/21 at 10:22 AM, Utilization Review note, "Plan to discharge to home today per private vehicle. Discussion had with daughter who says he doesn't qualify for Medicaid because he makes too much money on disability. Encouraged her to complete the paperwork and file anyway so she has an official denial."

9. 08/25/21 at 1:35 PM, "Patient discharged to home from Acute floor. Transferred to ER cot for transfer down to vehicle. Difficulty getting him from cot to his vehicle noted. Patient will be transported to home via EMS as he was unable to load into his van. Foley catheter remains intact to dependent drainage at least until he has his follow up with Dr in two weeks. He has home oxygen he wears at night. No further needs voiced at this time." Nurse note at 2:10 PM showed, "Staff had difficulty loading patient into his vehicle and ended up calling EMS to transport him to home. Discharge at this time."

Review of a document in Patient 1's medical record titled, "Education," for the dates of 08/16/21-08/25/21, was blank and showed no information.

Review of a document in Patient 1's medical record titled, "Discharge Instructions," showed, "Admit 08/16/21 ...Discharge 08/25/21 ...Activities: May shower., Gradually resume normal activities; Treatment Instructions: Change dressing to bottom as needed; General Instructions: Notify MD of elevated temperature, 100.5 degrees, drainage from wound, pain unrelieved by medication, any questions or concerns; Follow-up Appointments: Make a follow up appointment with Dr in two weeks ...Home Equipment: walker, wheelchair, Pt demonstrates equipment correctly."


Patient 1 was discharged to home on 08/25/21 with his and his family's objection, voicing concern that discharge was unsafe due to inability to safely care for him in the home environment.


During a phone interview on 10/12/21 at 11:25 AM, Patient 1's daughter, stated that the discharge paperwork showed that Patient 1 could use his walker and wheelchair although her father was bedridden. When he was discharged home, he was unable to get into the car and he was brought home by ambulance. She stated that she was provided with an application for Medicaid by the case manager but does not know if they ever tried to get him assistance from home health or a nursing home upon discharge. Once he was at home, he was unable to transfer from his wheelchair, sat in feces, and on 08/27/21, she called an ambulance to have him taken to a hospital in the next town, where he was admitted, and is still a patient.

During an interview on 10/13/21 at 2:00 PM, Patient 1's daughter, stated that the day of discharge, she informed Staff D, she did not feel Patient 1 was ready to be discharged, that it would not be safe, and that he had not moved in bed for two weeks. No education, resources, or recommendations were provided to her at discharge.


Patient 1's medical record lacked documented evidence of regular reevaluation of the patient's discharge planning process to identify changes that would require modification to the discharge plan and to update the discharge plan to reflect such changes; lacked documented evidence that problems were identified, addressed and updated prior to discharge and lacked documented evidence that the "Discharge Planner," dated 08/16/21, was updated to reflect changes in the patients inability to assist in his care. The medical record lacked documented evidence Patient 1 was given the opportunity to appeal discharge, and be allowed to remain in the facility until resolution of the appeal; and the medical record lacked documented evidence of education for the dates of 08/16/21 - 08/25/21.


During an interview on 10/14/21 at 8:32 AM, Staff F, Director PT, stated that Patient 1's level of function was declining, but due to staff, lack of adequate equipment, and patient limitations, physical therapy was not able to provide services for Patient 1. Staff F stated that patient would have been appropriate for a transfer to a higher level of care.


During an interview on 10/13/21 at 10:05 AM, Staff D, Utilization Review/Swing bed Coordinator, stated that discharge planning is the responsibility of social services. Staff D stated that she took over discharge planning responsibilities in December 2020. Staff D stated, " ...Discharge planning starts as soon as they are admitted. I try to get in there and visit with them a little bit and see what their needs are, what resources they have at home, what they currently are doing, if they have any equipment, any services, how they get their food, how they get their bathing done, and that sort of thing ...Documentation of discharge planning is supposed to be done on social services flowsheet ...I'm not a social worker and just trying to hit the hotspots and what we think the patient is going to need ..." She stated that Patient 1 and his daughter were provided an application for Medicaid and offered assistance in filling it out. Staff D was asked if she had documentation of other interventions for patient assistance other than providing a Medicaid application and Staff D stated, "I'm sorry, I don't. I might have on my scratch sheets but those aren't part of the chart." Staff D stated that physical therapy did not provide services to Patient 1 because it was considered a safety issue for the patient and staff due to Patient 1's size and weight. Staff D stated that the physician was aware that Patient 1 was not receiving physical therapy services. She verified that patient was discharged to home while requiring a four-six person assist for mobility/transfers, wound care, and with a Foley catheter. Staff D stated, "I had made the statement to (Staff H, Physician) that I didn't know how we were to get the patient home." When asked why the discharge documentation showed that patient was able to demonstrate the use of equipment (walker/wheelchair), Staff D stated that Patient 1 told her "I can do that ...He insisted he could use a walker ..." Staff D verified that Patient 1 was not able to demonstrate use of his walker and wheelchair. Staff D was not able to state whether Patient 1 was provided with discharge instructions/education for caring for wounds or Foley catheter care.


During an interview on 10/14/21 at 9:54 AM, Staff H, Physician, stated that patient was immobile from the day of admission through discharge. Staff H stated that Patient 1 was discharged from hospital upon completion of antibiotics for cellulitis. He stated that he spoke to Patient 1's family one time on the day before discharge and that family voiced, they did not want patient to be discharged from the hospital.