HospitalInspections.org

Based on staff interview and record review the facility failed to include the patient's representative in the development and implementation of the discharge plan for 1 of 10 applicable patients in the sample. (Patient #1). Findings include:

Per record review, Patient #1 has Alzheimer's dementia (type of chronic or persistent disorder of mental processes affecting memory, personality, and/or behavior) heart, kidney, and other nervous system conditions. S/he was admitted to the hospital on 12/16/16 from a residential care home with pneumonia and a pleural effusion (excess fluid in the lung). Per interview with Patient #1's legal guardian, Patient #1 was discharged two days later on a very cold day, dressed only in a hospital gown covered with blankets; and was sent back to the care home, alone in a cab.

Per review of the provider admission and discharge notes, Patient #1 refused to take antibiotics at the care home, became increasingly agitated, was up all night crying out in pain, and was very irritable with the staff at the care home. Patient #1 was sent to the Emergency Department via ambulance and was admitted for IV (in the vein) antibiotics and mood management. Patient #1's legal guardian had been at the hospital the day prior to discharge and had discussed with the provider the specific discharge requirements for a safe discharge for Patient#1. Per review of the nursing progress notes on 12/18/16 at 11:00 AM, the patient had written discharge orders to go back to the residential care home. Report was called to the residential care home; and Patient #1 verbalized understanding of discharge instructions and denied further questions.

Per record review Patient #1 was discharged on the weekend and the Case Manager who developed the discharge plan failed to consult with Patient #1's legal guardian regarding Patient#1's functional status, and specific discharge needs. Per interview on 2/21/17 at 2:35 PM with the Manager and Supervisor of Case Management and Social Work, each confirmed that Patient #1's legal guardian was not consulted nor given the opportunity to participate in plans regarding Patient #1's discharge needs.

Based on staff interview and record review, the hospital failed to identify discharge planning needs for 2 of 10 applicable patients in the sample.(Patient#1 and Patient #8). Findings include:

1. Per record review, Patient #1 has Alzheimer's dementia, heart, kidney, and other nervous system conditions. On 12/16/16, Patient #1 was admitted to the hospital and was newly diagnosed with pneumonia and a pleural effusion. Per interview with Patient #1's legal guardian, Patient #1 needed help getting dressed and had trouble getting in and out of vehicles; and upon discharge would need a wheelchair van and/or ambulance for transportation back to the residential care home where s/he resided. Patient #1 was discharged two days later, dressed only in a hospital gown, covered with blankets, and sent back to the home, alone in a cab. Per record review there was no evidence of an admission assessment/evaluation for his/her initial discharge needs. Per review of the policy "Discharge Planning and Patient Discharge" (revised/reviewed 2/3/17) under procedure it states, "2. All patients will be assessed within 24 hours of admission for initial discharge needs." Per interview on 2/21/17 at 2:35 PM with the Manager and Supervisor of Case Management and Social Work, each stated that it was the responsibility of the Case Manager to complete an initial discharge planning assessment/evaluation within 24 hours of admission. They each confirmed that the Case Manager failed to complete an assessment/evaluation of the initial discharge needs for Patient #1, per hospital policy/procedure.

2. Per record review, Patient #8 was admitted to the hospital on 1/30/17 with pneumonia and discharged home five days later. S/he has a history of asthma (chronic lung disease that inflames and narrows the airways), diabetes (metabolic disorder characterized by high blood sugar, insulin resistance and lack of insulin), some cognitive and memory deficits, and multiple hospital admissions for recurrent pneumonia. Upon further record review, there was no evidence of an admission assessment/evaluation for his/her initial discharge needs. Per review of the policy "Discharge Planning and Patient Discharge" (revised/reviewed 2/3/17) under procedure it states, "2. All patients will be assessed within 24 hours of admission for initial discharge needs." Per interview on 2/22/17 at 1:58 PM with the Director of Clinical Operations and Manager of Case Management and Social Work, each stated that it was the responsibility of the Case Manager to complete an initial discharge planning assessment/evaluation within 24 hours of admission. They each confirmed that the Case Manager failed to complete an assessment/evaluation of the initial discharge needs for Patient #8, per hospital policy/procedure.

Based on staff interview and record review the hospital failed to include the discharge planning evaluation in the medical record for 2 of 10 applicable patients in the sample (Patient #1, Patient #8). Findings include:

1. Per record review, Patient #1 has Alzheimer's dementia, heart, kidney, and other nervous system conditions. On 12/16/16, Patient #1 was admitted to the hospital and was newly diagnosed with pneumonia and a pleural effusion. Per interview with Patient #1's legal guardian, Patient #1 needed help getting dressed and had trouble getting in and out of vehicles; and upon discharge would need a wheelchair van and/or ambulance for transportation back to the residential care home where s/he resided. Patient #1 was discharged two days later, dressed only in a hospital gown, covered with blankets, and sent back to the home, alone in a cab. Per record review there was no evidence of an admission assessment/evaluation for his/her initial discharge needs in the medical record. Per review of the policy "Discharge Planning and Patient Discharge" (revised/reviewed 2/3/17) under procedure it states, "2. All patients will be assessed within 24 hours of admission for initial discharge needs." Per interview on 2/21/17 at 2:35 PM with the Manager and Supervisor of Case Management and Social Work, each stated that it was the responsibility of the Case Manager to complete an initial discharge planning assessment/evaluation within 24 hours of admission. They each confirmed that the Case Manager failed to complete and document in the medical record, an assessment/evaluation of the initial discharge needs for Patient #1, per hospital policy/procedure.

2. Per record review, Patient #8 was admitted to the hospital on 1/30/17 with pneumonia and discharged home five days later. S/he has a history of asthma (chronic lung disease that inflames and narrows the airways), diabetes (metabolic disorder characterized by high blood sugar, insulin resistance and lack of insulin), some cognitive and memory deficits, and multiple hospital admissions for recurrent pneumonia. Upon further record review, there was no evidence of an admission assessment/evaluation for his/her initial discharge needs in the medical record. Per review of the policy "Discharge Planning and Patient Discharge" (revised/reviewed 2/3/17) under procedure it states, "2. All patients will be assessed within 24 hours of admission for initial discharge needs." Per interview on 2/22/17 at 1:58 PM with the Director of Clinical Operations and Manager of Case Management and Social Work, each stated that it was the responsibility of the Case Manager to complete an initial discharge planning assessment/evaluation within 24 hours of admission. They each confirmed that the Case Manager failed to complete and document in the medical record, an assessment/evaluation of the initial discharge needs for Patient #8, per hospital policy/procedure.