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Based on hospital policy review, medical record review, and staff interviews, the hospital failed to arrange home health physical therapy for 1 of 4 patients being discharged with home health services reviewed. (Patient #2)

Findings included:

Review of the hospital policy titled "Patient Discharge" revised 10/15/2019 revealed " I. Policy:...The discharge plan will be monitored and revised as necessary throughout the hospital stay...Physician: Complete instructions for...follow up care and any DME (durable medical equipment) orders... Case Management: Reassess the discharge plan as needed. Add any home health info or DME information to the Discharge Routine. Discuss available Medicare/Managed Care Home Health agencies ...that are available in the geographic area requested by the patient/family when the discharge planning assessment indicates a need for home health or post-hospital extended care services. Provide the patient/family the opportunity to fully participate in the selection of services that will best meet their identified needs...Confirm arrangements for any medical supplies or equipment to be provided in the home."

Closed medical record review of Patient #2, a 65-year-old female patient admitted on 09/25/2021 at 2227 with abdominal and flank pain with vital signs temperature 98.9, pulse 70, respirations 15, blood pressure 179/83, and oxygen on room air of 95% (percent). Review of the History and Physical dated 09/25/2021 at 2241 by Medical Doctor (MD) #1 revealed "...assessment: chronic abdominal pain, acute and chronic heart failure, acute hypoxemic respiratory failure...chronic kidney disease stage III, and otherwise chronic conditions are...HTN (high blood pressure), HLD (hyperlipidemia), and GERD (gastroesophageal reflux disease) and DM II (diabetes type II)...History of Present Illness:...with several weeks of worsening bilateral lower extremity edema (swelling), shortness breath, and abdominal discomfort and was found to have acute hypoxic respiratory failure...and pursue diuretic (medication to increase the production of urine) regimen..." Review of the Case Management initial assessment dated 09/26/2021 at 0913 by Case Manager (CM) #2 revealed that Patient #2 lived at home, had walker, cane, nebulizer and BIPAP (non-invasive ventilation used for breathing support) currently in use. Patient #2 was given Pt. Choice Brochure for home health and DME services for review and case management was to continue to follow during hospitalization. Case management following for disposition needs..." Review revealed a physical therapy evaluation was completed on 09/26/2021 at 1500 by Physical Therapist (PT) #3. Review of the Progress Note dated 09/27/2021 at 1154 by Family Nurse Practitioner (NP) #4 revealed, "Physical therapy evaluating patient and recommending home with home health at discharge, patient/family agreeable. Case management following for disposition of needs..." Review of the final PT Progress Note dated 09/30/2021 at 1500 by PT #6 revealed a recommendation of HHPT (home health physical therapy). Review of the Discharge Summary dated 10/01/2021 at 1943 by MD #5 revealed "... Her strength continues to improve, and she was ambulating 50 feet with her walker in the room without desaturation (percentage of oxygen in blood is lower than it should be)...PT (physical therapy) recommending return home with HHPT (home-health physical therapy). She is medically stable for discharge..." Record review of the Physician Orders did not reveal an order for HHPT. Review of the Discharge Instructions for Patient #2 dated 10/01/2021 at 1830 by Registered Nurse, RN #8 revealed no mention of HHPT referral. Record review revealed there was no other case management or nursing notes requesting HHPT services for Patient #2 at discharge. Review revealed Patient #2 was discharged on 10/01/2021 at 1830 to home escorted by son.

Interview on 10/27/2021 at 1315 with the Director of Case Management, CM #9 revealed "...my expectation was the case manager would document notes on anything completed for the patient in the record..." Interview revealed not following up with PT recommendations for HHPT was a "missed" step. Interview revealed that when the Order and Certification for Home Health Services Form was completed and signed by the doctor, that case management staff would follow through with the referral. Interview revealed that home health physical therapy for Patient #2 was not completed.

Interview on 10/27/2021 at 1525 with discharging physician, MD #5 revealed "...I agree we did want home health physical therapy...I get that sheet [Certification for Home Health Agencies: Physician authorization for HHPT] to the case manager. It was probably (named) case manager because she did her O2....I am surprised the home health physical therapy wasn't ordered..." Interview revealed MD #2 completed an Order and Certification for Home Health Services form to order home health physical therapy at discharge for Patient #2. The form was given directly to case management staff or placed in the front of the patient's physical chart at the desk for case management to retrieve. Interview revealed that the discharging MD #2 had completed the order for home health referral for Patient #2.

Telephone interview on 10/28/2021 at 1035 with discharge RN #8 revealed "...I recall this patient. I discussed the O2 tank with the patient and the son. I don't recall discussing home health services..." Interview revealed that case management handles the set up for home health referrals. Interview revealed that RN #8 did not recall discussing home health physical therapy with Patient #2 on discharge.

Interview on 10/28/2021 at 1045 with Patient #2's Case Manager, CM #7 revealed "...as far as (named patient) I did not have any communication in huddle, or in the chart for a HHPT referral. Normally I can review the charts but with high census and acuity, I was not able too. Generally, I rely on huddle with the physician to receive that communication. I look for the certification signed order from the doctor to set up home health services. If I had received that communication, it would be in the record. There would have been a note. I did not talk with family regarding home health physical therapy. Interview revealed home health physical therapy was not completed for patient #2.

NC00181998