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Based on record review, policy review, and employee interviews, the facility failed to provide a safe Discharge Plan, which resulted in a readmission to another facility for 1 of 3 patients reviewed for discharge planning. (Patient #1, Hospital B)


The findings include:


Patient #1 was admitted to Hospital A on 05/12/2020 as a voluntary patient for psychiatric needs. Patient #1 completed therapy at Hospital A and was waiting for appropriate placement in the community. Records from Hospital A showed Patient #1 had mental and physical needs. Patient #1 had a community caseworker and resided in an Assisted Living Facility (ALF) prior to admission at Hospital A. Patient #1 is wheelchair bound due to a below the knee amputation on the right side. Records from Hospital A showed Patient #1 had low sodium levels and needed medical attention on 06/02/2020. Hospital A could not provide this type of medical attention. Patient #1 was transferred to Hospital B for appropriate medical attention on 06/02/2020. On review of Hospital A's records for Patient #1, all policies and procedures were followed, resulting in an appropriate transfer and discharge of Patient #1 from Hospital A.


A record review of Patient #1 at Hospital B revealed the patient arrived on 06/02/202 at 06:35pm by rescue from Hospital A for low sodium levels. Labs results on 06/02/202 at 07:04pm showed Patient #1's sodium level was 123. The Emergency Physician consulted an Admitting Physician for admission for Hyponatremia (low sodium) at 08:30 pm. The Admitting Physician admitted Patient #1 for Hyponatremia and medical clearance under a 23-hour observation.


On 06/03/2020 at 07:30am, Patient #1's labs showed a corrected sodium level of 134. The in-patient physician discharged Patient #1 for corrected sodium levels.


On 06/03/2020 at 11:45am, the nursing notes showed Employee #6, Registered Nurse (RN), noted in Patient #1's record that Hospital A was contacted to notify them that the patient was ready for discharge.


On 06/03/2020 at 11:59am, the Case Management notes for Patient #1 showed Employee #5, Case Manager (CM), noted:


-"SW attempted to contact patient; no answer."
-Unable to assess current mental status
-Information obtained from medical records
-Discharge barriers: None or N/A
-Patient goals and preferences after discharge: home
-Based on information gathered, is it likely that the patient's care needs can be met in the environment from which he/she entered the hospital? Yes
-If a caregiver is needed, is there a caregiver available, willing and capable to provide care? Not needed
Community Services needed: None

(photographic evidence obtained)


On 06/03/2020 at 12:04pm, the nursing notes showed Employee #6, RN noted in Patient #1's record, the patient's caregiver contacted the RN and stated the caregiver would pick the patient up at 2:30 pm.


On 06/03/2020 at 02:15pm, the nursing notes showed Employee #6, RN noted in Patient #1's record, the patient's caregiver was at the hospital to pick up the patient.


An interview was conducted with Employee #5, CM and the Director of Case Management on 06/23/2020 at 09:05am. Employee #5 stated she tried to call the phone number in the patient's demographic information of the medical record. Employee #5 stated Patient #1 had no other needs besides psychiatric care, and there were no physical needs. Employee #5 stated her documentation on 06/03/2020 was correct for Patient #1.


During the interview, Patient #1's medical record was reviewed. It was discovered the demographic information for Patient #1 was the same as the emergency contact listed for the patient. Employee #5 admitted the patient and the emergency contact had the same phone number, and it was possible she called the emergency contact and not the patient during her phone attempt to assess the patient.


In the interview with Employee #5 and the Director of Case Management, they both stated Patient #1 remained in the Emergency Department (ED) after being admitted on observation status by the Admitting Physician. They stated this was not uncommon when there are no available beds in the hospital. They explained Employee #5 was a Case Manager assigned to the ED, to assist with Case Management needs in the ED.


Employee #5 stated she did not attempt to see Patient #1, because of documented patient behaviors in the nursing notes. She confirmed that she should have assessed the patient in person according to the facility's policy and procedures. She stated she did not know Patient #1 was wheelchair bound.


A second interview with the Director of Case Management was conducted on 06/23/2020 at 11:49am. The Director admitted Employee #5 did not meet the expectation for Case Managers in the case of Patient #1. The Director stated this case is not their standard of patient care, and she recognized that. She stated it was expected that Case Managers conduct a full assessment on all patients; this was not acceptable and Employee #5, should have seen the patient. The Director confirmed Employee #5's Discharge note was incomplete and not appropriate for Patient #1. The Director stated that the Case Manager was supposed to round on every observation patient daily and confirmed this did not occur with Patient #1. The Director confirmed the facility policy and procedures relating to discharge planning was not followed.


In an interview, on 06/23/2020 at 03:47pm with the Director of Nursing (DON), she explained her expectation of discharging a patient that included proper education and understanding of discharge to the appropriate level of care. She would expect a Case Manager to see a patient in person.


Review of Policy and Procedures titled "Discharge Planning" revealed all patients identified as high risk patients admitted to Hospital B have the right to receive a Case Manager for individualized assessment of their needs for continuity of care upon discharge to the community or an alternate level of institutional care that is appropriate. The Case Management Department will screen all admissions for the following high-risk patient identification, diagnosis and at-risk populations which may require in-depth discharge planning assistance. (photographic evidence obtained)


After discharge of Patient #1 at Hospital B on 06/03/2020 at 02:15pm to a boarding home without a wheelchair ramp, the patient was visited by her community Case Manager. The patient was found sitting in her wheelchair outside the boarding home and appeared drugged or sedated. The patient was taken to Hospital C on 06/03/2020 at 07:16pm by Rescue for altered mental status. Records from Hospital C showed Patient #1 was admitted for patient placement and is currently still a patient, awaiting appropriate placement in the community.