HospitalInspections.org

Based on interview and record review, the hospital failed to implement an adequate discharge planning evaluation for use in establishing an appropriate discharge when they failed to include the patient's caregivers/support person(s) in the discharge planning and ensure an effective transition for 1 of 7 sampled patients (#1) from hospital to post-discharge care.

Findings:

Review of the medical record for patient #1 revealed that on 8/8/24 around 5:33 a.m. patient was transferred from a Skilled Nursing Facility (SNF), where she had been admitted on 07/19/24 for rehabilitation post right femur fracture, to the hospital Emergency Department (ED) via Emergency Medical Services (EMS) for complaints of chest pain. At the time of the transfer the SNF's transfer form dated 8/8/24 indicated patient was alert and oriented with ability to follow instructions but required a health care proxy to assist with decision making. Patient was non-ambulatory, incontinent of bowel and bladder, needed assistance with ADL's (activities of daily living), and was currently receiving rehabilitation therapy at the SNF.

The ED triage note dated 8/8/24 at 6:25 AM, indicated patient #1 arrived via EMS with a diagnosis of COPD and using 4 liters of oxygen. A brief cognitive assessment done as part of the patient's ED assessment noted patient knew her name, that she was currently in the hospital but did not know the year. Patient #1 was also assessed as a high fall risk, indicating no falls in past 3 months although she was in this hospital on 07/19/24 for repair of a right femur fracture post fall and discharged from this same hospital to the SNF for rehab post femur repair.

Continued ED record review noted hospitalization was considered at this time but not necessary noting stable cardiomegaly with no infiltrate and troponin comparisons from past hospitalization showing only slightly elevated levels on this ED visit. Disposition indicated patient would be discharged home in good condition with clinical impression of atypical chest pain and stable COPD.

Continued review of the ED general discharge instructions noted Patient #1 was discharged from the ED on 8/8/24 sometime around 11:00 AM and documented patient verbalized understanding of the discharge instructions and the plan of care. Review of the discharge instructions did not find a signature from patient #1 and no signature by a proxy or hospital representative and without an order for oxygen to be continued and/or case management consult related to discharge planning.

Further review of the ED discharge document dated 8/8/24 at 10:58 AM revealed patient #1 would be discharged to a SNF or an assisted living facility (ALF). Under additional information on that document, it noted the patient would be transported back to the ALF where she had been living prior to femur fracture, via a vendor transport service, although patient had been transferred to the ED from the SNF.

SNF nursing notes were obtained and revealed on 8/8/24 at 11:32 AM, patient #1's son called and let them know the hospital transferred his mother back to the ALF, where she previously resided in an independent living environment, instead of the skilled nursing facility where she was receiving active therapy post femur fracture. Upon the SNF's Administrator and Director of Nursing notification, they sent their facility driver to transport and pick up patient #1 and return her from her home to the SNF where she is currently receiving therapy.

Review of facility policy "Discharge Planning: By Outside Case Manager from Managed Care Providers" CP 14.02.12 PRO (DS); effective date 4/1/2007, last reviewed on 12/1/22 re: " ...involvement in transition planning to enhance unbroken existence of care over a period of time. The procedure showed the transition plans are created for all patients who need assistance returning safely to the community .... and planning arrangements are discussed with the patient and/or patients' representative.

On 9/30/24 at approximately 12:37 PM, during survey investigation, interview with the Director of Risk Manager and System Director of Emergency Services revealed hospital did not have any documentation of communication with family or the skilled nursing facility regarding discharge planning and facility's goal is to return patients to their previous location when appropriate.