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Based on record review and interview the facility failed to include the patient and caregiver/support person in the discharge planning process for 1 Patient (Pt.) #1 out of 12 patient records reviewed and failed to re-evaluate patient (Pt. #1) condition prior to discharge for 1 out of 12 patient records reviewed.


Findings Include:

The facility failed to re-evaluate the patient (Pt. #1) condition prior to discharge see Tag: A-0802

The facility failed to include the patient (Pt. #1) and caregiver/support person in the discharge planning process see Tag: A-808

Based on Record review and interview the facility failed to re-evaluate the condition of 1 of 12 (Patient #1) patients reviewed prior to discharge.

Findings:

Patient #1 was hospitalized as a result of trauma from a severe fall on 10/21/2024 and required physical therapy, occupational therapy and speech therapy. Pt. #1 was diagnosed with a traumatic brain injury due to a skull fracture and subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and subdural hemorrhage (bleeding on the outside of the brain). Pt. #1 was discharged home with home health services on 10/28/2024.

Review of Facility Policy last reviewed 10/28/2024, titled, "Discharge Planning," revealed, "Discharge planning will begin upon admission with an assessment of each patient's potential continuing care needs. Discharged patients will receive verbal and written instructions regarding their continuing care needs including arrangements for placement and other services...The hospital must discharge the patient, and also transfer or refer the patient....with all the necessary medical information pertaining to the patient's current course of illness and treatment....The discharge planning process and the discharge plan shall...ensure an effective transition of the patient from hospital to post-discharge care....[Facility] will identify at an early state of inpatient stay/admission, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and will provide a discharge planning evaluation for those patients...A discharge planning evaluation shall include an evaluation of the patient's likely need for appropriate post-hospital services and must also include a determination of the availability of the appropriate services as well as of the patient's access to those services....The patient's condition must be re-evaluated at least every seven (7) days to identify changes that require modification of the discharge plan. The discharge plan must be updated...to reflect these changes."

Ongoing review of Pt. #1's medical record revealed OT (occupational therapy) last saw Pt. #1 on 10/25/2024, 3 days before Pt. #1's discharge and PT (Physical Therapy) last saw Pt. #1 on 10/26/2024 2 days before Pt. #1's discharge.

Review of ST (Speech Therapy) note on 10/25/2024 at 3:03 PM revealed, "Pt. presents with cognitive deficits impacting thought organization, memory, attention and executive function skills. Pt demonstrates awareness of cognitive difficulties and was tearful at the end of session. Wife called at end of session. Discussed recommendation for ongoing ST at next level of care with Pt and wife. Both agreed with POC (plan of care). These deficits impact patient's functional safety and independence. Patient would benefit from ongoing ST services for cognition. Consider inpatient rehab."

Review of OT note on 10/27/2024 at 8:00 AM revealed, "Attempted to see pt for schedule OT session this AM. Upon arrival to room, pt resting in bed with ice packs to forehead and reports having a bad night with headache and neck pain. Physician in room. Pt declining participation this AM requesting to rest. Pt and spouse do mention some double vision, would benefit from further assessment next session."

Review of Provider Trauma note on 10/27/2024 at 10:22 AM revealed, "Recent PTOT note suggests home PT although there was some discussion of inpatient [Facility W] rehab. Continue therapy....and placement-vs-home assessment tomorrow....Reports he is severly uncomfortable and having 10/10 pain in his neck and head. He reports no sleep due to the pain. Unable to eat due to nausea. Felt no relief with addition of Fioricet (pain medication)....Discharge Planning: Therapy Recs IPR (Inpatient Rehabilitation)...Disposition: medically stable for discharge to IPR."

Review of Provider Neurosurgery note on 10/27/2024 at 11:28 AM revealed,"We were asked to see the patient about ongoing neck pain...Discharge planning....Therapy Recs: IPR...Disposition: Medically stable for discharge to IPR."

Review of Provider Internal Medicine note on 10/27/2024 at 11:59 AM revealed, "Chief Complaint/Reason for visit: Head/Neck Trauma, awaiting placement at [Facility W]."

Review of Provider Neurosurgery note on 10/28/2024 at 7:16 AM revealed, "Reports continued pain at the base of the head on the left that shoots up the back of the head and into the left eye, with blurry vision....Discharge orders in place."

Discharge order was placed by PA Z on 10/28/2024 at 11:16 AM and revealed, "Discharge Disposition Home or Self Care."
Pt. #1 was discharged on 10/28/2024 home with home health services.

Review of Provider Trauma discharge summary note on 10/28/2024 completed by Physician Assistant Z and co-signed by Provider AA at 1:23 PM revealed, "Discharge Destination: Home with HH (Home Health) vs IPR."

Review of Internal Med discharge summary on 10/28/2024 at 1:33 PM revealed, "Pt. discharged before I was able to evaluate him today...Since he discharged home instead of to acute rehab, I will fax this to his primary care doctor to coordinate labs and follow up. I also called [Pt. #1] and his wife so they know to expect a call."

On 11/19/2024 at 9:30 AM in an interview with Complainant A, Complainant A stated, "It was so scary to have him at home, I could barely get him up into the house, he was crying, I was crying. I wanted to appeal but I wasn't listened to, we were forced to go home and in the condition he was in, the discharge person and the case manager wouldn't listen. When [Staff BB] called the next day we were able to get him into [Facility W] that day and he was there until 11/9/2024 and is home now and doing much better. We were never told we had insurance approval to go to Inpatient Rehab before discharge."

On 12/04/2024 at 8:25 AM in an interview with Therapy Director J, when asked how is it determined where a patient is discharged to, J stated, "The discharge process is collaborative, our therapy recommendation doesn't dictate where a patient goes."

There was no documented evidence of discussions between disciplines regarding discharge planning.

On 12/04/2024 at 9:10 AM in an interview with Hospitalist L when asked what is the role of the hospitalist in the discharge process, Hospitalist L stated, "We discuss every morning on rounds, I review EPIC (electronic medical record) problem list, medications, determine what orders are needed for discharge, diet, activity, follow up. As a consult I don't always put in discharge orders." When asked what happened with Pt. #1's discharge and why it changed, L stated, "The recommendation was PT and OT and they were searching for IP rehab. I don't know what happened."

Based on record review and interview the facility failed to include Patient (Pt.) #1 and their family in the discharge planning process and failed to provide discharge appeal information 4 hours prior to discharge for 1 of 12 patients reviewed (Pt. #1).

Findings Include:

Review of Facility policy effective date 01/04/2023, titled, "Medicare IMM (Important Message) and MOON (Medicare Outpatient Observation Notice) Corporate Policy," revealed, "Delivery of the IM and Moon Notifications-Summary of Process:...1.[Facility] must issue the initial IM within 2 days of admission and must obtain the signature of the beneficiary or their representative. 2. [Facility] must also deliver a copy of the signed notice to each beneficiary not more than 2 days before the day of discharge....Follow up IM Notice: 1. The follow-up IM must also be provided to the patient as soon as possible prior to discharge, but no more than 2 days before....If the follow up notice is delivered on the day of discharge, the patient must be given at least 4 hours prior to discharge to consider their rights.

Review of Facility Policy last reviewed 10/28/2024, titled, "Discharge Planning," revealed, "The discharge planning process shall focus on patient goals and treatment preferences...in the discharge planning for post-discharge care. There must be documentation in the patient's medical record of the patient's goals and treatment preferences....and...include that the patient and their...support person was included in the development of the goals....The discharge planning process and the discharge plan shall be consistent with the patient's goals of care and their treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care....[Facility] will identify at an early state of inpatient stay/admission, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and will provide a discharge planning evaluation for those patients."

Review of Pt. #1's CM (case manager) note on 10/25/2024 at 11:59 AM revealed, "Expected Discharge disposition: Inpatient Rehab Facility...CM met with pt at the bedside in conjunction with spouse...over the phone to update on dcp (discharge care plan). CM adv (advised) ...discharge... that pt (physical therapy) recommended...HH (home health) by PT if pt has no support at home and OT=IPR. (Inpatient rehab facility). PT/spouse want IPR because [spouse] works during the day and no one will be available to assist pt during that time."

Pt. #1's medical record revealed Pt. #1 was accepted for IPR at Facility W on 10/25/2024 at 1:21 PM.

Review of Nursing Progress Note on 10/26/2024 at 3:02 AM revealed nursing notified the provider Pt. #1 was having uncontrolled headache, nausea and vomiting.

Review of Trauma progress note on 10/27/2024 at 10:22 AM revealed, "Wearing aspen collar for C5/6 herniated disk. Recent PTOT note suggests home PT although yesterday there was some discussion of inpatient [Name] rehab. Continue therapy, aspen collar, and placement-vs-home assessment tomorrow...Discharge Planning: Therapy Recs: IPR (Inpatient Rehab)...Disposition: medically stable for discharge to IPR."

Review of Neurosurgery progress note on 10/27/2024 at 11:28 AM revealed, "We were asked to see patient about ongoing neck pain...reports has severe pain at the base of the head on the left that shoots up the back of the head and into the left eye, with blurry vision...has intermittent numbness in the arm...reached back out to NSGY (neurosurgery) given severe pain limiting his mobility....Discharge planning:....Therapy Recs: IPR...Disposition. Medically stable for discharge to IPR."

Review of Internal Medicine Progress note completed by Hospitalist L on 10/27/2024 at 11:59 AM revealed, "Chief Complaint: Head/neck trauma, awaiting placement at [Facility W] Inpatient rehab Headache and nausea better today."

Discharge order was placed by PA Z on 10/28/2024 at 11:16 AM and revealed, "Discharge Disposition Home or Self Care."

Pt. #1 was discharged on 10/28/2024 home with home health services.

Review of 10/28/2024 10:09 AM nursing note revealed, "Pt. #1 has been safe from falls this shift, up with SBA (stand by assist) and 2ww (wheeled walker)...Pertinent information: moves very slow, gets dizzy when he gets up, it does subside some but continues when he does certain moves. Plan/discharge plan: home when medically ready. D/c home today, instructions given to patient and his wife...Taken out in a w/c by staff."

Review of Pt. #1's medical record revealed, Pt. #1's AVS (After visit summary) was printed on 10/28/2024 at 12:42 PM. Review of CM discharge note on 10/28/2024 at 12:07 PM revealed, "Therapy Recommendation: After PT/OT evaluation they are recommending that Patient would benefit from ongoing therapy with home health...RNCM [Registered Nurse Case Manager] contacted home health liaison to request ST (Speech Therapy) be added. RNCM updated at bedside while spouse on patient's speaker phone very upset about change in therapy recs and patient discharge disposition. IMM letter provided."

The order for Pt. #1's discharge was placed at 11:16 AM on 10/28/2024, the IMM (this notice provides information on discharge appeal rights and per hospital policy should be given at least 4 hours prior to discharge) was documented as given in the CM note on 10/28/2024 at 12:07 PM, Pt. #1's AVS was printed at the time of discharge at 12:42 PM. The nurses note on 10/28/2024 at 10:09 AM revealed pt. #1 was taken out by wheelchair. Pt. #1 received their IMM notice 37 minutes before getting their discharge instructions.

On 11/19/2024 at 9:30 AM in an interview with Complainant A, Complainant A stated, "It was so scary to have him at home, I could barely get him up into the house, he was crying, I was crying. I wanted to appeal but I wasn't listened to, we were forced to go home and in the condition he was in, the discharge person and the case manager wouldn't listen. When [Staff BB] called the next day we were able to get him into [Facility W] that day and he was there until 11/9/2024 and is home now and doing much better. We were never told we had insurance approval to go to Inpatient Rehab before discharge."

Pt. #1 was discharged on 10/28/2024 home with home health services. Based on review of the patients medical record, Pt. #1's status changed daily. The facility was initially recommending discharge to an inpatient rehab facility and then the recommendation changed on the date of discharge to home with home health services. There is no documentation as to when or why the discharge recommendation changed. There is no documented evidence that Pt.#1 or their spouse were informed the discharge plan was changing from IPR to home with home health until the day of discharge. There was no documented evidence that Pt. #1 or their spouse had been updated on the status of the referral to [Facility W] for IPR placement.