HospitalInspections.org

Based on interview and record review, the facility failed to ensure a complete discharge planning evaluation (plan for when a patient leaves the hospital) was initiated for one of 20 sampled patients (Patient 17).

This failure had the potential to result in adverse health outcomes for Patient 17, when needs and resources were not identified and made available upon discharge.

Findings:

On April 30, 2025, at 2:59 p.m., a review of Patient 17's medical record was conducted with the Informatics Practice Specialist (IPS). It indicated Patient 17 was admitted to the facility on April 27, 2025, for acute on chronic hypoxemic respiratory failure (a sudden worsening of patient's inability to breathe on their own).

A review of the facility's untitled and undated document indicated, "...[Name of Patient 17]...Date of Service: 04/27/2025 [April 27, 2025]...[Name of Medical Doctor (MD)]...Chief complaint...altered level of consciousness [a change in a person's ability to be aware of and understand his/her surroundings]...board and care facility reported she was unresponsive [not responding]..."

During the review, there was no documented evidence that a discharge plan of care was completed within 48 hours of Patient 17's admission.

On April 30, 2025, at 2:59 p.m., an interview was conducted with the IPS. The IPS stated there is no documentation a discharge plan was completed within 48 hours of Patient 17's admission.

On April 30, 2025, at 2:59 p.m., an interview was conducted with the Lead Case Manager (LCM). The LCM stated the case manager did not complete a discharge plan for Patient 17 within 48 hours of admission. The LCM stated the case manager should have completed a discharge plan for Patient 17 within 48 hours upon admission according to the facility policy. The LCM further stated it is important to complete a discharge plan of care to help plan "a good discharge" for the patient.

A review of the facility policy and procedure titled, "Discharge planning assessment reassessment for hospital case managers," dated January 11, 2024, indicated, "... Discharge planning... shall begin upon admission to the hospital to ensure that necessary care, services and support are in place in anticipation of the patient's safe transition [when patients move from the hospital to the patients home or another facility]...case manager will conduct an initial discharge planning evaluation upon admission, no later than 48 hours of admission..."