HospitalInspections.org

.
Based on record review and interview, the facility failed to provide a notice titled, "An Important Message from Medicare" to Medicare beneficiaries within 2 days of discharge for 2 of 3 patients.

Failure to do so created risk that patients may not be able to exercise rights in advance of furnishing or discontinuing patient care when needed.

Findings included:

1. On 05/08/19 at 3:00 PM, the investigator interviewed a Nurse Case Manager (Staff #4) about her role. She stated that it was the responsibility of the nurse care managers to ensure that the notice of "Important Message from Medicare" was issued and signed by Medicare patients/surrogates within 2 days of discharge so that they could make a determination about exercising their Medicare rights.

2. a. Record review of facility policy titled, "Discharge Planning Policy", #922, Approved on 11/2017, discussed the discharge planning process. The policy did not include information about responsibilities to issue the timely notice of "Important Message from Medicare" to Medicare patients.

b. In review of the RN Care Manager Job Description, Revised 06/18, it did not include information about RN Care Manager responsibilities to issue the timely notice of "Important Message from Medicare" to patients.

3. Record review of medical records showed the following omissions:

a. Patient #2 was 69 years old; admitted on 01/07/19 for altered mental status and discharged on 02/14/19. The patient was cooperative and calm at the time of discharge. There was no evidence in the record that the patient/surrogate was issued a Medicare notice about discharge rights.

b. Patient #3 was 86 year old; admitted on 02/10/19 for a falls and a laceration and discharged on 02/15/19. The patient was alert and cooperative at the time of admission. There was no evidence in the record that the patient/surrogate was issued a Medicare notice about discharge rights.
.

.
Based on record review and interview, the facility failed to implement a safe discharge plan for 1 of 1 patients.

Failure to do so created risk for patient harm due to negative health consequences of unmet needs.

Findings:

1. Record review of facility policy titled, "Discharge Planning," 922.00, Last revised 11/2017 included several elements:

a. Under the "Evaluation" section it stated that care management staff will evaluate current and anticipated clinical condition, current and anticipated living arrangement within 48 hours [of admission].

b. It also stated that care management staff will communicate with the anticipated caregiver to assure they are willing and able to meet the demands of care giving.

c. RN care managers and social workers will collaborate on developing a coordinated discharge plan using the evaluations and assessments of the interdisciplinary team.

d. Care Management will document assessment and plan for discharge in the electronic medical record.

e. The procedure did not include information about responsibility for re-starting community services for patients to be discharged who had previously required those services prior to hospitalization.

2. Record review of the medical record of Patient #1 showed the following:

a. She was admitted to the hospital on 02/01/19 via an Emergency Department visit on 01/31/19 from a local nursing home, with symptoms meeting criteria for sepsis (including probable pneumonia). The patient had many other serious health conditions. The patient discharged 10 days later to home with palliative care services. However after arrival home, it was identified that the patient's husband/family was not capable of providing the level of care that the patient required, including positioning and providing medications. Then the patient was sent to the Emergency Department for care at another facility.

b. The medical record showed that the patient did not receive a care management initial evaluation for discharge planning purposes. A social work note on 02/05/19 identified that the patient's husband was not able to assist with the patient's care due to his own medical status. That note also identified that prior to hospitalization the patient had been receiving over 125 hours of in-home services per month .

c. Physical therapy (PT) and occupational therapy (OT) consults were obtained. Both disciplines identified that the patient required maximum assistance with bed mobility and that she could not sit on the edge of the bed to ambulate. There was not evidence that the results of the evaluation were incorporated into the discharge plan except that nursing home care was the secondary plan if a bed became available that coincided with the time of discharge.

d. A hospice consultation was completed. However, the consultant did not reference information provided by the PT and OT evaluations and a prior MSW note and focused on the family's wishes. Staff did not address the capacity of the patient's husband to care for her.

e. The patient had access to over 120 hours of in-home care per week. Care management staff did not address re-starting in-home services for discharge to home.

f. A hospice consultation was completed. However, the consultant did not reference information provided by the PT and OT evaluations and a prior MSW note and focused on the family's wishes. The consultant (non-hospital staff) did not address the capacity of the patient's husband/family to manage/provide direct care to the patient.

3. a. On 05/10/19 at 10:10 AM, the investigator interviewed a hospice social worker (Staff #1). She identified that she would not have recommended hospice services in the home setting for the patient because of the level of the patient's basic needs. She did not think it was realistic that the patient's spouse/family could manage/provide for those needs.

b. On 05/10/19 at 11:30 AM, the investigator interviewed the social worker (Staff #2) who discharged the patient. She acknowledged that the patient did not receive a care management evaluation during her 10-day stay by a member of the care management team. Additionally, she stated that it is not the social workers responsibility to re-start in-home services for patients that were already authorized to receive those community services; that it was the family's responsibility. She also stated that she did not consider the content of the PT evaluation about the level of the patient's physical dependency. She also stated that she neglected to record the rationale for not communicating directly with the patient's spouse about readiness for implementing the discharge plan.

c. On 05/10/19 at 1:45 PM, the investigator interviewed the supervisor of the social worker (Staff #3). He indicated that it was the responsibility of social work staff to complete the case management evaluation as soon as possible after admission. He expected staff to identify major functional limitations. Additionally, staff were expected to document rationale of speaking with individuals that were not designated decision makers. He expected staff to incorporate the results of PT and OT evaluations in discharge planning and to re-start in-home community services already assigned to the patient. He verified that hospice staff for hospital patients were not hospital staff and that hospital staff always bore the responsibility for the discharge plans of hospital patients.

Additionally, the supervisor of the social worker acknowledged that there was not a procedure to guide hospital staff in discharging patients hospice services.
.