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Based on interview and record review, the hospital failed to arrange for the implementation of discharge plans for one of eight sampled patients discharged to skilled nursing facilities (SNF) when Patient 1 was discharged without confirming SNF had a bed available for Patient 1.

This failure resulted in Patient 1 being transported back to the hospital, delayed receipt of scheduled medications, and caused Patient 1 severe pain.

Findings:

During a review of Patient 1's History and Physical (H&P), dated 5/13/25, H&P indicated Patient 1 was admitted to the hospital with nausea and vomiting on 5/13/25. H&P indicated Patient 1 had a medical history of heart and lung disease and had pressure wounds and generalized body aches.

During a concurrent interview and record review, on 6/12/25, at 9:30 a.m. with Registered Nurse (RN) 1, Nursing Progress Notes (NPN), dated 5/16/25, were reviewed. NPN indicated "patient discharged via ambulance transport and arrived to [facility name] SNF and was informed there are no bed openings/no beds available until tomorrow morning ...Patient was brought back to the unit [at hospital] via EMS [Emergency Medical Services] transport. Upon arrival to unit patient stated being in 10/10 pain [ten out of ten, a pain scale used to rate pain with ten being the most severe pain]." RN 1 stated Patient 1's pain was managed through scheduled pain medication given every eight hours and Patient 1 left the hospital on 5/16/25 prior his scheduled afternoon dose. RN1 stated after consulting with the pharmacist, Patient 1's missed dose of pain medication was given late.

During a review of Prehospital Care Report 3.5 (PHCR), dated 5/16/25, PHCR indicated ambulance crew arrived at SNF to transport Patient 1 back to hospital and "PT [patient] did not have an available room at the SNF. Per nurses PT was supposed to be admitted at the facility the next day, and PT was a day too early. PT pain had increased to 11/10 pain during transport."

During a concurrent interview and record review, on 6/12/25, at 11:30 a.m. with Care Coordination Registered Nurse (CCRN) and Care Coordination Assistant (CCA), Patient 1's Final Discharge Plan (FNP), dated 5/16/25 and Discharge Planning Progress Notes (DPPN) were reviewed. FNP indicated Patient 1's expected discharge date was 5/16/25 to a skilled nursing facility. CCA stated she generally prepares the packet of clinical information to send to the facility and arranges patient transport when a patient is discharged to SNF. CCA stated she follows the directions given to her in DPPN and documents what she has done in the DPPN. DPPN entry dated 5/16/25 at 10:24 a.m., authored by CCRN, indicated "[Medical Doctor] states patient is ready to discharge to SNF today. I have asked CCA to arrange the discharge to SNF today." DPPN entry dated 5/16/25 at 12:02 p.m., authored by CCA, indicated, "transport arranged, medication records and orders were faxed, and SNF packet was assembled." CCA stated she did not contact the facility to confirm bed availability as she was not asked to do so. CCRN stated the Care Coordination department should confirm bed availability with SNF on the day of patient discharge. CCRN stated she writes a DPPN when she confirms bed availability. CCRN reviewed the DDPN for Patient 1 and stated "I did not make a note that I called. I must not have done it. We are short staffed on the weekends."

During an interview on 6/12/25 at 12:30 p.m. with Care Coordination Director (CCD), CCD stated he expected Care Coordination staff to verify bed availability on the day of discharge. CCD stated, "Sometimes the confirmation is done through the CarePort [patient referral electronic platform] instant messaging function." CCD confirmed there was no record of communication regarding bed availability on 5/16/25. CCD stated there were staff shortages on the weekends.

During a review of the facility's policy and procedure (P&P) titled, "Care Coordination Discharge Planning Policy", dated 11/21/22, the P&P indicated "Care Coordination team members also collaborate with third-party payers and community resources/partners to further after care and discharge plans."