HospitalInspections.org

Based on record review and interview, the hospital failed to reassess the patient's discharge plan in a timely manner to address continuing care needs after discharge for 1 of 2 patients (patient #1) discharged home with home health and durable medical equipment needs.

Findings:

Review of the medical record for patient #1 revealed an 80 year old bedbound female admitted from the nursing home via ambulance on 04/04/19 with increased white blood count, mouth nodules, decreased oral intake and no speech for two days. She had a history of dementia, diabetes mellitus, hypertension, malnutrition and poor dentition. Review of the History and Physical completed 04/04/19 revealed admission diagnoses included hypernatremic dehydration, acute kidney injury, hyperkalemia, urinary tract infection and severe malnutrition. Further review of the medical record revealed a feeding tube was surgically placed on 04/17/19.

A physician order was noted on 04/17/19 for social services consult for durable medical equipment (DME) for a hospital bed at home.
Review of the physician progress note dated 04/18/19 revealed plan for discharge home the next day.
The physician's initial discharge summary dated 04/19/19 revealed patient #1 had been cleared for discharge to home with home health and followup with primary care provider.
A physician order was noted on 04/19/19 at 4:18pm for discharge to home with home health - the order was discontinued on 04/22/19 at 3:02pm. A new order was written on 04/22/19 at 3:02pm for discharge home with home health.

Review of the hospital policy and procedure for Care Management Interventions (reviewed 02/03/18) revealed, in part, the following:
2 ...Consults and assessments will be completed within 24 hours except during weekends and holidays.
3 ...Automatic triggers and consults may be:
- Patients entering the hospital from a nursing home, hospice, home health.
- Patients needing equipment when discharged
- Patients needing home health ...community resources
5 ...The patient's ongoing care needs will be identified semi-weekly in the Continuum of Care meetings and additional services will be arranged as identified.

Review of the policy and procedure for Continuum of Care/Discharge Planning revealed, in part, the following:
4 ...Care management reassessment of patients:
-Patients identified through triggers will be seen within 24 hours except on weekends and during holidays
5 ...Care management personnel will reassess patients to determine the effectiveness and response to the intervention and the progress of discharge planning activities ...
A reassessment will occur if:
-a significant change occurs in their condition or social situation.
-length of stay of 5 days (completed by fifth work day) and continue reassessing every 5 days thereafter until discharge.
8 ...Reassessments will cover the following areas:
-Family support and capacity to care for patient
-Community resources available to patient
9 ...Additional contact with a patient's community resources for discharge plan will be documented.
13 ...All recommendations and referrals will be documented in the care management notes including communication with the patient's community resources that have been recommended as part of the patient's discharge plan.

Review of the initial Case Management assessment for patient #1 completed 04/10/19 at 3:33pm indicated plans for the patient to return to the nursing home.

On 04/12/19 at 6:57pm, an update of the Case Management assessment for patient #1 was noted: Social Worker was contacted by the unit nurse that the daughter of the patient requested to speak with the social worker. Discharge planning needs were discussed. The daughter communicated that she does not plan to return the patient to the nursing home - the daughter plans to take the patient home with her. The daughter also expressed that the patient will be having a PEG tube placement on Monday and was requesting a hospital bed and home health as discharge planning needs.

Continued review of the Case Management notes for patient #1 revealed no documented evidence of any further discharge planning activities until 4/18/19 at 10:14am - Continuum of Care note: Social Services consult DME needed hospital bed for home. Social Worker contacted DME by fax.
An interview on 07/02/19 at 2:30pm with S1RN Case Manager confirmed the consult order for the hospital bed for home had been written on 04/17/19 at 1:12pm.

Review of the Case Management note for patient #1 dated 04/19/19 at 4:15pm (Good Friday holiday): Received call from patient's nurse stating physician was asking if daughter could take patient home today. Social Worker called patient's daughter who stated, "My mother cannot go home until that hospital bed is delivered."

Review of the Case Management note for patient #1 dated 04/19/19 at 6:47pm: Patient has discharge orders for home with home health. Spoke with patient's daughter and she wants to appeal discharge decision. Paperwork signed and placed on chart. Medicare Appeals Department notified via fax and phone message.

Review of Case Management note for patient #1 dated 04/21/19 at 3:28pm: Received call from Appeals Department - appeal denied as appeal physician in agreement with attending physician's recommendation of discharge to home. Patient will assume financial responsibility of the hospital bill on 04/22/19 at 12:00 hours. Appeals Department will notify patient's daughter of above determination.

Review of Case Management note for patient #1 dated 04/21/19 at 3:38pm: Nurse contacted social worker in reference to patient's hospital bed. Social worker reviewed notes that referral was sent to DME on 04/18/19 - social worker will place a call to DME, but is not sure if they are open today. Placed call to DME answering service. Indicates the office is closed in observation of Easter holiday from Friday 04/19/19 through Monday 04/22/19 and will reopen Tuesday 04/23/19 at 9:00am.

Review of Case Management note for patient #1 dated 04/22/19 at 3:00pm: Case Management spoke with patient's daughter and went over events that happened since Friday, informed that continued hospital stay had been denied. Daughter requested transportation to bring her mother to her house. Ambulance called for transport.

Review of Case Management note for patient #1 dated 04/22/19 at 4:41pm: Phoned community resource and faxed referral for Jevity (tube feeding). Phoned home health agency answering service and faxed referral. Return call received.

Review of nurse note/discharge instructions for patient #1 revealed patient was discharged from facility on 04/22/19 at 5:30pm.

On 07/02/19 at 2:30pm, an interview with S1RN Case Manager confirmed that Case Management was first made aware of the discharge plan for patient #1 for home health and the need for a hospital bed and tube feeding supplies after discharge home on 04/12/19, during an interview with the patient's daughter. She further confirmed that the order for DME for a hospital bed was received on 04/17/19 at 1:12pm and the supplier was contacted 4/18/19 at 10:14am, when a fax was sent. She confirmed there was no documented evidence that the DME was contacted again to follow up and no other attempts were made to contact any alternate DME sources that were available during the holiday period. She confirmed that the failure to ensure available services post discharge caused a delay in the discharge for patient #1.