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Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING, was out of compliance.

A0820 - Standard: The hospital must arrange for the initial implementation of the patient's recommended discharge plan. As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care. The facility failed to ensure patients discharged from the facility were provided a plan which insured essential care services were available for the patient upon discharge in 2 out of 9 discharge records reviewed (Patient #2 and #3). The failure resulted in discharges to potentially unsafe environments where patients lacked the resources to manage personal and medical care needs.

Based on interviews and record review, the facility failed to ensure patients discharged from the facility were provided a plan which insured essential care services were available for the patient upon discharge in 2 out of 9 discharge records reviewed (Patient #2 and #3).

This failure resulted in discharges to potentially unsafe environments where patients were lacking necessary resources to care for themselves with new and ongoing medical concerns.

POLICY

According to Discharge of Patient, the Case Manager/Nursing Action should provide patient and family with information on community health care resources.

According to Discharge Risk Assessment and Planning, discharge planning involves determining the appropriate post-hospital discharge destination for a patient. Patient education related to the post discharge plan will be conducted by appropriate disciplines prior to the patients' discharge. Education includes how to obtain any continuing care, treatment, and/or services the patient will need. Discharge planning and information regarding alternatives is documented in the medical record.

According to the LACE Score Assessment, the LACE Score Assessment will be the guideline for prioritizing the assessment of patients. Patients with scores of 11 or greater will be seen within 24 hours of assessment completion. Patients with scores of 10 or below will be seen within 24-48 hours of assessment completion.

According to Discharge Process, the nursing staff will assure patient receives appropriate mode of transportation.

1. The hospital failed to ensure plans for safe placement and post hospitalization services required of patients following discharge.

a) Review of Patient #2's medical record showed s/he returned to the facility's emergency department (ED) on 9/23/16 after an unsuccessful discharge home due to suicidal ideation. Patient #2 stayed in the ED until s/he was readmitted to the hospital on 9/26/16 for management of medical conditions including longstanding quadriplegia and suprapubic catheter (a specialized catheter used for bladder emptying). According to documentation, during his/her 3-day stay in the ED, Patient #2 required the emptying and cleaning of the suprapubic catheter, bathing and feeding by the ED staff.

A Case Management Assessment was performed on 9/27/16 which identified the patient had been evicted from his/her home, was dependent for all care needs and was dependent on others to obtain and administer his/her medications.

On 11/14/16 the Case Manager (CM) documented the patient was not appropriate for an assisted living facility because s/he was unable to care for his/herself without assistance. Additionally, Patient #2 was not appropriate for home health care services, as the patient needed more assistance than any home health agency could provide and the patient would need multiple visits per day.

i) Documentation by a case manager on 11/18/16 revealed Patient #2 called police with an allegation of assault by hospital staff. The responding police officer informed the case manager at the time, that although the patient had several warrants, an arrest would not occur because the jail could not provide the extensive medical care required by the quadriplegic patient.

ii) The case manager documented on 12/09/16 the outcome of a meeting held on 12/08/16 which included hospital administration, Adult Protective Services (APS), a psychiatrist and a behavioral health organization. The meeting was called to discuss discharge planning for Patient #2. According to the note, multiple facilities had refused acceptance of the patient because of legal concerns, behaviors and his/her need for total care.

On 12/12/16, a court hearing took place, which awarded temporary guardianship of the patient to a family member to assist in the placement of the patient in a long-term care facility and management of Patient #2's finances.

Continued assessments of the patient's post-discharge needs were made by case management. Part of the assessment involved the assignment of a LACE Assessment Score which identified patients at risk for readmission or death within thirty days of discharge. Four parameters were measured including hospital length of stay, acuity level upon admission, co-morbidities (additional health diagnoses) and the number of ED visits in the last six months. A LACE score of 11 or higher placed a patient at high risk and required the patient have a medical follow-up appointment no later than 48 hours after discharge and referrals should be made to agencies which provided care assistance. Patient #2 was shown to have a LACE score of 13. There was no documentation services were arranged for the patient post discharge.

An occupational therapy note, dated 1/11/17, stated the patient was at his/her functional baseline which required a Hoyer lift (mechanical lift) for all transfers and total assistance for dressing, bathing and toileting tasks. The occupational therapist deemed the patient was inappropriate for therapies due to physical limitations. However, there was no evidence a Hoyer lift was arranged for the patient's use upon discharge.

Review of the Discharge Instructions, dated 2/21/17, revealed the patient would be discharged to the city court but would benefit from continuous nursing care at a long-term facility for care of the suprapubic catheter, to prevent skin ulcerations, and provide regular personal hygiene due to his/her inability to mobilize independently. However, there was no documentation that discharge services had been arranged for the patient.

iii) On 2/20/17, the day before the patient's discharge, case management documentation revealed Patient #2 was scheduled for a court hearing on 2/21/17 at 1:15 p.m. The discharge plan involved patient transport to the courthouse by ambulance. The Director of Care Management (Director #9) would call APS to have them find a place for the patient to stay after the court hearing. There was no documentation in the medical record to show Director #9 spoke with anyone at APS and placement for Patient #2 had been arranged.

According to documentation, the case manager informed the patient's nurse that without an address to arrange for home oxygen Patient #2 would have to remain admitted. The case manager documented the nurse stated the 4.5L of oxygen was for comfort only and could be titrated off.

iv) On the 2/21/17, the day of discharge, the patient's nurse documented s/he had received report Patient #2 was to go to court on a pass accompanied by a Certified Nurse Assistant (CNA) and would return to the hospital after court. The nurse then documented at 9:30 a.m. a conversation occurred with the case manager in which the patient's discharge plan was discussed. Patient #2 would be provided with his/her filled medication prescriptions prior to discharge. The patient was sent by ambulance to the courthouse at 10:45 a.m.

A second nursing note dated 2/21/17 at 11:30 a.m. showed the midline catheter (an intravenous line) had not been removed prior to Patient #2's discharge. The primary nurse and the nurse manager went to the courthouse, located the patient and removed the midline while the patient was at the courthouse.

v) A final documentation note written by the case manager on 2/21/17 at 4:33 p.m. showed the patient was transported to the judicial building with all belongings and Director # 9 had contacted APS to notify them of the discharge.

b) During an interview with the Nurse Manager (Manager #10) on 3/30/17 at 10:07 a.m., s/he stated, Patient #2 was very difficult to place due to his/her psychological and medical care needs. There was no actual safe placement for the patient, therefore APS was called. Upon discharge, nurses needed to know the discharge destination and the transportation arrangements for the patient. Placement of the patient depended on their care needs at discharge, such as home health or equipment for home and oxygen. If a patient were homeless, staff would contact family for assistance or reach out to organizations in the community. The patient could be placed in a hotel temporarily but that was typically avoided. Manager #10 stated s/he believed APS made arrangements to place Patient #2 in a hotel after discharge from the facility. However, there was no documentation the facility spoke with APS and confirmed a hotel and services required for the quadriplegic patient had been arranged prior to discharge from the facility.

c) An interview was conducted with Director #9 on 3/30/17 at 8:20 a.m. Director #9 stated APS was called when there was a concern for a patient's well-being after discharge. APS should be called before and at discharge. Director #9 stated in the case of Patient #2, s/he needed to attend a court hearing and was discharged to the court not knowing if the court would take him/her into custody. Director #9 stated s/he relied on the physician to determine a safe discharge disposition. S/he confirmed there was no documentation to show APS agreed to assume responsibility for the medical care of Patient #2.

d) At 10:20 a.m. on 3/30/17 the Vice-President of Ancillary Operations (VP #13) was interviewed and affirmed familiarity with Patient #2. According to VP #13, an agreement was made with APS, prior to discharge, to provide placement for the patient after discharge. APS was told the patient had to go to court and they were responsible for the care of Patient #2 after the court appearance. VP #13 stated there was no expectation for the hospital to verify placement of Patient #2 since APS was a government agency. All conversations with APS regarding Patient #2 were verbal.

During the same interview, the Chief Executive Officer (CEO #14) was present. S/he questioned what constituted a safe discharge. Patient #2 was medically cleared for months prior to the court hearing. APS was informed we would provide safe transport.

There was no documentation within the medical record to show APS agreed to accept responsibility for the medical care and safe placement of Patient #2 after discharge from the facility. Additionally, there was no documentation the patient had been set up with services to support him/her as a quadriplegic patient who required assistance multiple times throughout the day.






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2. The facility failed to provide Patient #3 with the appropriate community resources necessary to ensure a safe discharge.

a) Review of Patient #3's medical record showed s/he was a victim of sexual and physical assault and was admitted to the facility on 12/31/16. Injuries included fractures (broken bones) to his/her skull and left little finger. Patient #3 required admission to the Intensive Care Unit and underwent surgery on 1/01/17 to repair the left finger fracture. On 1/02/17, Patient #3 was transferred to a medical/surgical unit. Upon transfer, Patient #3 informed the unit admitting nurse s/he needed to talk to someone about placement after discharge as s/he had nowhere to go since the assault.

On 1/04/17, over 24 hours after Patient #3's request for discharge planning service, a case manager met with Patient #3. The case manager documented the anticipated discharge date was 1/06/17 and the anticipated plan was for Patient #3 to have been released to a shelter. Patient #3 was discharged later that evening on 1/04/17.

Patient #3's medical record showed no evidence s/he was instructed to go to the shelter for a safe place to stay post discharge. Further Patient #3's medical record showed a prescription for narcotics to be used for pain control, however, no instructions were provided to the patient as to where s/he could get this prescription filled. Lastly, no evidence of Patient #3's transportation to the shelter was evident in the medical record.

b) An interview was conducted with Registered Nurse (RN) #6 on 3/29/17 at 2:46 p.m. S/he stated patient discharge instructions should have included which pharmacy would be available to fill prescriptions. The discharge of a homeless individual was the same as any other patient discharge. When resources were provided by the facility they would be documented. The facility should have documented the transportation of the patient, whether it was a family member picking them up or if a taxi voucher was provided to the patient's destination post discharge.

During a review of Patient #3's medical record with RN #6, s/he confirmed there was not a pharmacy list provided that explained where Patient #3 could fill his/her prescriptions for pain. Additionally, there was no evidence that a taxi voucher was provided to Patient #3 upon discharge on 1/04/17 at 7:35 p.m.

c) During an interview on 3/30/17 at 8:10 a.m., Charge RN #11 stated if a patient did not have a home to return to after discharge, the facility staff should have reached out to family, friends, and community resources to ensure a safe discharge home. This was not evident in Patient #3's medical record.

d) On 3/29/17 at 11:58 a.m., an interview was conducted with Case Manager (CM) #4. S/he stated case managers were expected to assess patients' discharge needs within 24 hours of their admission and this would be documented in the medical record. S/he also explained a LACE Evaluation was done on every patient upon admission to determine the level of care needed post discharge.

According to the medical record, Patient #3 was assessed to have a LACE score of 7, scoring moderate on his/her needs post discharge. Patient #3 had been in the facility 86 hours before a case manager saw him/her and 36 hours after making the request to see a case manager. Patient #3 first saw a case manager just hours before his/her time of discharge.

e) An interview was conducted with the Director of Care Management (Director #9) on 3/30/17 at 8:20 a.m. S/he stated a case manager would set an anticipated discharge date so patients were ready for discharge before the anticipated date. Director #9 relied on the physician to determine a safe discharge disposition.

A review of Patient #3's medical record was conducted with Director #9 who stated s/he was unable to determine if Patient #3 was instructed to go to the shelter after discharge as the physician recommended. Further, Director #9 was unsure of the shelters policies and procedures. S/he did not know how the shelter handled patients in need of narcotics for pain control, as was the case with Patient #3.

According to Director #9, there was no documentation to show how Patient #3 left the facility. It could not be determined if the physician's discharge orders for Patient #3 were followed. After review of Patient #3's medical record, Director #9 could not determine if Patient #3's discharge was safe with the documentation provided.

f) On 3/30/17 at 10:07 a.m. an interview and review of Patient #3's medical record was conducted with Nurse Manager (Manager) #10. S/he stated there was no documentation to show Patient #3 was provided with a taxi voucher upon discharge from the facility. Manager #3 could not confirm Patient #3 was discharged according to the physician's recommendations.