HospitalInspections.org

Based on interview and record review, the facility failed to specify a discharge destination which would affect continuing care needs for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient came to the Emergency Room on 4/27/15 at 3:45 PM and admitted to the hospital on 4/27/17 at 8:55 PM.

The Agency for Health Care Administration document "Instructions to Licensed Health Care Providers", signed by physician A on 5/03/17 read, "Facility name: Family Care Home." This indicated the name of a facility that the patient was eventually sent to at discharge. This form had checks in boxes that indicated "needs supervision" for the following activities of daily living: ambulation; eating; and transferring. This form also had checks in boxes that indicated "needs assistance" for the following activities of daily living: bathing, dressing, self-care (grooming) and toileting. The document also read, "Require 24-hour nursing or psychiatric care? Yes. 24 hour supervision." There was no documentation in the record after the completion of this form to indicate that all of the preceding mentioned services were no longer needed by the patient. Thus, the physician indicated that the patient needed the services that only a licensed Assisted Living Facility was authorized to provide in the State of Florida, upon discharge.

Physician A's orders of 5/04/17 at 9:41 AM read, "Unconditional discharge." Regarding the meaning of this phrase, during an interview of the Risk Manager on 6/21/17 at 11 AM, she stated this meant that there were no stipulations to keep the patient in the hospital anymore. This order was acknowledged by nursing staff at 9:52 AM on 5/04/17. Under the heading of "Discharge to:", the order document was blank. There was no documentation in the medical record that indicated any steps taken by nursing or case management staff to determine the actual destination which the physician had intended for the patient with his specific discharge order. As the order stood alone, it was unknown whether or not the physician wanted the patient to go home or to any other licensed health care facility. A document with the heading "Discharge Instructions" of 5/04/17 at 9:54 AM, initially signed by an advanced registered nurse practitioner (ARNP) B, and signed by physician A, who had signed the previously mentioned AHCA form on 5/04/17 at 2:29 PM, read, "Discharge to: SNF [skilled nursing facility]."

A Case Management note of 5/04/17 at 11:23 AM read, "Call received from [a person at a senior resource organization that assists placing patients in facilities], who said that she secured a Family Care Home for patient.... Informed patient's sister, she is Okay with facility, assist with signing choice letter, placed in chart." The document "Patient Choice Letter" (undated) read, "Used for patients selecting SNF, HHA [home health agency], hospice... services....Please acknowledge that you declined the list of home health agencies or skilled nursing facilities (initial).... I hereby choose to use Family Care Home in Orlando, FL." This form was signed by the patient. Nursing went over this form with the patient at 11:23 AM, after the discharge order had been written. Since this form indicated that it was intended for use in the discharge of patients to licensed entities of one form or another, it reflected an understanding that the patient was going to such a location, despite the lack of explicit physician orders in this regard. The patient left the facility at 12:51 PM on 5/04/17. The Family Care Home facility was not a licensed healthcare facility and was therefore not appropriate for addressing the continued needs of the patient as they had been written on the AHCA form on 5/03/17.

The Discharge Summary, dictated on 5/04/17 at 9:48 PM and signed by ARNP B and physician C read, "Case Manager was involved for placement. Today, the patient was placed to a Family Care Home, therefore the patient was discharged."

Thus, a patient with documented post-discharge needs that could only be addressed by a licensed healthcare facility had a discharge order which did not specify any type of intended destination. The patient was subsequently transferred to a non-licensed facility.

On 6/21/17 at approximately 4:15 PM, the Risk Manager confirmed the findings.