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Based on record review and interview, the facility failed to follow their policy by not updating one patient's (P-1) plan of care after a change in the patient's condition for 1 (P-1) of 10 patients reviewed, resulting in the requirement for rehospitalization and inadequate preparation for care at home. Findings include:

See tag A-0802: Failure to re-evaluate a discharge plan after a change in condition.

Based on record review and interview, the facility failed to follow their policy by not updating one patient's (P-1) plan of care after a change in the patient's condition for 1 (P-1) of 10 patients reviewed, resulting in the requirement for rehospitalization and inadequate preparation for care at home. Findings include:

On 5/30/2024 at 1401 record review of the History and Physical for P-1 revealed she was an 89-year-old female who was transferred to the facility on 11/14/2023 after a 4-day admission at a smaller affiliated facility for sepsis associated with possible pneumonia, left lower extremity osteomyelitis and infected diabetic foot wound. P-1 was alert and oriented to person and place and GCS (Glasgow Coma Scale - tool used to measure the consciousness of patients) during admission was 13-14 with episodes of confusion and disorientation. After an extended stay, the daughter decided the patient should return home with home care.

On 05/30/2024 at 1400 record review revealed a group note from therapy dated 12/5/2023 at 0858 in which it was documented, "pt with change in participatory status today due extreme [sic] lethargy/somnolent being."

A note from nursing dated 12/6/2023 at 1024 reveals "At bedside shift report, patient was barely responsive to painful stimulus. She was not opening her eyes or speaking at all. Vitals were stable in the morning and her sugar was within normal limits. We completed her discharge and EMS came to pick her up at 10:05. I attempted to give her a medication before she left and was unable to get her to respond. I continued to take her vitals which were normal. I called a rapid response to ensure discharge was still appropriate" ...the provider came to the room and the nurse documented she was told "to alert the family, but that there was nothing more we could do for her". I attempted to call the daughter twice and she did not respond either time."

On 05/30/2024 record review of documentation from Case Manager (CM) dated 12/6/2023 at 1514 reveals "Confirmed pt ready to DC (discharge) w/provider & DC orders placed. PCS already on the chart. Updated bedside RN of plan of to DC at 0900. EMS delayed d/t 911 traffic. Then pt had rapid response (was then cancelled) around 0945. When CM was able to make it to the floor around 1100 bedside RN stated pt had been unresponsive but still able to be discharged home via EMS. Called and l/m message for daughter...that pt DC home late & scripts sent to Apothecary. Pt DC home w/home health via EMS today." Further review of documentation from case management notes dated 12/6/2023 at 1546 reveals "Received call...patient's daughter refused to take her once EMS arrived". Review of case management documentation did not reveal the patient's home and daughter were ready to care for an unresponsive patient.

On 5/30/2024 at 1400 review of the EMS documentation "Prehospital Care Report" dated 12/6/2023 reveals EMS arrived at the facility for transport to patient's home at 0945 and left with P-1 at 1039. Narrative History Text reveals "Arrived to find an 89-year-old female unresponsive mouth open, eyes closed, shallow breathing at a rate of 28." and "Our delay on scene was due to ...staff calling rapid response to her room because she was unresponsive and making sure we could do the transfer and tried to get a hold of family to let them know her current condition. Family did not answer the phone. Nurse stated the physician signed off and was ok for her to be transferred." and "Upon arrival to patients' residence, daughter met us outside and we told her the patient is unresponsive. Daughter now wants her brought to the hospital because she doesn't want to feel responsible for an unresponsive person." Further review of EMS notes reveled P-1 was unresponsive during transfer with a GCS of 3. P-1 was transported to another hospital and expired within 24 hours.

On 5/30/2024 at 1603 an interview with the Director of Quality/Patient Safety Officer (Staff B) was conducted and revealed an incident report was filed on 12/8/2023 by Staff J regarding the Rapid Response that was cancelled for P-1. Staff B stated follow-up was requested by Staff J and "nothing further was done".

On 5/31/2024 at 0929 an interview with the Director of Case Management (Staff F) was conducted and revealed she did not see P-1 during her admission but was made aware of the case because of the issues related to the son and daughter's difference in opinion. Staff F revealed she did review the case of P-1 and it was her understanding that the family would not accept Hospice Care but wanted Home Health Care. Staff F revealed "our rule of thumb is if a patient looks like they are going to die within 24-48 hours we won't let them go unless family says to take her home."

On 5/31/2024 at 1126 an interview with the 6th Floor Manager (Staff J) was conducted. Staff J revealed she did remember P-1 and that there was a Rapid Response called on her unit with EMS at the bedside. The nurse called the Rapid Response because P-1 was not responsive, and she wanted to make sure the discharge was still appropriate. Staff J revealed the Internal Medicine physician was at the bedside of P-1 and cancelled the Rapid Response secondary to the discharge plan and DNR/DNI status. Staff J revealed the RN at the beside was concerned because P-1 was obtunded, which was a change in her status. Staff J revealed she filed an incident report in the facility's incident reporting system, Company T, because "it seemed strange". Staff J revealed the RN tried to call the family and contacted Case Management about the change in status and questioning if the transfer should continue. Staff J revealed there were issues regarding concerns with the family between the son and the daughter and P-1's level of consciousness did "go in and out" but the daughter had not come to the facility throughout the admission and may not have been aware of this change.

On 5/31/2024 at 1350 during review of policy, Discharge Planning, last revision date of 11/2020 revealed on page 2, paragraph 5, under Procedure, "...may have a change in condition and a discharge planning evaluation requested. Reassessments are made. Discharge plans are modified as needed. ' " and paragraph 6 states, "Follow-up/transfer/other referrals for continuity of care will be based on the patient's assessed needs at the time of discharge."