HospitalInspections.org

Based on interviews and document review, facility staff failed to include in discharge planning evaluation the post-discharge needs for durable medical equipment. For 1 (one) of 7 (seven) patients included in the sample. Patient #3

The findings include:

Review of the medical record indicates Patient #3 was admitted to the facility on 10/14/24 with diagnosis of acute encephalopathy secondary to sepsis and MSSA bacteremia (Methicillin-Sensitive Staphylococcus Aureus bloodstream infection). During the hospital stay the patient required intubation, sedation, vasopressor support and admission to intensive care (ICU) and received consults with infectious disease provider, physical therapy, occupational therapy and case management. Patient #3 transferred out of the ICU to a medical step-down unit on 10/17/24.

Patient #3 was evaluated by occupational therapy (OT) on 10/17/24 and received treatments on 10/22/24 and 10/24/24. Patient #3 was instructed on the use of a rolling walker on 10/22/24. On 10/24/24 Staff #14 documented that the patient is questioning the validity of therapy and states they don't need anyone to take care of them. Staff #14 documented their concern related to patient's limited recall and need for "nearly constant" cues during routine ADLs (activities of daily living). Staff #14 recommended daily rehab services with home health to lessen the risk of falls or injury to "frail" spouse.

Physical therapy (PT), Staff #15, evaluated Patient #3 on 10/17/24 and concluded that Patient #3 requires moderate assistance by 2 people for bed mobility, sit to stand and transfer to chair. Gait could not be assessed and recommended PT at minimum of 3 times weekly. PT documentation by Staff #16 on 10/22/24 indicated Patient #3 was independent for all ADLs prior to admission and did not require any assistive device for ambulation. "Currently, patient requires maximum assistance by one person for bed mobility and transfers... Patient refused to participate in ambulation activities because of back pain...Given pt's current assistance requirement and overall weakness versus (their) prior level of function, pt is not safe to return home at this time as (they) is an extremely high fall risk. Strongly urging rehab at a SNF prior to return home." There are no further PT notes prior to discharge.

A nursing note on 10/22/24 by Staff #17 documented a "walk test" indicating oxygen saturation 97% on room air while resting and 93% while ambulating. The note didn't document the distance Patient #3 walked or if an assistive device was used.

Case management/discharge planning documentation by Staff #18 indicated initial phone contact with patient's spouse on 10/16/24 when Patient #3 was intubated. The documentation further indicated that Patient #3 didn't have any DME (durable medical equipment) at home and has not received home health care or been admitted to a SNF (skilled nursing facility).

On 10/24/24, Staff #12 documented, that Patient #3 "will be discharged today after 5 days of negative blood cultures" and it is unlikely patient will be able to take care of self at home and spouse is unable to care for the patient alone. Patient #3 and spouse refused SNF placement. Patient #3 was discharged home with home health care. Documentation indicates Patient #3 maintains throughout the hospital stay, their refusal of placement in a skilled nursing facility and their wish to go home.

Review of policy "Case Management/Utilization Review Plan" effective 3/2024 indicated that discharge planning needs are assessed at admission. The case manager is responsible for identifying those patients who may require services after discharge and facilitating a smooth and timely transition to home or other settings. Reassessments are performed as conditions change. Case management will assess for change in condition when completing utilization review, make appropriate arrangements to meet the needs of the patient/family and if necessary to effectively communicate with the next level of care providers. Duties of case management includes but is not limited to DME arrangement and contacting home health agencies.

Interviews were conducted on 12/11/24 at 1:45 PM with case management Staff #4 and Staff #7. Staff #7 explained that when a patient is ready for discharge, case management staff will assess patient needs based on physician orders, therapy notes, and conversations with nursing staff, the physician and family. It would be the case manager who arranges needed DME.

Review of the medical record indicated Patient #3 had no DME at home, did not have documented ambulation by PT, had only been out of bed with the assistance of a rolling walker and staff and was identified by PT "an extremely high fall risk". Staff #7 explained that under these circumstances the expectation would be to arrange for a walker and bedside/over toilet commode chair and possibly a shower stall. Prior to discharge the case management staff failed to include the evaluation for needed DME.