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Based on interview and record review, the hospital failed to ensure the discharge planning evaluation was completed for one of two sampled patients (Patient 1) as per the hospital's P&P when discharged the patient on 7/14/25 at 1319 hours as evidenced by:

* Patient 1's discharge instruction was missing self-care and home care information for the nephrostomy tube.

* Patient 1's feelings of being unsafe and anxious about going home were not adequately addressed or documented. NP 1 did not document or communicate Patient 1's concerns about sepsis and nephrostomy tube care to the attending provider prior to discharge the patient.

* The hospital's case management staff failed to conduct an initial assessment and properly evaluate Patient 1's medical and psychosocial needs before discharged Patient 1.

These failures had the potential to result in an unsafe discharge of the patient.

Findings:

Review of the hospital's P&P titled Interdisciplinary Discharge Planning dated March 2025 showed the hospital will discharge or transfer patients to an appropriate level of care/setting based on the patient's individual needs. Discharge planning assessments include, but are not limited to, the likelihood of a patient ' s capacity for self-care at time of discharge, patient returning to previous living environment, patient's needs for psychosocial or physical care at time of discharge and/or patient's need for post-hospital care/ treatment/ services. Discharge planning activities also include ongoing communication and collaboration with the patient and family to incorporate patient's treatment goals and to validate patient's agreement with proposed discharge plan. A copy of the discharge summary/after visit summary will be provided to the patient or designated caregiver at the time of discharge. Discharge instructions will include self-care, information regarding home care.

Review of the hospital's Case Management Roles and Expectations dated September 2024 showed the key roles and responsibilities for CM are to coordinate patient care and discharge planning, communicate with patient/families and to ensure the documentation was accurate and timely. The Case Manager Expectations section showed to attend daily team rounds and maintain active communication with Clinical Management Assistants, conduct in-person or phone-based initial meetings with patients/family, and complete an initial assessment within 48 hours of patient admission.

On 7/24/25 at 1043 hours, Patient 1's medical record was reviewed with the Sr. Risk & Regulatory Professional and the Assistant Director of Risk and Regulatory. Patient 1's medical record showed Patient 1 came to the hospital ED on 7/12/25 at 1950 hours and discharged on 7/14/25 at 1319 hours. The patient returned to the hospital ED on 7/14/25 at 1654 hours and discharged on 7/14/25 at 2004 hours.

Review of the ED Provider Notes dated 7/12/25 at 1950 hours, showed Patient 1 came to the ED for a urinary catheter problem (left nephrostomy tube with decreased output, strong odor, and cloudy for two days, with the pain level of 8 out of 10 [10 being the worst pain, 0 being no pain]). The patient presented changes in her urine output and associated pain to the nephrostomy tube. The urine volume in the nephrostomy bag had significantly decreased, with only small drops by morning. The patient did not flush the tube due to lack of instruction. The ED attending physician documented on 7/12/25 at 2217 hours, the ED provider attempted to flush the tube with 50 ml with unsuccessful return.

The medical record showed that after the ED staying, Patient 1 was admitted to hospital observation on 7/13/25 at 0204 hours and was discharged on 7/14/25 at 1319 hours. The patient was sent to the hospitality lounge (the discharge lounge, which aids in patient flow by assisting in the discharge process and resolving patient discharge barriers) after being discharged from the observation unit to wait for a ride.

Review of Patient Care Timeline from 7/12/25 1950 hours to 7/14/25 1319 hours, showed the following:

* On 7/12/25 at 1950 hours, Patient 1 arrived in the ED.

* On 7/13/25 at 0134 hours, DC planning of Living arrangements on admission discussed with family members.

* On 7/13/25 at 0415 hours, the patient's head-to-toe assessment showed the patient had a need for emotional.

* On 7/13/25 at 0723 hours, the assessment for left nephrostomy showed the site was clean, dry, and reddened (redness/moist at puncture site).

* On 7/13/25 at 0728 hours, NP 1 was assigned as a team member for Patient 1's for 1st call services.

* On 7/13/25 at 1716 hours, NP 1 documented in Discharge throughout: the patient was ready for discharge, there were no barriers.

* On 7/13/25 at 1900 hours, NP 1 signed out the duty to be the 1st call.

* On 7/14/25 at 0704 hours, the DC Prep Milestones was completed.

* On 7/14/25 at 0718 hours, NP 1 was assigned as a team member for Patient 1's 1st call services.

* On 7/14/25 at 1221 hours, NP 1 documented DC prep milestones completed, remove peripheral IV lines prior DC, reviewed and printed the Discharge Patient-Review & Print form.

* On 7/14/25 at 1238 hours, the RN spoke with the DC lounge staff, the patient would be waiting for family ride at the DC lounge. Patient needed instruction.

Review of the After Visit Summary showed Patient 1's signature and time was 7/14/25 at 1345 hours, the time the patient was presenting at the DC lounge. The form did not include self-care nor information regarding home care of the patient's nephrostomy tube.

Review of RN 1's Interdisciplinary note dated 7/14/25 at 1319 hours, showed Patient 1 did not feel safe to go home, NP 1 was notified. The patient was advised to go to the ED if any sign and symptoms recurred.

On 7/24/25 1335 hours, an interview with RN 1 was conducted. RN 1 stated the Discharge Lounge is a hospitality lounge. The patients came after they were discharged, and no longer as hospital patients. RN 1 stated Patient 1 complained about the weakness in hospitality lounge and stated she was not safe to go home. RN 1 stated Patient 1 was evaluated for orthostatic blood pressure and findings were negative. RN 1 stated NP 1 communicated with Patient 1 and family. RN 1 stated Patient 1 was discharged home, and if the patient felt it needed to be further evaluated, they could go the ED.

On 7/25/25 1205 hours, an interview was conducted with NP 1. NP 1 stated Patient 1 told her regarding feeling anxious for possible occurrence of sepsis, the problems with the nephrostomy tube and care. NP 1 stated she did not document this communication in the record nor communicate with the attending provider. NP 1 was asked about the discharge planning process including psychosocial and physical needs. NP 1 stated NP 1 provided the care as the patient medical needs. NP 1 stated Patient 1 and family showed up on the ED after leaving the hospitality lounge.

On 7/24/25 at 1519 and 7/25/25 at 0938 hours, an interview with a concurrent review of Patient 1's medical record was conducted with the Manager of Case Management. The Manager of Case Management reviewed Patient 1's medical record and stated Patient 1's ED visit was on a weekend, and the patient was discharged on Monday. The Manager of Case Management was not able to locate a Case Management initial assessment documented in the record. The Manager of Case Management stated that Case Management was not fully staffed over the weekends and would not be able to assess all the patients. On Monday, the Case Managers reviewed the patient list to evaluate the patients who were identified for referral or discharge facilities. Patient 1 was not evaluated by the Case Manager before discharge. The Manager of Case Management stated if the patient felt unsafe and felt anxious during hospitalization, the patient should have been assessed for psychosocial needs.

Further review of Patient 1's medical record showed the Patient Care Timeline from 7/14/25 at 1654 hours to 7/14/25 at 2004 hours, showing Patient 1 arrived in the ED on 7/14/25 at 1645 hours. On 7/14/25 at 2004 hours, the patient was discharged.

Review of the ED Provider Notes dated 7/14/25 at 1654 hours, showed Patient 1 presented to the ED two days ago (7/12/25) and was evaluated for dysfunction of the nephrostomy tube. During the hospital course, Patient 1 had a urine culture growing Klebsiella and was discharged on nitrofurantoin (an antibiotic used to treat urinary tract infection). The patient was clinically appropriate for discharge home. However, the patient returned reporting weakness and was unable to ambulate more than a few steps without becoming weak as well as persistent decreased urinary output via the nephrostomy tube. Upon further discussion, the patient noted fear of not being able to care for herself at home and the patient's family member noted fear of the risk of sepsis with the nephrostomy tube remaining without replacement. The ED provider had an extensive discussion with Patient 1 and the patient's family member, addressing their significant fear about sepsis. The Workup Summary section dated 7/14/25 at 1945 hours, showed the case manager was contacted regarding home health options, and the patient was eligible for home health but needed to go through the patient's primary care provider.