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Based on record review and interview, the facility failed to identify the likelyhood that 1 of 13 (#2) patients would suffer adverse health consequences upon discharge. This failure resulted in patient #2 being admitted to another hospital for surgery.

Findings:


Discharge summary dictated by patient #2's attending physician on 07/30/12 states" patient was observed for 24 hours. H (hemoglobin) and H (hematocrit) remained stable. He will be discharged home today with pain medication and he is up and walking. Vicodin p.r.n. (as needed). Diet, regular. Exercise, no heavy lifting x 6 weeks. No driving x 2 weeks. Activity, choice. Follow up with myself in 1 week, [physician's name]. Also gave him a work excuse for 40 days, but he is advised no significant rough activity or heavy type activity for a while, this could be up to 3 months. Will follow with CAT [computerized axilary tomography] scan as an outpatient."

On 08/23/2012 at 3:50 PM an interview was conducted with patient #2's attending physician. He stated he discharged the patient because he assessed the patient and the patient was alert, looked good, and his hemoglobin was stable. He was eating and had family at home. He did not appear uncomfortable. He did not anticipate any problems. He wondered about the patient ' s activity level after discharge. He instructed the patient to limit activity, no driving, and to follow up with physician. He stated the doctor at another named hospital called him and told him the patient was there and would have surgery. He called the patient and talked with him after surgery. The patient said he was feeling better. He further stated if he had it to do again, he would keep the patient for several days and repeat the CT scan. He stated the standards of care are probably different at larger hospitals. He stated in the future he would keep this type of patient longer and repeat the CT. He stated in retrospect he probably should have kept him, but he looked good and wanted to go home.

On 08/23/2012 at 1:30 PM the Case Manager, Supervisor was interviewed. She stated the primary focus is on Observation patient who need to be discharged within 24 hours. Case managers may not see a patient the same day. On Saturday and Sunday may not have collaborative care but a number is given to the operator so the Case Manager is available in house. Everyone has access to a resource guide in every area to give out to a patient. The nurse can call the case manager to come and make arrangements to send to nursing home, etc. She said patient Brett Carver ' s note reflected he had not been seen by case management and it was left up to the Registered Nurse and physician to make arrangements for the patient.

On 08/22/2012 an interview was conducted with another hospitalist. He said he does not feel comfortable discharging directly from intensive care unit (ICU) and would rather step-down first. He always tries to order discharge planning for his patients.

Based on record review and interview, the facility failed to plan for services 1 of 13 (#1) patients would require once discharged from the facility.
Findings:


At 10:30 AM on 08/22/2012 in an interview conducted with the Director of Quality, she said the discharge planning process involved the Case Manager and/or nursing personnel assessing for discharge planning needs and initiates the plan for nursing home or rehabilitation placement, durable medical equipment, home health care, hospice or transportation as needed. Discharge planning activities include referral to services required.

On 08/22/12 at 01:05 PM, an interview with the Case Manager revealed the collaborative care note is the document tool used for discharge planning notes. When a patient is admitted the collaborative note is done after the initial screening by the admitting Registered Nurse. Reassessment is made every 48 hours. The Collaborative Care Meeting is used to discuss special circumstances. Collaboration with Staff, Patient, Family, Physicians and Family are used for specific placements. If a patient wants to go home despite the Physician's order to send to a Facility they make sure that there is someone to take care of them. Usually if there is family, the family will provide transportation when discharged. If they are going to a skilled nursing facility, they have transport once the patient is discharged. The hospital may make the discharged patients follow up medical appointments depending on the patient needs or preferences.

A review of the medical record for patient #4, revealed the Social Work notes included on the admission data dated 06/22/2012 the plan was to discharge the patient home with Home Health Care at the patient's request. The patient said she lived alone but had a good support system with friends and family. On 06/29/2012 the patient expressed concerns to nursing and therapy that she was not prepared to go home and was not strong enough. The patient reported that if the insurance company did not authorize SNF (Skilled Nursing Facility), she would return to home. She stated she had a goddaughter that could stay with her during recovery. On 07/03/2012 the discharge plan notes indicated she was not accepted at the 3 facilities the family requested. The case manager notes indicated she contacted 5 more facilities and was waiting for acceptance. One facility said they would take her when her Vancomycin was completed.

A review of the nurses' notes on 07/23/2012 revealed at 1815 (6:15 PM) the patient and family stated they were confused over the discharge. The patient stated she lived alone and had no one to help her. The charge nurse was informed. The patient was to stay until morning for Case Management to reevaluate per charge nurse. On 07/24/2012 at 12:30 PM the patient received instructions of the discharge plan option of Home Care vs. SNF. Case Management was notified of the patient's desire to go to a SNF. A further review of the nurses' notes revealed at 1830 (6: 30 PM) the patient stated understanding of the discharge instructions. She further stated "What do I do if I get home and need help?" The note stated, "Instructed patient to call 911 for any sign of active bleeding, inability to ambulate or unrelieved pain, fever or worsening symptoms. She stated her brother would be here soon." At 1940 (7:40 PM) the patient left the floor via wheelchair.


The Collaborative Care Worksheet dated 07/23/2012 revealed the Case Manager spoke with the patient at bedside and the patient was requesting to go home with family. She stated her god-daughter will be there to stay with her. All clinical information was sent to an infusion provider. The company stated that the service would take a couple of hours to set up; attending nurse and the patient were notified. Another note on 07/23/2012 stated the Home Health Care would have a nurse available the following day. The Discharge Assessment/Social Service Care Conference revealed no facilities in Ocala took her insurance. The patient was approved for Home Health Care.

Continued record review revealed on 07/24/2012 the patient changed her mind and requested to go to a SNF. The Case Manager received authorization. The patient was discharged on 07/24/2012 home. On 07/26/2012 a Discharge/Assessment Social Services note revealed the Discharge Plan: Home with the goddaughter, home IV infusion company and DME (durable medical equipment) so she can complete the 12 weeks Vancomycin. The patient had been discharged on 07/24/2012, two days prior to this documentation.

On 07/26/2012 a Discharge Assessment/Social Service note revealed a call was received from the Home Health Care asking about who was to supply the wheelchair, walker, and bedside commode. The Case Manager realized that no DME had been requested since the patient was to go to a SNF. The Case Manager gave the Home Health Care company the phone and fax numbers for the insurance company and the Home Health Care company was to get the authorization for the DME, request a Home Health Agency and home therapy.