HospitalInspections.org

Based on review of hospital policy, medical records, staff interviews and email notification from the Home Health Agency, the hospital staff failed to complete the final electronic process for the transition from hospital acute care to Home Health Agency services was provided for the discharge plans of 1 of 5 patients (Patient #1).

Review on 07/23/2024 of the hospital policy, Discharge Planning revised/reviewed October 2024 revealed, "SCOPE/PURPOSE to ensure patients, families, and their caregivers (as identified by the patient) have the knowledge to transition successfully from the hospital to the next level of care ..."

Closed medical record review on 07/23/2024 revealed, Patient #1 was a 77-year-old female admitted to the facility with a diagnosis of severe sepsis. On 05/21/2024 a Registered Nurse Navigator completed as part of the admission process documented Discharge Planning ...Do you wish to designate an individual who will care for or assist you in your residence following discharge from the hospital and to who the hospital shall provide information regarding your discharge plan and follow-up care? ... 'No' ... at 0056 the initial Care Management order was entered by the admitting Medical Doctor (MD). At 0230 the Nursing Admission Assessment revealed ...Integumentary, Sacral abrasion present on admission. Epidermis thin with loss of subcutaneous tissue, Braden score 15 (The Braden Scale was a risk assessment tool that helps predict the likelihood of pressure ulcers developing. On 05/22/2024 at 1626, the Wound/Ostomy Care Registered Nurse (WOCN) assessed Patient #1 and documented ... 6 x 10 wound with dry deep red tissue...Deep tissue pressure injury present on admission. Likely to evolve into full thickness wound (stage 3 or stage 4) ... Pt (patient) educated on wound evolution, recommend following up with wound care clinic for further wound management upon discharge. Pt states she lives alone, may need assistance with dressing changes. MD made aware. On 05/24/2024 at 1503 the discharging MD ordered Home Health Agency care services for Nursing, Physical therapy, and Occupational Therapy. At 1504 an email, Care Management RN documented referral was initiated for Patient #1's preferred Home Health Agency. Review revealed an email from the Home Health Agency accepted referral of the patient with a Start of Care (SOC) date of 05/25/2024 or 05/26/2024. Review of the Discharge Summary completed by the MD at 1512 revealed "...FOLLOW UP INSTRUCTIONS I have had discussion with the patient about the hospital stay, instructions for continuing care, and need for close physician follow up. I have reviewed the discharge medications and discharge record..." but failed to reveal documented ordered Home Health Agency for nursing, physical therapy, and occupational services. Review failed to reveal completed Care Management Progress Notes during the admission. Review failed to reveal evidence of the RN education of care for the sacral wound or provision of needed supplies at the time of discharge.

Interview on 07/23/2024 at 0930 with the Wound Ostomy Care Registered Nurse (WOCN) revealed, a recall of Patient #1. The WOCN recalled having discussion with Patient #1 and with the covering Medical Provider for Patient #1 with regards to the order for sacral ointment and dressing changes. The WOCN also discussed with the covering Medical Provider the need for Patient #1 to have Home Care assistance for application of ointment, dressing changes and to assess the healing of the sacral wound. The Medical Provider for Patient #1 would be the responsible person to include on the Discharge Summary and After Visit Summary the required needs for the sacral wound.

Interview on 07/23/2024 at 1100 with the Registered Nurse (RN) who discharged Patient #1 revealed, the RN recalled performance of the dressing change prior to discharge on 05/24/2024 from the Medical Surgical Unit. The RN recalled verbal instructions provided to Patient #1 as to how the process of dressing change was performed. The RN had no recall of Home Health Agency care as included in the Discharge Summary or the After Visit Summary provided to the patient at the time of discharge. RN interview revealed if the RN had any questions or felt the need for HHA was needed for a patient, the RN would have no issue with contacting the Medical Provider directly or contacting the Charge RN for further resource discussions.

Interview on 07/23/2024 at 1404 with the Care Manager Registered Nurse (CMRN) assigned to assist with the Discharge Planning for Patient #1 with the Supervising Care Manager revealed, the CM assigned had vague recall of the patient and the situation. The CMRN had been working in the position since February of 2024 (less than 3 months). The process of provision of Discharge Planning for Patient #1 included referrals to Home Health Agency for Registered Nurse, Physical Therapy and Occupational Therapy evaluation and treatment had been initiated on 05/24/2024 at 1504 prior to discharge. On 05/24/2025 at 1505 the Home Health Agency of choice was documented as accepting the patient with a planned start of care (SOC) date of 05/25/2024 or 05/26/2024.

Interview on 07/23/2024 at 1500 with the discharging Medical Doctor (MD) for Patient #1 on 05/24/2024 revealed the MD expected the patient to have HHA care with wound dressing change before the 7-day mark of being discharged from the hospital. The MD would have documented in the medical record if there was any contact with the family. Interview revealed the MD was led to believe the CM was in the process of setting up the HHA visit prior to the actual discharge of the patient.

Telephone interview on 08/23/2024 at 1510 with the Branch Director of the Home Health Agency chosen by Patient #1 for post-acute care services revealed, a delay from the hospital to HHA process of notification to begin services. Interview revealed it appeared the hospital CMRN failed to make the electronic selection until 05/28/2024 to inform the HHA of completion of the discharge planning process to notify the HHA to begin services. Interview revealed Patient #1 had requested the date of 05/30/2024 as the start of care.

On 08/30/2024 at 1053 review of email from the Home Health Agency selected by Patient #1 revealed, the CMRN forgot to make the electronic selection until 5/28/2024 for services to begin for Nursing, Physical Therapy and Occupational Therapy.
NC00218417