HospitalInspections.org

Based on interview, record review, and policy review, the provider failed to ensure one of eight current patient's (2) discharge planning needs and goals were re-assessed and documented to ensure appropriate and timely discharge back to his home. Findings include:

1. Interview and review of patient 2's medical record with registered nurse (RN)/care coordinator A on 1/22/2020 at 4:45 p.m. revealed:*He had been admitted on 11/26/19.
*His diagnoses and condition included: muscular dystrophy, scoliosis, and a recent tracheostomy (trach) with ventilator use at night.
*His 11/27/19 nurses note by RN/care coordinator A included:-His trach was new on 10/14/19.
-He was admitted from a hospital in another state.
-His mother planned to room in with him during his hospital stay.
-His mother was concerned about his schooling options.
-His estimated length of stay was two to three months.
*His 11/27/19 note by licensed social worker (LSW) B included:
-Similar information to the above note.
-She indicated he was awaiting home nursing through a home health agency to be able to discharge to home with his family.
*There were no further notes regarding his discharge planning needs or the status of getting home health nurses.
*RN/care coordinator A indicated:
-His mother took him to school every day in their home town, so he was gone most of the day.
-Staff assisted with his medical needs when he was in the hospital and during the night.
-The discharge plan was for him to go home as soon as the home health agency had nurses available to assist with his medical needs at home.
--They had not been able to get a home health nurse so he was remaining in the hospital until that could be arranged.
*She confirmed:
-There were no further discharge planning notes other than the above two notes that were from the day after his admission.
-It had been nearly two months since his admission, which was near the end of his estimated length of stay.
-Discharge planning should have been re-assessed and documented periodically.
*She indicated staff had been in contact with the home health agency since his admission.
-The discharge planning updates should have been documented.

Further interview and record review with RN/care coordinator A at 4:50 p.m. revealed:*She brought an undated and unsigned Pyscho-Social Admission/Discharge Assessment form that she stated had not been scanned into his medical record yet.
*She stated the form was completed at the time of admission and it should have been scanned into his medical record timely.
*It should have been signed and dated to support who had completed it.
*The initial discharge planning area of the form included:
-Description of barriers with existing assets and resources had been left blank.
-Patient/family goals for discharge was: "To achieve securing enough home nurses with [home health agency] to be able to have Pt [patient] discharge to home."
-Prognosis for achievement and length of stay was: "ELOS [estimated length of stay]: 3-6 months."
-Predicted discharge location was: "Home w/ [with] parents & home nursing."
*RN/care coordinator A confirmed his family completed a large portion of his medical care needs.
-The staff assisted with his medical care needs when he was in the hospital and at night so his mother could sleep.
*Discharge planning was a team effort by the interdisciplinary team which included herself and the LSW.
*She confirmed there was a lack of discharge planning re-assessment and documentation in his medical record.

Interview on 1/23/2020 at 3:00 p.m. with LSW B regarding patient 2's discharge planning confirmed the above information. She agreed the medical record had not supported discharge planning re-assessment and documentation.

Interview on 1/23/2020 at 3:05 p.m. with director of nursing C regarding patient 2's discharge planning needs and documentation revealed:*She confirmed the above information.
*Discharge planning needs should have been re-assessed and documented periodically to support it was being completed.
*She stated in the future she would expect the care coordinator and LSW to document discharge planning at least every other week for every patient.

Review of the provider's 5/22/19 Admission and Discharge Protocol for Inpatient Rehabilitation/Medically Complex Program policy revealed:*"10. At the time of admission, discharge planning will begin. Included in the discharge planning process will be the payor, physicians, parent/guardian, and Interdisciplinary Team (IDT)."*"11. The IDT will utilize and assess the following areas in the discharge planning process:-a. Physical illness and its impact.
-b. Cognitive/communication status.
-c. Legal status.
-d. Description of problems with existing assets and resources.
-e. Prognosis for identified outcomes.
-f. Plans to resolve problems.
-g. Social supports.
-h. Cultural/social issues impacting discharge.
-i. Barriers to discharge will be identified and discharge goals would be determined."*There was no mention of:
-The process for re-assessment of discharge planning needs.
-When or how to document related to discharge planning.