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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43, Discharge Planning, was out of compliance. The standard level deficiency determined out of compliance was §482.43(b) Discharge Planning Evaluation (A-0806): The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care. Findings under the standard level deficiency are as follows:

Based on interviews and document review, the facility failed to implement discharge planning recommendations to ensure post-hospital care needs were met. Specifically, the facility failed to ensure a patient was safe to be discharged home in accordance with facility policy. This failure was identified in one of six patients (Patient #3).

Findings include:

Facility policies:

According to the Discharge Planning policy, healthcare professionals should collaborate to ensure that each patient has a plan for continuing care during the transition into the community and thereafter. The components of discharge planning ensure that the patient is appropriate for discharge/ transition to a lower level of care with the provision of appropriate and available resources and services upon discharge to meet the needs for continuity of care. The implementation of a safe discharge plan reduces the likelihood of a hospital readmission and provides for appropriate and available resources and services to meet the patients' needs for continuity of care.

According to the Fall Prevention and Post Fall Management policy, factors assessed in fall risk include medications, substance use, gait, transferring and ambulatory aids, secondary diagnoses, and factors that may predispose a patient to fall. High fall risk patients with a Morse (an assessment used to determine a patient's likelihood of falling) greater than or equal to 50 require a continuous physical presence, within arms reach of the patient, during toileting.

1. The facility failed to ensure a patient was safe to be discharged home according to facility policy.

A. Document review

i. A review of Patient #3's medical record revealed Patient #3 was a now deceased 71-year-old admitted on 3/14/24 for an ankle fracture (break in the bone) after a fall. Patient #3 had a medical history of heart failure, respiratory (breathing) failure, diabetes mellitus (blood sugar imbalance), obesity (excessive fat deposits), and chronic pain. The admitting physician's note revealed the physician believed Patient #3's use of opioids (narcotic pain medications) and poorly controlled blood sugar had contributed to the fall. The discharge planning notes by multiple case managers throughout Patient #3's stay revealed the patient had been on hospice before arriving at the facility and was going to be discharged home on hospice, however, the patient refused and staff sought placement in a skilled nursing facility (SNF). Case management notes on 3/25/24 revealed Patient #3's insurance had refused SNF placement and the facility was not able to resubmit the request for authorization until 4/1/24. The case management notes on 3/25/24 further revealed the patient had "agreed" to return home.

A nursing note entered by registered nurse (RN) #3 on 3/26/24 at 9:28 a.m. (eight hours and eight minutes before discharge), revealed Patient #3 scored 85 on the Morse Fall Risk Assessment, placing them at a high risk for falls, and nursing interventions were implemented which included supervision with ambulation and assistance with toileting.

Physical therapist (Therapist) #1 assessed Patient #3 on 3/26/24 at 4:15 p.m., the day of discharge, and documented Patient #3 required assistance with ambulation (walking), transferring, and toileting. Therapist #1 described Patient #3 to be at an elevated risk for falls with a risk of additional injuries. Therapist #1's note revealed insurance would not cover SNF placement and recommended the patient be supervised if they returned home. Therapist #1 also included the patient was not to bear weight on their right leg and foot. Additionally, Therapist #1 added Patient #3's safety awareness was decreased due to balance, medical status, strength, range of motion (ROM), and decreased insight.

Physician #5's note from 3/25/24 at 9:03 p.m. revealed Patient #3 was waiting on a "safe discharge" to a skilled nursing rehabilitation facility. However, on 3/26/24 at 5:59 p.m., the day of discharge, Physician #5 wrote Patient #3 was "agreeable" to discharging home since their insurance would not cover SNF placement, although this patient was at a high risk for readmission due to insurance delays. They also wrote the patient would have support at home three times a day from a private caregiving company. Physician #5 wrote Patient #3 was not able to receive home health services as they were not yet established with a primary care physician (PCP) and their PCP appointment was to be scheduled "as soon as possible" (scheduled nine days later on 4/4/24), to receive care at home. The discharge medication list revealed Physician #5 discharged Patient #3 home on multiple medications, including Fentanyl (a narcotic pain medication), Oxycodone (a narcotic pain medication), and Temazepam (a medication used for sleep) to assist in the transition of care.

Patient #3's discharge home on 3/26/24 was in contrast to the 3/25/24 physician notes, nursing notes, and physical therapy notes which revealed Patient #3 had an impaired ability to care for themselves, they were at higher risk of physical harm without adequate supervision, and they ultimately required SNF placement to ensure proper care and a safe discharge.

This was also in contrast to the Discharge Planning policy which read, healthcare professionals should collaborate to ensure each patient had a plan for continuing care during the transition into the community and thereafter. The components of discharge planning ensured the patient was appropriate for discharge to a lower level of care with the provision of appropriate and available resources and services upon discharge to meet the needs for continuity of care. The implementation of a safe discharge plan provided for appropriate and available resources and services to meet the patients' needs for continuity of care.

B. Interviews

i. An interview was conducted on 5/13/24 at 2:04 p.m. with Therapist #1. Therapist #1 stated when they assessed patients for discharge, they conducted different balance tests and identified fall risk through a score used to evaluate patients' safety. Therapist #1 stated if the patient lived alone, they would determine the level of assistance a patient required. Therapist #1 also stated if a patient required two people to assist with mobility, it was not safe to discharge the patient home.

Therapist #1 stated they informed Physician #5 that Patient #3 required someone present to physically assist them if they discharged home. Therapist #1 stated they did not recommend Patient #3 to be discharged home alone. Therapist #1 stated Patient #3 had difficulty transferring to the bedside commode and was unable to toilet independently. Therapist #3 stated they were unsure how Patient #3 would have managed care at home without assistance. Therapist #1 stated they were recently made aware Patient #3 had passed away shortly after being discharged home.

ii. An interview was conducted on 5/15/24 at 9:01 a.m. with care coordinator RN #7. RN #7 stated they assisted Physician #5 with discharge planning. They stated Patient #3's insurance would not cover SNF placement until 4/1/24. RN #7 stated some patients did remain at the hospital while they waited for placement and Patient #3's insurance may have covered the physician-recommended placement to a SNF in April, but felt Patient #3 did not want to wait on insurance.

RN #7 stated Patient #3 did not have a PCP, which was necessary to set up home health care, so RN #7 helped to set up a PCP appointment on 4/4/24, nine days after discharge. RN #7 stated it was Patient #3's choice to leave the facility to return home, although now, RN #7 did not consider this an ideal discharge.

RN #7 stated they were aware the care team believed Patient 3 should have been discharged to a SNF or had skilled nursing available. They stated Patient #3 had a family member who was going to help provide home care and supervision. They also stated they were not sure if this family member had been involved in the care decisions while at the facility, if they knew of the patient's needs, or if they were involved in the discharge planning process. RN #7 stated at the time of discharge, the patient was on many sedating (sleep-inducing) medications. They stated the medications Fentanyl and Oxycodone were opioid pain medications and the medication Temazepam was used for sleep. RN #7 stated these medications, when taken together, created an increased risk for respiratory depression (inadequate breathing), confusion, and loss of balance. RN #7 stated Patient #3 did not have an ideal discharge when they were discharged home, without skilled nursing assistance or being discharged to a SNF.

iii. An interview was conducted with RN #3 on 5/13/24 at 3:32 p.m. RN #3 stated they had cared for Patient #3 and Patient #3 had difficulty with ambulation and transfers. They stated Patient #3 scored high on the Morse Fall Risk Assessment which meant the patient would probably fall. They stated they were present while Physician #5 and Patient #3 had a conversation about disposition (placement) on the day of discharge, and while Patient #3 did not refuse to leave, Patient #3 did not want to go home. RN #3 stated Patient #3 was discharged home due to insurance's refusal to cover Patient #3's stay. RN #3 stated they were unsure if this was a safe discharge for Patient #3. They stated discharging home put Patient #3 at risk for falls with the inability to get themselves back up, failure to thrive (a state of decline with decreased ability and increased health concerns), and a risk of hospital readmission.

iv. An interview was conducted on 5/13/24 at 2:21 p.m. with case manager (CM) #2. CM #2 stated they should follow the recommendations of physical and occupational therapies and the instruction of the patient's physicians to ensure a safe discharge. CM #2 stated physicians had the final say on when and where a patient would be discharged. CM #2 stated it was important for patients to be discharged appropriately to ensure patient safety and for patients to succeed at home without the need to be readmitted.

This was in contrast to the medical record which revealed CM #2 had met with Patient #3 on 3/26/24 to discuss Patient #3 discharging home with support after insurance did not authorize SNF placement until after 4/1/24. CM #2 stated Patient #3 agreed to be discharged home and had support from private caregivers, although they did not know what level or frequency of care that entailed.

v. An interview was conducted on 5/15/24 at 10:02 a.m. with Physician #5. Physician #5 stated they evaluated Patient #3 while they waited to be discharged to a SNF. Physician #5 stated they decided to discharge Patient #3 home due to insurance issues. Physician #5 stated Patient #3 needed to see a PCP to receive assistance from home health nurses, and they had set up an appointment with a PCP for Patient #3 as soon as possible. Physician #5 stated Patient #3 was discharged home with a front-wheeled walker, and required one-person assistance to safely use the walker because they were a high fall risk. Physician #5 stated it was important for Patient #3 to be discharged home with someone to assist them because they were at high risk for falls.

Physician #5 stated they called Patient #3's family member as a courtesy to inform them of the upcoming discharge and requested the family member keep an eye on the patient. Physician #5 stated as Patient #3 was cognitively aware, this call was only to inform the family, not to ensure the family member would be able to supervise the patient upon discharge. Physician #5 stated Patient #3 was taking high doses of narcotics, Fentanyl and Oxycodone, and the medication Temazepam upon coming to the facility and Physician #5 was concerned that there was an elevated risk for unsafe medication interactions. Physician #5 stated there was a risk of mixing opioids (narcotic pain medications) with high doses of long-acting benzodiazepines (a medication used for anxiety that slows down activity in the brain and causes sedation). Physician #5 stated they discharged Patient #3 home with a 30-day supply of narcotic pain medications to assist in the transition of care. Physician #5 stated discharging Patient #3 home on sedating medications put Patient #3 at risk for decreased balance and respiratory depression.

Provider #5 stated the medical record indicated Patient #3 was deceased, although they were unsure how they had died. Physician #5 stated Patient #3 should have been discharged to a SNF, which was the best placement option for them.