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Based on record review and interview, the facility failed to document options offered to the patient/family to provide care that met the needs of the patient and desires of the family/caregiver in the development of the discharge and outpatient care plan for 1 (#1) of 30 (#1 through #30) patients.

This deficient practice had the likelihood to effect all patients of the facility.

Findings included.

On 3/20/2019 in the conference room an interview with the facilities Case Manager (CM), staff #4, wasconducted regarding the arrangements for discharge described in the medical record (MR) for Patient (Pt/pt) #1. The documentation in the MR did not explain the discharge planning process for pt #1 and did not show evidence of options for care, other than home health, that were provided to the patient and her family/caregivers.

Pt #1's MR revealed she was evaluated in the ED, and it was determined she had bilateral fractures of the lower legs, heel bones and fracture of the right ankle. The hospital did not have an orthopedic specialist on staff and an orthopedic specialist in a larger hospital was consulted. The specialist declined to admit pt #1 and instead recommended discharge home to be followed-up on an outpatient basis for casting of her bilateral legs and feet. The ED physician notified the CM of the recommended discharge home and also notified the patient she would be discharged home with follow-up on an outpatient basis with the orthopedic specialist.

Pt #1 and the pt's son explained at that time she had no person in her home capable of assisting her with meeting her daily needs because her daughter-in-law, who previously had been her care taker, had just had a baby and also had the flu and was too sick to help care for her. Her son voiced their need for 24 hour care.

The CM, Staff #4, arranged for home health care. Staff #4 indicated ,the son believed this was 24 hour care and when she explained to him it was not. The son then stated, "That's not gonna help us". The son repeated his wife had just had a baby and also had the flu and he had to work.

Review of pt #1's MR failed to identify documentation that other avenues of care were offered. An interview with the CM, staff #4, revealed she "believed" she offered respite care with a long term care facility. But she confirmed it was not documented. There also was no documentation that a sitter service was offered, meals of wheels had been offered or any other option other than home health services. The MR did not contain discussion with the patient or families regarding their questions or concerns. The staff #4 stated, the family finally said, "We'll figure it out".

Further review of the MR found no evidence that arrangement for DME (Durable Medical Equipment) such as a bedside commode to facilitate bowel and bladder function with the least amount of transfer weight to the patients bilateral legs had been initiated. When the CM was asked about the DME she confirmed that home health would take care of that. The CM was reminded that the patient might be home as long as 24 hours before a home health nurse arrived to admit her to their services and longer than that to order the needed DME and have it delivered.

Based on record review and interview the facility's nursing department failed to document evaluation of the patient/family ability to care for the patient upon discharge, and failed to document education for both the patient and the family for how and when to medicate with the available pain medications which were identified in the home and provided upon discharge, to maintain control of pain for 1 (#1) of 30 (#1 through #30) patients identified.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.



On 3/20/2019, at 10:00 AM, in the conference room, an interview with the Case Manager (CM), staff #4, revealed, she had visit pt #1 in the Emergency Department, (ED). Staff #4 confirmed, "This was normal for pt #1". "Pt #1 was in the ED frequently for fractures because she had sever Osteoporosis". The staff #4 was reminded frequent visits to the ED may be normal but did she believe multiple fractures (5) were less painful because fractures were normal for pt #1? She replied,"No". The CM had failed to insure the Registered Nurse (RN) educated the patient/family related to how to dose and which drug to use to correctly dose the patient for optimum pain control, once she was discharged home.


Review of pt #1's MR, found no evidence of patient/family education regarding the home management of pt #1's pain. Within the MR a home medication reconciliation form was identified. The home medication reconciliation form indicated the pt used Tylenol #3 at home and pt #1 was discharged with a prescription for Ultram which is a synthetic opioid analgesic pain medication. Ultram is used to treat moderately to moderately severe pain. The ED RN staff #10, failed to document that the family/patient was educated on how to dose and when to dose with the pain medication she had at home and the pain medication she had a prescription for.

Neither the RN CM, staff #4, nor the RN in the ED, staff #10, documented other needs pt #1 might have such as effective pain management and lack of knowledge in using pain medication at home. The RN CM, #4, and the RN in the ED staff #10, failed to document education of the patient/family including, if Tylenol #3 and/or Ultram were ineffective for pain control, what should they patient/family do. The family and/or patient would need to notify pt #1's PCP of her recent visit to the ED and subsequent bilateral fractures and the need for another method of pain control.

On 3/20/2019 at 11:00 AM, an interview with the ED physician, staff #8, confirmed the patient's Primary Care Physician, (PCP) would be responsible for writing a prescription for anything stronger than Ultram. The PCP had not been notified of the pt's recent ED visit and diagnosis of fall with multiple fractures.

The patient was evaluated the following day for home health services and the Registered Nurse who arrived to conduct the admission process found pt #1 with nausea and vomiting related to uncontrolled pain. Pt #1 was transported to the hospital in a larger city where the orthopedic specialist worked. He admitted her for pain control and casting for her bilateral fractures of her lower legs and feet. Pt #1 was discharged to inpatient rehabilitation and later safely discharged home.