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Based on record review and interview, the facility failed to document that patients were included and participated in a discussion of the evaluation results of his/her discharge plan for 5 of 5 sampled patients (#2 - 6). This failure may result in a discharge that does not fit the patient's needs or preferences, such as the discharge of Patient #1 to a lower level of care than her discharge evaluations would support. The findings are:



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A. Record review of discharge planning records for Patient #2, 3, 4, 5, and 6 indicated the facility failed to document that patients were involved in a discussion of the discharge planning evaluation results.

B. During interview on 08/04/2015 at 3:47 pm, the Manager of Case Management stated, "It is not documented that a discussion of the evaluation [for all 5 patients] is held with either the patient or patient's representative."

Based on record review and interviews, the facility does not track the readmission of patients who have filed complaints. The facility also does not track the relationship between readmissions and problems with discharge planning. This failed practice increased the risk for another discharge with readmission. The findings are:


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A. Record review of the readmission log revealed that the record does not indicate whether the reason for readmission was related to discharge planning.

B. During interview on 08/04/15 at 4:47 pm, the Manager of Case Management stated that readmissions are tracked, but whether the reason for readmission was related to discharge planning are not tracked.

Based on interview and record review, the facility failed to initiate a "Plan Do Check Act" project, the form of a process improvement for the facility, from a failed grievance response to Patient #1. The findings are:

A. Record review for Patient #1 revealed no facility response letter to the grievance filed by the spouse of Patient #1.

B. During interview on 08/03/15 at 3:30 pm, the Chief Nursing Officer explained she had received the letter from the spouse of Patient #1. She admitted that she failed to forward the letter to the Risk Officer who responds to all grievances.

C. During interview on 08/03/15 at 2:45 pm, the Chief Nursing Officer and Director of Quality stated that the failure to respond to Patient #1's grievance should have triggered a performance improvement project.

D. During interview on 08/04/15 at 10:15 am, the Director of Quality confirmed that the breakdown in the facility grievance procedure did not reach the quality tracking and should have triggered a performance improvement project. She stated, "this incident should have gone through the Quality committee to the Medical Executive Committee to the Advisory Board."

E. Review of the facility's policy Patient Rights: Grievance Procedure approved 09/17/14 revealed the following:
1. Purpose: 1.1 To describe the process for the prompt resolution of a patient's(or her/his representative)grievance regarding an alleged violation of patient rights....
2. Definitions: 3.6 All verbal or written complaints regarding situations that endanger the patient or organization compliance with CMS requirements are considered grievances. Such events will be immediately investigated.
3. Procedure: 6.6 All grievances are to be submitted to the Risk Department.
4. Procedure: 6.9 If, within seven (7) business days, the grievance is not resolved, an acknowledgement letter will be sent to the patient or her/his representative with an estimate date of completion for the investigation.
5. Procedure: 6.14 The grievance is incorporated in the hospital's QAPI process.

Based on record review and interviews, the case management nurse failed to update the discharge plan for Patient #1 for the 04/10/15 discharge to home from the facility. This failed practice limited the family's options, expedited a clinically inappropriate discharge of Patient #1 to home, exposed Patient #1 to unnecessary risks to her health and directly contributed to her readmission to the facility 2 days later. The findings are:

A. Record review of the discharge notes for Patient #1 confirmed she was not able to speak, swallow or move as she did before surgery on 04/09/15 for removal of a tumor on her neck at the hospital. Physical therapy notes for 04/11/15 at 11:00 am indicated Patient #1 as:
1. "Physical Therapy: Appropriate for skilled therapy (occupational therapy); communication unclear; maximum assist with 2 people to turn in bed; only able to move the right upper extremity with strength rated at 2 out of 5; unable to participate in range of motion; global tone is rigid; liquids must be thickened to a 'nectar' consistency to slow swallow to avoid aspiration and solid food pureed to manage chewing and swallowing."
2. A computed tomography (CT) of the head was performed to assess Patient # 1's slurred speech. Results of the CT were negative.

B. Review of the facilities policy "Case Management; Discharge Planning and Discharge to a lower level of care," approved on 02/08/15, indicated the following:
Purpose: To provide guidelines for facilitating transition from an inpatient setting to home, community or other environment.
The guidelines include: "Problem solve with patient/family as needed...recommendations for continued care/level of care...follow-up with needed additional care. "

C. Review of the facility's policy titled "Case Management: Discharge Planning" dated 02/08/15 revealed the following:
1. "Policy: 1.1 Case managers should collaborate with other members of the health care team to assess, evaluate, implement, and reassess the discharge plan..."
2. "Procedure: 2.5 Discharge scenarios should be discussed with the patient, guardian and patient representative or family members. The Case Manager informs the patient and family/representative when it is involved in the decision making about ongoing care about the kinds of continuing care, treatment and services that the patient should need. 2.6 The patient or family should be informed of their freedom to choose among participating providers and when possible, respects the patient's and family's preferences when they are expressed. The hospital does not limit the qualified providers that are available to the patient."

D. During interview on 08/03/15 at 11:15 am, the complainant affirmed the lack of options presented by the Case Manager for Patient #1's discharge. The spouse was also concerned whether he had adequate care for Patient #1 at home. (The spouse is 72 years old.) The spouse stated that the service of the principal caregiver, who provided most of the daytime care at home, was no longer available.

E. During interview on 08/03/15 at 3:45 pm, the Manager of Case Management stated, "In this instance the Case Manager was not empathetic, not a patient advocate; the situation required de-escalation."

Based on record review and interview, the facility failed to document that patients were given a choice of home health agencies, rehabilitation facilities or skilled nursing facilities for 5 of 5 sampled patients (#2 - 6). This failure could result in a discharge to a facility that did not meet the needs or preferences of the patient. The findings are:

A. Record review of the discharge planning records for Patient #2, 3, 4, 5, and 6 revealed that there was no documentation of their having been offered a choice of facilities prior to transfer to the care of home health agencies, rehabilitation or skilled nursing facilities.

B. During interview on 08/04/15 at 3:38 pm, the Manager of Case Management confirmed there was no documentation that current patients were "given a choice of home health agency, rehabilitation or skilled nursing facility."

Based on record review and interview, the facility failed to provide a list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's pre-admission medications, in 4 out of 5 sampled patients (#3, 4, 5, and 6). These failures could expose patient to potential negative side effects from drug interactions. The findings are:

A. Record review of the discharge planning records of Patient #3, 4, 5, and 6 revealed that the list of medications given to the patient at discharge does not clearly indicate any changes from pre-admission medications.

B. During interview on 08/04/15 at 3:50 pm, the Manager of Case Management stated, "The only way to tell which are new medications is to compare the discharge medication list with the pre-admission list."

Based on record review and interview, the facility failed to evaluate Patient #1 for possible skilled nursing placement. This failure limited the family's options and resulted in a discharge to a lower level of care than was clinically appropriate for Patient #1. This failure also exposed Patient #1 to unnecessary risks to her health and necessitated her readmission to the facility 2 days later. The findings are:

A. Record reviewed of the discharge notes for Patient #1 confirmed she was not able to speak, swallow or move as she did before surgery on 04/09/15 for removal of a tumor on her neck at the hospital. Physical therapy notes dated 04/11/15 at 11:00 am indicated Patient #1 as:
1. "Physical Therapy: Appropriate for skilled therapy (occupational therapy); communication unclear; maximum assist with 2 people to turn in bed; only able to move the right upper extremity with strength rated at 2 out 5; unable to participate in range of motion; global tone is rigid; liquids must be thickened to a 'nectar' consistency to slow swallow to avoid aspiration and solid food pureed to manage chewing and swallowing."
2. A computed tomography (CT) of the head was performed to assess Patient #1's slurred speech. The results were negative.

B. Review of the facilities policy "Case Management; Discharge Planning and Discharge to a lower level of care," approved on 02/08/15, indicated the following:
Purpose: To provide guidelines for facilitating transition from an inpatient setting to home, community or other environment.
The guidelines include: Problem solve with patient/family as needed...recommendations for continued care/level of care...follow-up with needed additional care.

C. Review of the facility's policy titled "Case Management: Discharge Planning" dated 02/08/15 revealed the following:
1. Policy: 1.1 Case managers should collaborate with other members of the health care team to assess, evaluate, implement, and reassess the discharge plan...
2. Procedure: 2.5 Discharge scenarios should be discussed with the patient, guardian and patient representative or family members. The Case Manager informs the patient and family/representative when it is involved in the decision making about ongoing care about the kinds of continuing care, treatment and services that the patient should need. 2.6 The patient or family should be informed of their freedom to choose among participating providers and when possible, respects the patient's and family's preferences when they are expressed. The hospital does not limit the qualified providers that are available to the patient.
3. Guidelines: 14. Review of the facilities policy "Case Management; Discharge Planning and Discharge to a lower level of care", approved on 02/08/15, indicated the following:
Purpose: To provide guidelines for facilitating transition from an inpatient setting to home, community or other environment.
The guidelines include:
4. Problem solve with patient/family as needed...recommendations for continued care/level of care...follow-up with needed additional care...
5. Discharge information is documented on the case management Progress note and should include: recommendations for continued/level of care; follow-up, as needed, with additional services

D. Record view of the Case Manager's notes for Patient #1 dated 04/10/15 indicated the following:
"Patient is unable to talk clearly. Husband reports patient normally can speak clearly and use her arms and hands to feed herself and to manipulate the controls (toggle) of her electric wheel chair. Husband stated he takes care of his wife night. That their long time caregiver became a nurse and is now working at [a health care facility]. Attempted to explain why Dr. [name of physician] plans discharge and that to keep the patient in the hospital would need a medical reason. Explained that their care taking issues are a social issue and not solved by the hospital. Attempted to explain that the patient may just be under the effects of the multiple medications she has received: anesthesia, narcotics, antidepressant, and Parkinson's medications. Informed them that if the patient cannot keep herself hydrated then she is not medically ready to go home, and would talk to Dr. [name of physician]about that and request a speech eval[uation] as well as therapy eval[uation]s. Multiple calls to Dr. [name of physician] by nurses and House Supervisor, he refused to talk to cm....Disposition will depend on response to treatment."

D. During interview on 08/03/15 at 11:15 am, the complainant affirmed the lack of options presented by the Case Manager for Patient #1's discharge. The spouse was also concerned whether he had adequate care for Patient #1 at home. (The spouse is 72 years old.) The spouse stated that the service of the principal caregiver, who provided most of the daytime care at home, was no longer available.

E. During interview on 08/03/15 at 3:45 pm, the Manager of Case Management stated, "In this instance the case manager was not empathetic, not a patient advocate; the situation required de-escalation."

Based on record review and interview, the facility failed to provide a list of Medicare-participating home health agencies (HHAs) and skilled nursing facilities (SNFs) in the discharge plan for those patients for whom the plan indicated home health or post-hospital extended care services are required for 4 of 5 patients (#3, 4, 5 and 6). This failure could lead to a discharge to a facility that does not meet the needs and/or preferences of the patient. The findings are:

A. Record review of the discharge planning records of Patient #3, 4, 5, and 6 revealed that the facility did not provide a list of Medicare participating home health agencies (HHAs) and skilled nursing facilities (SNFs) in the discharge plan for those patients for whom the plan indicated home health or post-hospital extended care services were required.

B. During interview on 08/04/2015 at 3:40 pm, the Manager of Case Management stated that the discharge plan did not reflect that a list of Medicare participating facilities is provided to patients needing those services.