HospitalInspections.org

Based on document review, interview and policy review, the facility failed to identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge without adequate discharge planning, in 1 of 19 medical records reviewed (#2 ). Findings include:

On 1/13/2021 at approximately 1340 during the review of patient #2's medical record, the absence of a social worker assessment and/or consult was noted. Patient #2 was admitted on 10/22/2020 through the Emergency Department with complaints of nausea and abdominal pain.

Document review of patient #2's medical record occurred on 1/13/2021 at 1530. The patient presented to the Emergency Room on 10/22/2020 at 1600. The Emergency Room physician's note stated, "78-year-old male presents to the emergency department with complaints of abdominal pain that has been worsening over the last few days. He states the pain is currently 7/10 in severity and sharp/stabbing in quality. He states the pain is in the right upper quadrant that radiates into his back. He was recently diagnosed with gallstones and was told by his surgeon to come back to the emergency department for evaluation. He denies any fevers or chills. He does complain of significant decrease in appetite."

Further documentation stated, "The patient 78-year-old male past medical significant for hypertension, hyperlipidemia, peripheral vascular disease, gastroesophageal flu disease, history of cardiac catheterization, and stent recently November 2019. He came to the hospital complaining of abdominal pain right upper quadrant radiates to the back not having nausea, vomiting, fever, chills, cough, shortness of breath, dyspnea, exertion orthopnea, no diarrhea, constipation, melena, hematemesis, hematemesis, no dizziness, no vertigo, no chest pain, or palpitation. Patient had increased indirect hyperbilirubinemia and cholelithiasis. Patient was on IV antibiotic. General surgery consulted. Patient was admitted to hospital for further evaluation and treatment."

The patient had abdominal surgery on 10/27/2020. The patient was evaluated on 10/28/2020 by physical therapy. According to the physical therapy notes on 10/28/2020 the patient was identified to need home care services. Further review of the patient's medical chart included documentation on 10/30/2020 at 1447 by staff BB, a case manager that stated, "Spoke with NP, (staff Z the patient's physician) notified her that he will be handling order for Home Care. Spoke with pt's son and relayed that home care would be arranged through the dr's office. Will continue to follow til HC (home care) is in place."

The discharge summary on 10/29/20 at 1045 stated, "Patient was admitted to hospital with abdominal pain symptomatic cholelithiasis and hyperbilirubinemia. He had an MRI of the abdomen showed cholelithiasis without choledocholithiasis. Patient has history of coronary artery disease. He was seen by cardiology. Patient to continue on aspirin and Plavix. Patient has history of hypertension and bulimia. Patient was started on IV antibiotic seen by general surgery. Patient had laparoscopic cholecystectomy. Patient had postop increased bilirubin. HIDA scan (scan used to identify gallstones located in the gallbladder or the biliary duct of the gallbladder) was negative for obstruction. Patient was cleared for discharge from surgical standpoint. He had urinary tension urology consulted. He was discharged with Foley catheter need to follow-up with urology outpatient."

On 1/13/2021 at 1330 an interview occurred with staff BB, the case manager for patient #2. Staff BB was queried if home care was established for patient #2. Staff BB stated that the patient's physician stated he would establish home care for patient #2 per the nurse practitioner for the physician and that no order was received because the physician prefers to handle all home care needs out of his office.

On 1/13/2021 at 1400 an interview occurred with staff Z, the patient's physician. Staff Z was queried why he did not give an order for home care for the patient. Staff Z stated that his office establishes home care for his patients where the patients can continue with the home care agency the patient already has as part of their care. Staff Z was then asked if the patient had home care already established. Staff Z stated he was unsure if the patient already had home care, but he thought the patient was already with a home care agency. Staff Z was then informed that the patient did not have home care established and the patient was discharged without home care. Staff Z stated that he was misinformed. Staff Z was then asked if he had ever been made aware that the patient was in need of home care. Staff Z stated that he was not aware that the patient did not have home care and apologized. Staff Z stated that he would make changes and let the facility staff arrange for home care for patients in the future.