HospitalInspections.org

Based on interview, and document review, it was determined the facility staff failed to ensure a thorough discharge planning evaluation was included in the patient's medical record, or completed as per the facility's policy.

Findings:

A review of the "Discharge Planning Review" for Patient #2 from 11/25/2022 at 9:37 p.m. that was provided to the surveyors as the "discharge nursing evaluation" contained the documentation that for "Living Arrangements - Family members" was documented. There was no other documentation for the discharge categories: Pt states they have adequate discharge help; Support Systems; Type of Home; Assessment indicates discharge needs; Patient expects to be discharged to; Caregiver Discharge Teaching Completed; and Has discharge transport been arranged." On 11/29/2022 at 5:57 p.m. the "Discharge Planning Review" documented "Yes" to "Has transport been arranged". No other documentation was noted in the other discharge categories.

A review of the nursing note from 11/29/2022 at 5:44 p.m. contained the evidence "Pt left unit with all [the patient's] personal belonging. Pt don't have SOB [shortness of breath], no pain."

The facility failed to provide documentation of discharge instructions or after visit summary (AVS) that was provided to the patient, and there was no documentation in the medical record that the patient was given or offered the discharge instructions.

During an interview on 2/14/2023 at 10:15 a.m., SM12 stated that discharge planning starts upon admission, and case management gets involved when the patient gets to the unit so that they can anticipate the patient's discharge needs. SM12 stated that case management is always involved in discharge planning and there wouldn't be a time when a patient would not have a discharge plan. SM12 stated that patients in observation status also get a discharge plan. SM12 stated that case management usually sees the patient within a day of admission or may even see them in the ED. SM12 stated that it is automatic that case management will help with discharge planning.

During an interview on 2/14/2023 at 11:17 a.m. with case management, SM22 stated that SM22 spoke with the doctor for Patient #2 and was told that the patient is ready for discharge and does not have any needs. SM22 stated that discharge planning starts as soon as the patient is admitted to inpatient or to observation status. SM22 stated that there would "probably" be a note when discharge planning began, and then a note if there were any changes or after "three days". SM22 stated that SM22 saw Patient #2 on the day of the patient's discharge. SM22's note was dated and time 11/29/2022 at 4:59 p.m. A nursing note from 11/29/2022 at 5:44 p.m. documented that "Pt [patient] left unit with all her personal belonging [sic]. Pt don't have SOB, no pain." SM22 did not know if anyone else saw Patient #2 prior to that. SM22 stated SM22 looked at the nursing notes and patient notes and determined the patient had "no needs". SM22 then stated that SM22 did not recall seeing any prior case management notes.

During an interview on 2/14/2023 at 11:24 a.m., SM20 stated that for discharge "screenings" patient's are interviewed and then it is documented, and is expected to occur within twenty-four (24) business hours of admission. SM20 stated that currently the facility is seeing ninety (90) percent of patients within twenty-four (24) hours and that everyone that is in observation status or admitted to inpatient gets discharge planning, as per the facility's policy.

A review of the facility's policy titled "Patient Admission Status" last approved 12/2021 states in part:
...CMS Definitions ...
Outpatient" An individual who has not been admitted by the hospital as an inpatient but received services from the hospital and is registered in the hospital records as an outpatient. The following patient types are examples of outpatient services: ... Observation: A type of Outpatient Services furnished by a hospital on the hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing or other staff. These services must be reasonable and necessary to evaluate an outpatient's condition or determine the need for a possible admission to the hospital as an inpatient ...

A review of the facility's policy titled "Discharge Planning - Acute Care" last approved 2/2020 states in part:
[The facility] shall provide discharge planning for all admitted patients and those patients placed in observation status according to federal, state and accreditation organization regulatory requirements ...
Overview
This hospital's discharge planning process shall apply to all admitted patients and those patients placed in observation status and shall consist of four (4) stages:
Screening all inpatients to determine which are at risk for adverse health consequences post-discharge if they lack discharge planning.
Evaluation of the post-discharge needs of inpatients in the first stage, or of inpatients who request an evaluation, or whose physician requests an evaluation.
Development of a discharge plan if indicated by the evaluation or at the request of the patient's physician.
Initiation of the implementation of the discharge plan prior to the discharge of an inpatient ...
4. At a minimum, the discharge planning process shall be initiated at the time of admission ...
11. Written discharge instructions shall be given to the patient/family in a manner that the patient family can understand. The discharge instructions shall be signed by the patient or responsible party acknowledging receipt of discharge instruction ...
Procedure
1. The initial assessment/evaluation for discharge planning needs shall be conducted during the nursing admission assessment or prior to admission for patients within a designated critical path.
Based on observation, interviews, and document review, there is deficient practice related to the facility not following their discharge policy. As per the documentation provided to the surveyor, Patient #2 was not thoroughly screened or evaluated for discharge planning. There was no documentation that the case manager saw Patient #2 or created a discharge plan until about an hour prior to the patient's discharge on 11/29/2022 after five (5) days at the facility.

The above concerns were discussed at the exit conference on 2/14/2023 at 12:15 p.m.