HospitalInspections.org

Based on medical record review, document review, and staff interview, it was determined the facility failed to document a completed discharge assessment including a referral to home health in three (3) of ten (10) patients, patient #2, #7, and #10. This failure has the potential to negatively impact all patients discharged from the facility.

Findings include:

A medical record review was conducted for patient #2. The patient presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 04/28/23 at 5:06 a.m. with a chief complaint of confusion. A physical therapy (PT) evaluation was completed on 05/01/23 at 10:00 a.m. and recommended home health for continuing PT. A Discharge Summary was completed on 05/01/23 at 1:25 p.m. by provider #1 and states in part, "... Physical Therapy has evaluated the patient. At this time, patient can be discharged home. [Patient #2] will need 24 [twenty-four] hour care to make sure [patient #2] is stable and not falling. This can be reevaluated by PCP [primary care physician] at follow-up. Patient has returned to near baseline and it is appropriate for discharge at this time." Patient #2 was discharged home with family on 05/01/23 at 2:08 p.m. A written order signed by physician #4 on 05/02/23, orders home health services for skilled nursing, occupational, and physical therapy. May it be noted, there is no documentation in patient #2 medical record of a discharge planning evaluation, and no evidence home health was notified prior to the patient's discharge.

A medical record review was conducted for patient #7. The patient was admitted to the facility on 04/18/23 for diabetic ketoacidosis. A discharge summary completed on 05/02/23 by physician #4 states in part, "Physical therapy (PT) and occupational therapy (OT) were consulted. Patient can be discharged home this time. [Patient #7] will have home health for PT/OT ..." A social worker note on 05/01/23 explained the patient will be discharged with family, and taken to Michigan. The patient was discharged with family on 05/02/23. No further documentation was noted in the patient's record for a follow up with home health.

A medical record review was conducted for patient #10. The patient was admitted to the facility on 04/28/23 with a diagnosis of acute CVA (cerebrovascular accident). A discharge summary completed by physician #4 on 04/30/23 at 1:16 p.m. states in part, "... Continue home health for lower extremity lymphedema and Venous stasis ulcers ..." The patient was discharged home with family on 04/30/23. May it be noted, there is no discharge planning assessment, or home health referral, in the patient's medical record.

A review of the policy titled "Discharge Planning", reviewed 6/12/23. The policy has a section titled "Discharge Planning Process" which states in pertinent part, "I. Discharge planning will be initiated by the social worker / care management team as soon as possible after admission. The social worker/care management team shall be responsible for promptly assessing, identifying, and coordinating the needs of all patients, regardless of payment source, who pose a potential disposition problem ... III. The finding of each patient review shall be documented appropriately and accurately in the progress notes of the patient's medical record. In the absence of the social worker/care management team as on weekends and holidays, the nursing staff will facilitate the discharge planning Process."

An interview was conducted with the Case Manager (CM) on 08/08/23 at 9:14 a.m. Regarding patient #2, the CM states, "I remember that I met with the family. the nurses document in their assessment if there's any needs. The nursing assessment needs would consult to the social worker. I did meet with the patient and the family, but I did not document anything on [patient #2] . We identified [patient #2] needed home health and set that up. Nothing was documented."

An additional interview was conducted with the CM on 08/09/23 at 11:30 a.m. Regarding patient #7, the CM explained if the patient went to Michigan, they probably didn't have a PCP there to set up home health. The CM confirmed, however, there was no documentation to this. Regarding patient #10, the CM stated, the patient was discharged on a Sunday, so case management is not here on the weekends, and the home health would've been set up over the phone on the following Monday by the Transitional Care nurse. The floor nurses do not set up home health on discharge."

An interview was conducted with the Transitional Care Coordinator (TCC) on 08/09/23 at 12:03 p.m. Regarding patient #10, the TCC states, "If the patient was discharged over the weekend I would call them on the phone after discharge and set up home health."

Based on medical record review, document review, and staff interview, it was determined the facility failed to document the patient's freedom of choice for home health in two (2) of ten (10) patients, patient #2 and #10. This failure has the potential to negatively impact all patients discharged from the facility.

Findings include:

A medical record review was conducted for patient #2. The patient presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 04/28/23 at 5:06 a.m. with a chief complaint of confusion. A physical therapy (PT) evaluation was completed on 05/01/23 at 10:00 a.m. and recommended home health for continuing PT. A Discharge Summary was completed on 05/01/23 at 1:25 p.m. by provider #1 and states in part, "... Physical Therapy has evaluated the patient. At this time, patient can be discharged home. [Patient #2] will need 24 [twenty-four] hour care to make sure [patient #2] is stable and not falling. This can be reevaluated by PCP [primary care physician] at follow-up. Patient has returned to near baseline and it is appropriate for discharge at this time. Patient #2 was discharged home with family on 05/01/23 at 2:08 p.m. A written order signed by physician #4 on 05/02/23, orders home health services for skilled nursing, occupational, and physical therapy.

May it be noted, there is no documentation in patient #2 medical record of a freedom of choice for home health services.

A medical record review was conducted for patient #10. The patient was admitted to the facility on 04/28/23 with a diagnosis of acute CVA (cerebrovascular accident). A discharge summary completed by physician #4 on 04/30/23 at 1:16 p.m. states in part, "... Continue home health for lower extremity lymphedema and Venous stasis ulcers ..." The patient was discharged home with family on 04/30/23. May it be noted there is no home health freedom of choice in the patient's medical record.

An interview was conducted with the Case Manager (CM) on 08/08/23 at 9:14 a.m. Regarding patient #2, the CM states, "We identified [patient #2] needed home health and set that up. Normally we get a documented freedom of choice, but in this case I did not get one."

An additional interview was conducted with the CM on 08/09/23 at 11:30 a.m. Regarding patient #10, the CM stated, "The patient was discharged on a Sunday, so case management is not here on the weekends, and the home health would've been set up over the phone on the following Monday by the Transitional Care nurse. The floor nurses do not set up home health on discharge."

An interview was conducted with the Transitional Care Coordinator (TCC) on 08/09/23 at 12:03 p.m. Regarding patient #10, the TCC states, "If the patient was discharged over the weekend I would call them on the phone after discharge and set up home health. Sometimes they decline here and then decide when I call that they want it. I usually document a verbal freedom of choice in my note. In this case, I do not see anything documented."