HospitalInspections.org

Based on interview and document review the hospital failed to implement a discharge planning process for 1 of 10 patients reviewed who was discharged to home in a taxi without family, the patient's home health agency was not notified of the discharge, the patient was unable to get into her home, did not have necessary services available and was brought back to the hospital.

The hospital's system failure resulted in the hospital's inability to ensure adequate discharge planning coordination and implementation.

Therefore the hospital was unable to meet the Condition of Participation of Discharge Planning at 42 CFR482.43. This deficient practice had the potential to impact all patients discharged to home care from the hospital. Findings include:

See A0820. Based on interview and document review the hospital failed to arrange for the implementation of the patient's discharge plan for 1 of 10 patients reviewed, Patient #1 (P-1), when the patient was discharged home and required home care services that were not initiated. The patient was unable to unlock her home and did not know who to call or how to care for herself and was brought back to to the hospital.

Based on interview and document review the hospital failed to implement a discharge planning process for 1 of 10 patients reviewed who was discharged to home in a taxi without family, the patient's home health agency was not notified of the discharge, the patient was unable to get into her home, did not have necessary services available and was brought back to the hospital.

Findings include:

Medical record review revealed P-1 was admitted to the hospital on 5/7/2015 with diagnoses that included a Right MCA ischemic infarct, (stroke), and diabetes. P-1 was legally blind.

P-1's Social Service assessment, dated 5/8/2015 revealed P-1's baseline included home health care two times daily for assist with cooking, cleaning, meals, laundry, shopping, etc.

P-1's occupational therapy assessment dated 5/11/2015 revealed P-1 had personal care assistant (PCA) services prior to admission for assist with activities of daily living including meals, cooking medication set-up and laundry: And would continue the need for assistance with activities of daily living.

P-1 was discharged on 5/11/2015 with physician orders signed at 11:06 a.m. that included home health services, and medications that included insulin Lantus 100 unit/ml, 15 units subcutaneous one time daily.

P-1's Hospital Summary with Dismissal date 5/11/2015 revealed P-1's speech pathology discharge summary stated P-1 was exhibiting nonaphasic communicative deficits as evaluated by the speech pathology physician, indicating she would benefit from further cognitive evaluation and to have an appointment set up.

Triage nurse notes dated 5/11/2015 at 4:53 p.m. revealed P-1 was discharged from the hospital via a taxi cab at 11:00 a.m. and her home was locked. P-1 could not get into the home and P-1 returned to the hospital via taxi cab. P-1's home care agency was not aware P-1 had been discharged. The Home Health nurse requested orders for insulin and current medications. The triage nurse returned the call to the Home Health Nurse and informed her the doctor ordered to check P-1's blood sugars and see if the patient is eating and drinking safely and recommended starting with Lantus 7 units tomorrow morning (5/12/2015).

An interview with the Registered Nurse H (RN-H) on 7/14/2015 at 3:30 p.m. revealed RN-H was responsible for discharging P-1 from the hospital on 5/11/2015. RN-H stated she was new to her role and was not aware that the home health agency was to be notified of P-1's discharge, so she did not send the physician orders to the agency, nor did she call the agency to inform them of P-1's discharge.

An interview with P-1's home health nurse/case manager (CM-E) on 7/8/2015 at 10:30 a.m. revealed P-1 was discharged from the hospital on 5/11/2015. CM-E stated the home care agency was aware the patient was in the hospital, but had not been notified that P-1 was discharging that day and that P-1 had no required services set up. P-1's sister called an off-duty staff member from the home health agency to request help because P-1 was discharged from the hospital but no one knew where she was. The off-duty staff member called the home health agency off-duty nurse case manager (CM-E) for P-1. CM-E stated she called numerous cab companies to find P-1. When she found P-1, she had been riding in a cab for two and a half hours in a hospital gown and flip flop shoes without socks in 30 degree weather. CM-E stated the cab driver said he did not know what to do with P-1 after he brought her home from the hospital, because P-1 could not get into her locked home and could not remember who to call, could not remember any phone numbers, or where her key was. CM-E stated she told the cab driver to bring P-1 back to the hospital and CM-E met P-1 there. CM-E stated she and P-1's public health nurse were able to arrange emergency funding for a locksmith to come to the home and unlock the door. CM-E and the county public health nurse assisted P-1 to get cleaned up, get her medications and have a meal. CM-E stated P-1 has dementia and is legally blind and the services she receives from the home health agency include assistance 2 times daily 7 days a week for dressing, grooming, medication set-up and reminders, meals, laundry, housekeeping and shopping.

A fax dated 5/12/2015 was reviewed and revealed physician orders for P-1's ongoing care faxed to the home health agency on 5/12/2015 at 22:06, the day after P-1's discharge from the hospital.

The policy titled Discharge Planning, dated revised 7/17/2014 and provided by the hospital was reviewed. The following was noted under the section titled Procedure statements, 4. When further ongoing care is needed upon dismissal, patient information is communicated to the next health care provider to ensure continuity of care. The staff registered nurse contacts the continuing care agency prior to discharge to discuss ongoing care needs and confirm services to be provided.