HospitalInspections.org

Based on interview and record review, the facility failed to collaborate and coordinate a discharge plan for 1 of 10 sampled patients (#1).

Findings:

Patient #1 was admitted to the facility on 12/16/16. He had a history of mental illness, homelessness, paraplegia, indwelling urinary catheter and a powered wheelchair for ambulation. He was seen by psychiatric services on 1/03/17 for depression and medication recommendation. The recommendation was to collaborate with case manager for counseling therapy treatment in the community upon discharge.

The case management notes, dated 1/01/17, reflected that the manager was awaiting call back from a skilled nursing facility for patient placement. A case management progress note, dated 01/08/17, reflected that the patient was waiting for shelter placement. On 1/12/17, the note reflected that patient was discharged to a home in Ocala, Lake County.

A discharge summary by the physician, dated 1/10/17 at 4:05 PM, read, "the patient was supposed to go into the hotel and now, the case manager found that the patient can be accepted in a facility which is more appropriate in Ocala area....So he will be sent to SNF [skilled nursing facility] and will be followed by his PCP [primary care physician] in 1 week."

An interview with the patient's case manager on 5/04/17 at 12 PM revealed that the patient was difficult to place. She stated that he was discharged to a boarding home near Ocala, Florida. She stated that he did not require placement in a SNF because he was independent with his activities of daily living, was able to self-catheterize, and had completed his intravenous antibiotics. The case manager stated that the patient was made aware of the placement to the boarding home. She could not say how the patient would follow-up with his PCP, and about the psychiatry recommendation for counseling treatments in the community, since he was transferred to Ocala.

A review of the "Discharge Planning" policy, approved 3/08/16, read, "The patient ...is counseled by the interdisciplinary team to assure that the patient is: a. prepared for post hospital care, b. kept informed of the status or progress of the discharge plan, c. able to verbalize and or demonstrate the care needed and d. accepts the discharge plan."