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Based on interview, record review and review of facility policy, the facility failed to reevaluate the discharge needs and plans of 1 of 4 sampled patients who were discharged from the hospital (#4).

Findings:

Patient #4's medical record revealed she was 79 years old, presented to the hospital Emergency Department (ED) on 6/28/2022, and was admitted to the Intensive care unit. The physician's discharge summary revealed diagnoses of acute hypoxic and hypercapnic respiratory failure, acute on chronic obstructive pulmonary disease exacerbation and lung cancer stage III. Prior to admission she was on oxygen at 2-3 liters via nasal cannula.

A Case Management (CM) report/assessment dated 6/29/21 read, "Patient Goals and preferences after discharge: Home, ? HHC" (Home Health Care); Home Services needed: Home Health."

A narrative CM note dated 6/29/21 read, " Spoke with patient . . . Discharge Plan is home, ? HHC."

A physical therapy (PT) note dated 6/30/21 at 3:58 PM read, "Discharge Planning Recommendation: HH (home health) and RW (rolling walker." Home health care was recommended.

A physician's note dated 6/30/21 reflected that the patient was in a stable condition and could be discharged home.

There was no documentation in the patient's medical record that a discharge reevaluation of needs for home health care was done. There was no documentation found that the patient's discharge needs were discussed with the patient or the family to include any home health care or transportation needs. The patient did not receive a home health referral upon discharge, and it was unknown how the patient left the hospital or with whom.

The patient's medical record revealed the discharge instruction/information template was blank and not filled out which would generate discharge information to give to the patient/family. There was no evidence found that the patient/family received any discharge instruction/information prior to her discharge home. The medical record did not reflect notification to the family of the patient's discharge, and if any transportation needs were needed upon discharge.

On 2/07/23 at 11:35 AM, the Director of Case Management and the Director of Quality revealed that every patient receives a printout of their discharge instructions which includes their discharge referrals, follow-up appointments, discharge medications, and any additional information. The facility discharge instructions include a signature line for the patient's signature, and also a signature line for Caregiver/RN/Doctor for facility employee signature, both followed by a date and timeline of the signatures. The Director of Case Management and the Director of Quality confirmed there was no discharge instruction of information for patient #4 in the record that the patient received this upon discharge. The Director of Case Management and the Director of Quality confirmed that patient #4 did not receive a home health referral upon discharge. They related every day an interdisciplinary meeting is completed for each patient which discussed their status and needs. They observed and confirmed the PT note dated 6/30/21 that recommended home health for the patient and the initial case management documentation for "? home health" in the case management assessment. They related the patient most likely left the hospital before the interdisciplinary meeting was held. Patient #4 left the hospital on June 30, 2022, without a home health order, discharge instructions, was readmitted to the hospital the following day, July 1, 2022, and expired on July 6, 2022.

The hospital's "Discharge Planning Policy 10844975" Approved 6/06/22, read in part, "Discharge planning is an interdisciplinary process that begins at the time of admission to the hospital to identify patients with expected post-acute care needs . . . The Case Manager/Social Worker endeavors to conduct Discharge planning assessment/reassessment by the next business day and identification for post-acute hospital services and received referrals. a.) Assessment and identification of discharge planning needs by nursing, physician, case managers, or other members of the interdisciplinary team . . . The Case Manager/Social Worker collaborates and/or makes appropriate referrals to other members of the health team, including but not limited to, treating physicians, clinical dieticians, therapists, ...and other ancillary departments as needed . . . The Case Manager/Social Worker evaluates the needs of the patient on an ongoing basis, when there is a significant change in the patient's condition/functional status or level of care, and prior to discharge to determine whether a change in the status of the patient and/or caregivers indicate a need to adjust the discharge plan. The discharge planning reassessments are documented in the electronic documentation system . . . After interviewing the patient or persons acting on behalf, reviewing the medical record, and consulting the physician and members of the interdisciplinary team, as required, the Case Manager/MSW will provide the patient with a full range of realistic options for post hospital continuation of care . . . The Case Manager/Social Worker documents discharge planning activity in the electronic documentation system . . . including but not limited to, patient/family decisions and choice information, provider referrals, contact information, outcome, time frames, status updates, and follow-up discussions with patients, care providers, payers, funding agencies. . . When post-acute services have been arranged, the Case Manager/Social Worker notifies the patient, the nurse, and other members of the heath care team, as appropriate regards the finalized discharge plan . . . The patient and persons acting on his/her behalf are counseled by the interdisciplinary team to assure that the patient/caregiver is:
a. prepared for post-acute care b. kept informed of the status or progress of the discharge plan, c. able to verbalize and/or demonstrate the care needed by the patient."

The policy "Patient Discharge Process-Nursing" 943757, Approved 3/10/21, read in part, "The RN completes the following and educates the patient: Medication - reviewed and finalized, Core Measures Compliance, Discharge Instructions, Clarify transportation. If any barriers or issues, the RN is to notify Case Management to arrange for transportation."