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Based on record review, staff interviews and review of the facility policy for Care Management Discharge Planning the facility failed to provide a discharge planning evaluation for 2 of 10 sampled patients (Patients 2 and 5) which included their capacity for self care in the home environment. The facility census was 178. This finding has the potential for harm and or readmission to the hospital due to failure to be discharged without ensuring the discharge plan was as safe as possible for the patient.

Findings are:

A. Record review of the facility policy titled "Care Management Discharge Planning" (last revised 4/2018) states "Discharge Planning is considered an integral part of comprehensive health care for patients. It is a interdisciplinary process through which the Case Management staff and/or other members of the health care team, ensure the appropriate and timely plans are made for post hospital care and sustained post discharge." Staff are to "Evaluate post discharge needs as identified by patient or their representative and interdisciplinary care team." Staff are to "Develop a discharge plan if applicable to ensure a safe and sustainable discharge that includes offering choice of services to patients and referrals to alternate levels of care as applicable. Services offered may include but are not limited to home health, durable medical equipment, post acute services and community resources." The section titled "Implementation of the discharge plan." states that staff will "Identify the appropriate mode of transportation. The nurse or Care Manager will collaborate with the patient, family/support system to arrange appropriate transportation."

B. A review of Patient 2's Electronic Medical Record on 4/11/18 revealed the patient was admitted to the acute hospital emergently from a stay in the hospital's inpatient rehabilitation unit on 2/25/18. The discharge summary from the inpatient rehabilitation stay dated 2/26/18 notes the patient was admitted to rehabilitation unit post bilateral Below the Knee Amputation (BKA). The patient had a previous left BKA and used a prosthesis on that leg. The right BKA was done at another hospital on 2/4/18. The patient developed dyspnea during his rehabilitation stay and required transfer and readmission to the acute hospital ICU on 2/25/18. Diagnosis included acute respiratory failure with hypoxia, congestive heart failure, obstructive sleep apnea, diabetes, chronic kidney failure Stage III, peripheral vascular disease. The patient was alert and oriented and was their own responsible party.

The nursing assessment on admission (2/25/18 at 6:26 AM) notes the patient is 1-2 assist for transfer with a slide board. The right BKA requires wound care with ACE (compression) wrap. The nursing admission assessment includes discharge planning screening questions. The nurse documented the patient lives with the spouse in a private residence and does not have previous in home services. The patient is noted as having a history of left BKA with a prostheses.

Review of a Case Management note by Social Worker (SW) "A" documented that the patient transferred from rehabilitation and will not be returning to rehabilitation. Case Management/Discharge Planning services were requested by PT (Physical Therapy). Interdisciplinary Team meeting notes dated 2/27/18 notes the patient will "most likely [return] home from here. LACE score 14." (LACE is a risk for readmission tool used by staff to identify patients at high risk of readmission or death within 30 days of discharge. A score of 10 or greater identifies a patient at high risk.)

On 2/28/18 a referral was sent for Home Health for PT, OT and bath aide. The patient refused to participate in PT or Occupational Therapy (OT). Nursing Notes (NN) on 3/2/18 noted at 1:29 AM that the patient was up with 1 person assist with a walker and left lower extremity prosthesis. NN on 3/2/18 at 8:00AM, the day of discharge to home, stated the patient was non weight bearing on the right. The stump wound had not healed for a prosthesis to be fitted during the patient's stay. This left the patient with 1 usable limb which had a prosthesis. On 3/2/18, SW A documented the patient was ready for discharge to home. The notes state "the patient will need ambulance transport home, as there are 16 stairs to [his/her] apartment." A local private ambulance company was called by SW A who will have "multiple guys and a safety administrator there". The patient is obese with weight greater than 300 pounds. The patient requested a transport chair and a prescription was obtained from the physician. The patient's spouse was getting a commode. The Home Health per discharge plan "was notified and will follow". The Medical Record failed to contain an order for Home Health services. The Discharge Instructions to the patient failed to identify Home Health services were to be provided. The patient was discharged home with the spouse.

Readmission record review from a different hospital was reviewed. The record notes that on 3/12/18 the patient was brought by paramedics to the hospital for complaint of chest pain. The patient stated they had been "sleeping in [his/her] wheelchair x (times) 1 week since [he/she] cannot transfer to bed and did not get [his/her] recliner. The Discharge Summary dated 3/15/18 stated the patient "needs rehab [rehabilitation] at SNF [Skilled Nursing Facility]. The patient discharged to a local SNF.

C. Staff interview on 4/12/18 at 12:15 PM with Registered Nurse (RN) "B" revealed RN B discharged Patient 2 on 3/2/18. RN B stated the patient could stand, turn and pivot with 1 staff assist and use of gait belt an walker with the prosthetic left leg. The patient required assist to the bathroom to get up and down. The nurse recalled assisting the patient to the bathroom and having to assist the patient to get the pants up and down. RN B recalled asking the patient how he/she was going to do this at home. The patient told RN B that they would "rise to the occasion." The patient also said that if the spouse was there that he/she would help. The patient did not say if the spouse was home to help or worked outside the home. The nurse said that during Patient 2's stay the patient required 5 liters of Oxygen at night. The patient told RN B they had 16 steps to the apartment and when asked by the nurse how the patient planned to go to follow up appointments the patient said he/she "would not be, once home no plans to go anywhere." The nurse confirmed Home Health was set up for the patient but the order was not entered so it did not show on discharge instructions. At discharge the spouse was at the house waiting for the Oxygen to arrive. The nurse stated he/she "did not feel patient was safe going home that day." At Interdisciplinary Care Rounds on 3/2/18 staff noted the patient had refused rehab, refused SNF and was non compliant with a lot of cares. The staff made the patient aware they did not feel it was safe to go home and let SW A know this. The nurse stated that the patient's spouse was not educated on how to help transfer the patient.

D. Staff interview on 4/12/18 with SW A at 9 AM revealed Patient 2 originally thought he/she was going back to the acute rehabilitation after discharge from the hospital. SW A related that upon checking with them that the patient did not meet the criteria for 3 hours of therapy per day. The patient frequently refused therapy during the rehabilitation stay. The patient wanted then to go home with the spouse. Safety concerns regarding the home plan was discussed with the patient while on rehabilitation. The plan was for the patient to go home on Home Health (HH), the patient had previously used the same HH service. SW A stated "I did not meet [his/her] discharge planning need. I should have addressed discharge planning with the patient." The SW further stated that "I did not discuss with the patient [his/her] options and safety, just used the rehabilitation discharge plan" and "did not develop a new plan post acute care stay."

E. Administrative interview with the Director of Quality/Safety on 4/12/18 at 9:40 AM, after reviewing the record for Patient 2 confirmed discharge planning services for acute stay should be separate from the prior rehabilitation discharge planning services.


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F. A review of Patient 5's medical record for 2/16/18-2/19/18 revealed the patient was admitted on 2/16/18 from the emergency department (ED) due to an infection and drainage to wounds on feet following severe frostbite. The ED record revealed that Patient 5 had a "Severe frostbite to all of the fingers with several areas of necrotic (dead tissue) tissue on fingers. There is also an open wound on the plantar surface (bottom) of the left foot, with necrotic tissue on the distal (end) portion of the toes. Wounds are malodorous (foul smell)." "The patient has a history of some right-sided weakness due to a traumatic brain injury that occurred 19 years ago. The patient uses a walker." A review of the History and Physical dated 2/16/18 for Patient 5 revealed, "Patient with hx (history) of frostbite with necrosis of hands and feet with increased odor of feet. Patient denies fever or chills, no frank drainage, no pain, has numb feet, still with pain in hands. Came to and was admitted for concern of infection. MRI ( Magnetic Resonance Imaging- a special scan to picture the internal body structures.) was done and results are pending."

This is the 2nd inpatient hospital stay for Patient 5, the patient had been hospitalized 1/23/18-2/12/18 for Rehabilitation following the initial frostbite incident. Patient 5 had been sent home 2/12/18 to do own dressing changes, there had been services in place (home health, bath aid, physical therapy, occupational therapy and a registered nurse to follow up), although these services did not start because the patient did not keep an appointment for establishment of a primary care physician that was scheduled for the patient 2 days after discharge by the hospital.

Review of the discharge plans for Patient 5 for the 2/16/18-2/19/18 stay revealed:
-On 2/17/18 at 5:51 PM Interdisciplinary Care Rounds with 1 nurse (the patients nurse for that shift) present identified the Discharge Needs: home; Anticipated Discharge Date: unknown.
-On 2/18/18 at 11:31 AM Interdisciplinary Care Rounds with 1 nurse (the patients nurse for that shift) present identified the Discharge Needs: home; Anticipated Discharge Date: possibly Monday. LACE score: 10 (LACE index identifies patients that are at risk for readmission or death within 30 days of discharge. The scores range from 1-19, a score of 0-4=Low risk; 5-9=Moderate risk; and a score of 10 or greater=High risk of readmission or death.)
-On 2/19/18 at 10:35 AM Interdisciplinary Care Rounds with 2 nurses (the pt's nurse for that shift and the charge nurse) present identified the Discharge Needs: left BLANK; Anticipated Discharge Date: unknown; LACE score 10.
-On 2/19/18 at 4:06 PM a Discharge Plan note made by a Case Manager RN (CM RN G) "Received call from bedside nurse stating that Patient has been discharged and needs a ride home. Informed (nurse) that I can give Patient a bus pass. Checked w/ (with) Metro Transit and the closest they can get Patient is (address) - which Patient would have 6 blocks to walk. Spoke w/ bedside nurse and informed of this. (Nurse) stated that Patient is not able to walk that far and asked about getting the Patient a cab. Informed (Nurse) that (gender) would need to speak w/ OD (officer of day) regarding that, or Patient can pay for it or find a ride home. Received call from nurse manager for unit, asking about calling cab and if they would be able to tell her what it would cost. Informed that the only cab company was Happy Cab. The nurse had the number. No other assistance needed."

Review of the discharge instructions dated 2/19/18 3:58 PM revealed, two follow up appointments; instructions to schedule an appointment as soon as possible at a clinic; Apply aloe vera topical get twice daily to sites of dermal injury, bacitracin ointment topically once daily for 10 days in morning, and home medications.

An interview with the Manager of the Social Workers (SW B) on 4/12/18 at 2:10 PM revealed after reviewing Patient 5's 2/16/18-2/19/18 hospital stay:
-The patient was admitted on Friday 2/16/18 at 2:58 PM and dismissed on Monday 2/19/18 at 4:15 PM.
-There is not a social worker or case manager at the facility over the weekend and that Monday the case manager for the area that this patient was on was not in so the other case managers were trying to help as needed. But, there is a social worker/case manager on call over the weekend.
-Upon review of the record, SW B verified that there were no additional case manager/social worker notes and that no one was called regarding this case over the weekend. SW B verified that a LACE score of 10 does usually indicate a formalized discharge plan and discharge services would be expected. Also informed SW B that this patient was discharged from this facility on 2/12/18 and was readmitted on 2/16/18, when asked if this would have also indicated a formalized discharge plan and discharge services would be expected, SW B stated, "Yes".

The medical record lacked a note that indicated what mode of transportation for Patient 5 was arranged to assist Patient 5 to successfully arrive home.

Review of the Care Management Discharge Planning Policy and Procedure (originated 8/1984 and last revised 4/2018) revealed:
-Implementation of the Discharge Plan. 1) Identify the appropriate mode of transportation. a) The nurse or Care Manager will collaborate with the patient, family/support system to arrange appropriate transportation.

Review of a Readmission record for Patient 5 from a different hospital revealed that Patient 5 was admitted on 2/24/18 for gangrene (dead tissue) of foot and required debridement/amputation of multiple digits (fingers and toes) with reconstructive surgery as a result of the frostbite.

Based on record review and staff interview the facility failed to provide education to the patient and family for safe transfers for 1 (Patient 2) of 10 sampled patients. This finding has the potential to cause the patient to have a fall or accident causing harm when discharged to the home setting. The facility census was 178.

Findings are:

A. Record review of the facility policy titled "Care Management Discharge Planning" (last revised 4/2018) states "Discharge Planning is considered an integral part of comprehensive health care for patients. It is a interdisciplinary process through which the Case Management staff and/or other members of the health care team, ensure the appropriate and timely plans are made for post hospital care and sustained post discharge."

B. An review of Patient's 2 electronic Medical Record on 4/11/18 revealed the patient was admitted to the acute hospital emergently from a stay in the hospital's inpatient rehabilitation unit on 2/25/18. The discharge summary from the inpatient rehabilitation stay (dated 2/26/18) notes the patient was admitted to rehabilitation unit post bilateral Below the Knee Amputation (BKA). The patient had a previous left BKA and used a prosthesis on that leg. The right BKA was done at another hospital on 2/4/18. The patient developed dyspnea during his rehabilitation stay and required transfer and readmission to the acute hospital ICU on 2/25/18. Diagnosis included acute respiratory failure with hypoxia, congestive heart failure, obstructive sleep apnea, diabetes, chronic kidney failure Stage III, peripheral vascular disease. The patient was alert and oriented and was their own responsible party.

The nursing assessment on admission (2/25/18 at 6:26 AM) noted the patient was 1-2 assist for transfer with a slide board. The right BKA requires wound care with ACE (compression) wrap. The nursing admission assessment includes discharge planning screening questions. The nurse documented the patient lives with the spouse in a private residence and does not have previous in home services. The patient is noted as having a history of left BKA with a prostheses.

C. Staff interview (4/12/18 at 12:15 PM) with Registered Nurse (RN) "B" revealed RN B discharged Patient 2 on 3/2/18. RN B stated the patient could stand, turn and pivot with 1 staff assist and use of gait belt an walker with the prosthetic left leg. The patient required assist to the bathroom to get up and down. The nurse recalled assisting the patient to the bathroom and having to assist the patient to get the pants up and down. RN B recalled asking the patient how he/she was going to do this at home. The patient told RN B that they would "rise to the occasion." The patient also said that if the spouse was there that he/she would help. The patient did not say if the spouse was home to help or worked outside the home. The patient told RN B they had 16 steps to the apartment and when asked by the nurse how the patient planned to go to follow up appointments the patient said he/she "would not be, once home no plans to go anywhere." The nurse stated he/she "did not feel patient was safe going home that day. At Interdisciplinary Care Rounds on 3/2/18, the patient was noted as having refused rehab, refused SNF, and non compliant with a lot of cares. The staff made the patient aware they did not feel it was safe to go home and let SW A know this. The nurse stated that the patient/wife was not educated on how to safely assist with transfers.

D. Staff interview with RN "C", a Clinical Nurse Specialist, on 4/12/18 at 11:45 AM confirmed upon review of PT/OT notes and conversation with PT/OT staff that the patient and family were not provided education on safe transfers during the acute care stay.