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Based on record review, policy review and staff interview it was determined the facility failed to provide an appropriate discharge for two (#5, #8) of 10 sampled patients.

Findings included:

1. The History and Physical for Patient #5 dated 1/5/17 at 9:30 a.m. and signed by the Nurse Practitioner included documentation the patient was admitted on an involuntary basis on 1/5/17. The notes indicated the patient's past medical history included Chronic Obstructive Pulmonary Disease (COPD or emphysema) hypertension, arthritis, and diabetes type 2. The patient was a high fall risk and usually ambulated with a walker or used a wheelchair for longer distances. The Nurse Practitioner indicated Patient #5 was being treated for a mild flare up of her COPD with medications and nebulizer breathing treatments, her hypertension was being treated with medications, and her diabetes type 2 required monitoring with finger stick blood tests and oral medication.

The Psycho-Social Assessment dated 1/5/17 at 4:01 p.m. documented the patient's husband and daughter wanted Patient #5 to go home with home health care as the initial discharge plan. The note indicated further follow-up was needed to determine an appropriate level of care at discharge. The family indicated their plan was to look into Assisted Living Facility placement, but until they could make those arrangements, they wanted to try to take care of the patient at home with her husband and home health care.

The Interdisciplinary Treatment Plan Medical Problem Sheets indicated the staff had identified the following medical problems for Patient #5 at the time of her admission on 1/5/17:
COPD
Cerebrovascular Disease and Hypertension
Diabetes
Chronic back pain

The detailed review of the record failed to reveal any evidence of the reassessment of the patient's medical problems with regard to discharge planning needs.

The Physician's Orders included an order to discharge Patient #5 home dated 1/9/17 at 8:05 a.m.

The Discharge Care Plan and Home Medications form include spaces to document Behavioral Health and Medical Diagnoses at Discharge. The section for Behavioral Health Diagnoses listed Acute Delirium, Major Neurocognitive Disorder, and Alzheimer's Disorder with behavioral disturbances. The section designated for Medical Diagnoses was blank.

The section for indicating medical equipment needs was marked "N/A" (not applicable). The section labeled Self Care activities indicated the patient needed no assistance bathing, dressing, using the bathroom, stairs, cooking, housecleaning, shopping, getting to doctor's appointments, picking up prescriptions or managing bills. The review of the record failed to reveal any evidence of the manner in which Patient #5 was assessed for the ability to perform these tasks without assistance. There was no evidence of the manner in which Patient #5 was assessed to determine she did not require medical equipment. The form was signed by a bachelor's prepared Discharge Planner.

The review of the record failed to reveal any evidence a Registered Nurse or other qualified medical professional was involved in the discharge planning process or assessed Patient #5 regarding her medical conditions and potential medical needs after discharge.

There was no evidence the facility staff discussed the family's request for home health services with the patient's physician prior to her discharge.

The review of the record failed to reveal any evidence the family of Patient #5 was included in the decision making process that resulted in the final discharge plan to discharge the patient home without home health services prior to her discharge. There was no evidence the need for home health services was discussed with or offered to Patient #5 at any time prior to her discharge.

The note dated 1/9/17 at 4:30 p.m., approximately 8 hours after the physician had written the order to discharge the patient, signed by the Discharge Planner indicated the Discharge Planner received a call from Patient #5's daughter inquiring why home health services were not ordered. The Discharge Planner documented she informed the daughter the patient did not have benefits for home health care through her insurance plan.

An interview was conducted with the Discharge Planner responsible for Patient #5's discharge planning on 2/14/17 at approximately 4:00 p.m. In response to questions, the Discharge Planner confirmed she had contacted the patient's insurance plan and had been told no benefits were available for home health services. The Discharge Planner indicated she did not know, nor did she inquire, whether home health services were being requested for the patient's medical needs or her behavioral health needs. The Discharge Planner indicated she did not discuss the family's request for home health services with either the attending psychiatrist or the attending medical physician. The Discharge Planner indicated she did not inform the patient or any member of the family of the denial of insurance benefits for home health services prior to the patient's discharge. She did not inquire whether the family had any interest in making financial arrangements to cover the cost of home health services privately. She did not offer the patient or the patient's family any alternatives to home health services, or attempt to determine exactly what needs the family felt needed to be met after the patient's discharge. She confirmed the above findings.

2. The review of the physician orders dated 1/2/17 at 9:25 a.m., revealed an order for Patient #8 to restart Lovenox (a blood thinner medication) by subcutaneous injection daily. The physician orders dated 1/3/17 at 10:25 a.m., included an order for home health care to be arranged when the patient was discharged.

The social worker/discharge planner note dated 1/3/17 at 3:14 p.m., revealed a referral was made to a home health agency. The note indicated the psychiatric care Medicare payor source had no home health benefits. There was no evidence the social worker/discharge planner indicated why (medical and/or psychiatric) the patient needed home health care post discharge.

There was no evidence the physician, registered nurse or patient was notified of the denial for home care. There was no documentation of the patient and/or family being able to administer the Lovenox injection.

The Social worker/discharge planner note dated 1/4/17 at 10:48 a.m., revealed the patient was discharged home. Review of the Discharge Care Plan dated 1/4/17 at 10:41 a.m., indicated the patient was discharged on the Lovenox injection.

On 2/14/17 at 3:55 p.m., an interview was conducted with the Discharge Planner for Unit C, where the patient had been located. She confirmed, after reviewing the record, there was no documentation the physician, registered nurse or patient was notified there were no home health benefits. She confirmed there was no documentation as to why home health care was ordered. She stated she did not know who or how the injection was to be administered.