HospitalInspections.org

Based on policy review, closed medical record review and staff interviews, the facility failed to reassess the patient's need for outpatient physical therapy as recommended prior to discharge for 1 of 4 sampled patients (#4).

The findings include:

Review of the "Discharge Planning Services" policy revised September 2012 revealed "Purpose: To evaluate the need for discharge services specifically aligned with individual patient needs. To provide continuity of care for inpatients upon discharge through the utilization of other community resources when an acute level of care is no longer needed. ... If the patient is able to return home, the Case Manager will assist in obtaining necessary services or equipment as ordered. ..."

Closed medical record review of Patient #4 revealed a 55 year-old female that was admitted through the emergency department on 08/28/2014 for chest pain and non-ketotic hyperglycemia. Review of the record revealed a physician's order dated 08/28/2014 at 0936 for physical therapy to evaluate and treat. Review of the record revealed a physical therapist evaluated the patient on 08/28/2014 at 1310 and recommended the patient to be discharged with outpatient physical therapy services. Review revealed the physical therapy note was documented on 08/28/2014 at 1522. Review of Discharge Planning notes revealed the patient was discharged home with no arrangement for outpatient physical therapy. Review of the notes revealed the patient had a walker and wheelchair prior to admission and was discharged with the same. Discharge instructions included follow up appointments with the patient's physicians and education related medications and dietary needs.

Interview on 10/09/2014 at 1110 with PT #4 revealed she was the physical therapist that evaluated Patient #4 on 08/28/2014. The staff member stated she remembered the patient and stated that the patient already had a walker that she came to the hospital with and that she had done well walking short distances. The staff member stated that the patient needed "stand by assistance" when walking. PT #1 stated the patient was cognitively intact and she lived at home with her husband. Interview revealed the staff member recommended discharging the patient home with outpatient physical therapy for strengthening, fall prevention and evaluation of the home for safety. The physical therapist stated that the Case Manager was responsible for arranging the outpatient physical therapy prior to discharge. Interview revealed the patient was evaluated at 1310 and her note was documented at 1522. Interview confirmed the patient discharged (left the hospital) at 1426.

Interview on 10/09/2014 at 1120 with RN #5 revealed she was the case manager that was involved with Patient #4 on 08/28/2014 and she remembered the patient. Interview revealed the case manager was not aware of the recommendation from physical therapy for outpatient physical therapy after discharge. The staff member stated if she had known about the outpatient physical therapy need she would have talked with the physician to get an order. Interview revealed she would have talked with the family and provided a choice of services and made arrangements for the physical therapy. The nurse stated "I did not know physical therapy was recommended. There were no notes written at the time of discharge." Interview confirmed there was a failure to coordinate recommended services for the patient upon discharge.