HospitalInspections.org

Based on record review, interviews, and review of the policy "Inpatient Assessment and Discharge Planning Evaluation", Case Management hospital staff failed to ensure a list of IRFs (Inpatient Rehab Facilities) and SNFs (Skilled Nursing Facilities) had been documented as provided to Patient #11 (1 of 20 patients reviewed for discharge planning) prior to discharge to ensure patient/family preferences had been taken into account.

The findings included:

Review on 10/30/24 at 1:00PM with Social Worker (SW) #1 of scanned in documents in Patient #11's medical record revealed the choice form for SNF (Skilled Nursing Facilities) and STR (Short Term Rehab) had been printed on 7/17/24 at 5:29PM; which was after the patient had been discharged. There had been no other Choice Form documented in the patient's medical record. The choice form included the SNFs Bethea Retirement Community, Morrell Nursing and Rehab, and Florence Presbyterian Community of SC (South Carolina) with the CMS (Centers for Medicare and Medicaid Services) star ratings listed. The bottom of the form included information "Optional: By signing this document I recognize I was presented with choice of a post-acute care provider. SW #1 had signed the form and above Patient #11's typed name was handwritten the patient's name with "verbal consent", under the handwritten name. The form had been dated for 7/17/24. During an interview on 10/30/24 at 1:05PM, SW#1 reviewed his/her case management notes and the Choice Form s/he had documented for Patient #11 and verified it had been printed/signed indicating Patient #11's verbal consent after the patient's discharge on 7/17/24. According to SW #1, s/he had provided the choice form to the patient the day of discharge, with the patient giving verbal consent. S/he stated s/he had written verbal consent given as this had been done previously due to the Covid precautions. S/he has since received education that this is not acceptable; that if the patient were alert and oriented, they would need to sign or have 2 witnesses signing the patient had given his/her verbal consent. During an interview on 10/30/24 at 3:04PM, Registered Nurse (RN) Case Manager #1 stated s/he originally talked to Patient #11 and the patient's daughter about Morrell SNF and Encompass IPR (Inpatient Rehab). When asked about the choice form process s/he stated that they usually give patients a list of options. S/he believed they had given the patient the 2 choices. S/he believed s/he uploaded the choice form with a verbal signature. RN Case Manager stated they had two chooses with more options. The daughters had visited Morrell SNF and decided they did not want that SNF. RN Case Manager #1 stated it was late when s/he spoke to the family, and s/he might not have scanned in the choice form.

Review on 11/6/24 at 2:32PM of the Case Management policy that was in effect during Patient #11's hospitalization in July 2024 entitled, "Inpatient Assessment and Discharge Planning Evaluation", last revised 7/2023, revealed the purpose of the policy was " ...To provide a means of assessing admissions for discharge planning needs in order to develop a proactive discharge plan that accommodates the patient's needs and facilitates the flow of the patient through the continuum of care ... The initial assessment also identifies those who may be at high risk of requiring post-hospital services. For these patients, discharge plans are aimed at ensuring the patient has the appropriate care after leaving the hospital setting. 2. Social Determinants of Health Assessment- The Case Management team completes this assessment as part of their initial inpatient assessment. This assessment helps identify high risk patients for discharge planning interventions and community referral needs. 3. Ongoing Assessment - The Case Management team will re-evaluate discharge plans during multidisciplinary rounds to ensure the plan continues to meet discharge needs of the patient. Needed updates will occur at a minimum when the patient moves from one level of care to another, one unit location to another within the same level of care or after the patient undergoes a surgical intervention. When post-acute service needs are identified using any of the above assessments, the Case Management Department assures that the patient's right to involvement in his or her care is honored by offering patient choice where more than one option exists."