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Based on interview, review of medical records and review of hospital documents, it was determined that the hospital failed to provide a discharge planning evaluation which included an evaluation of the likelihood of the patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital for Patient #1. The hospital's failure to do so potentially contributed to the re-admission of Patient #1 to the hospital, and potentially placed all patients who were discharged to home at risk for negative health outcomes.


Findings include:

Review of the "Medical Social Work Scope of Practice", #16731, showed under "Scope of Services", that the Medical Social Workers (MSWs) were available to assess, refer, and consult regarding certain patient populations. The scope stated that the MSWs could assist with...the discharge planning of discharge for those patient populations included in the list.

-On May 17, 2017 at 1:00 pm, Staff #4, the Manager of Case Management (Discharge Planning), stated that the MSWs received orders for discharge from the patient's provider on the days of discharge.

-On May 24, 2017 at 11:05 am, the Manager stated that the MSWs attended daily multi-disciplinary rounds, during which time patients' post-discharge needs were discussed among the disciplines who participated in the rounds. The Manager was asked how the input from other disciplines who attended rounds was captured and incorporated into the discharge plan.

-During the May 24, 2017 interview at 11:05 am the Manager was asked if there was a defined, written process for how rounds were conducted, and how the input from various disciplines was incorporated into the discharge planning evaluation.

-On May 24, 2017, at 1:15 a.m, the Manager stated that physicians wrote orders for the patients to be discharged with home health services, but the orders did not include which post-discharge disciplines, such as nursing or physical therapy, were necessary for the patient, what services were to be performed, or the frequency or duration of that care. The Manager stated "social work decides".

-The medical record for Patient #1 was reviewed with the Manager of Case Management and Staff #5, the Director of Quality Management. Documentation did not include an assessment of the ability of Patient #1 to function at home, including managing her newly-ordered oxygen, for the week and a half until home health services could assess the patient and begin care. No documentation was found that the family's availability and ability to provide care had been evaluated.

-Review of the discharge planning notes did not include documented input from nursing, physical therapy or respiratory therapy relative to the patient's abilities for self-care post-discharge.

-On 03/03/17, 5 days after her initial discharge, Patient #1 was readmitted to the Emergency Department with a diagnosis of "acute hypercarbic respiratory failure - secondary to COPD and O2 [oxygen] at 4 LNC". The admitting physician documented that the patient had "...been using oxygen at 4 L for the past several days...". The patient's discharge instructions noted that the oxygen was supposed to have been set at 2 liters per nasal cannula (LNC).

Based on interview and review of medical records, it was determined that the hospital failed to assure the initial implementation of the discharge plan for Patient #1. The hospital's failure to do so potentially contributed to the patient's negative health outcome and readmission to the hospital, and placed other patients at risk for negative health outcomes.

Ref. citation written under Tag 0806

Findings include:

-In an email dated March 21, 2017, the complainant stated that the family of Patient #1 had not been able to provide care for the patient at home, but they had been told the patient could not be left alone at night. The patient's spouse worked in a different part of the State, and the patient's daughter had her own family responsibilities. The complainant stated that the patient's family was "...unable to meet her [the patient's] needs for overnight care..."

-The medical record for Patient #1 was reviewed with Staff #4, the Manager of Case Management and Staff #5, the Director of Quality Management. Review of the medical record for Patient #1 showed MSW documentation beginning on 02/19/17, and ending with a discharge note on 2/28/17. Documentation on 2/28 showed that the home health services would not be able to see the patient "...until on or after 03/07/17. MD, pt. and pt. husband all updated and agreeable to to this start date..." The patient was readmitted to the hospital before home health services evaluated the patient.

-Documentation in the medical record did not include an assessment of the patient's ability to function at home, including managing her newly-ordered oxygen, for the week and a half until home health services could assess the patient and begin care. No documentation was found that addressed the family's availability to provide necessary care.

-Review of the medical record showed that, 03/03/17, the Patient was readmitted to the hospital with a diagnosis of "acute hypercarbic [abnormally elevated levels of carbon dioxide in the blood] respiratory failure - secondary to COPD and O2 [oxygen] at 4 LNC". The admitting physician documented that the patient had "...been using oxygen at 4 L for the past several days...". The patient's discharge instructions noted that the oxygen was supposed to have been set at 2 liters per nasal cannula (LNC).

-An email dated 03/03/17, written by a hospital MSW, stated that the patient had been readmitted after discharge on 02/28/17. The MSW documented that "...there was some issues with the pt's home O2 post discharge..." A supplier went to the patient's home to set up the patient's oxygen equipment, but the oxygen was not delivered. "...awaiting the pt's oxygen delivery which never arrived. Upon further exploration, it was determined that the DME supplier had not received the referral from SVH...pt. and spouse state that the home health service "...has not yet opened for services and that they have not received a call to setup a time for intake."

Based on interview and review of hospital documents, it was determined that the hospital failed to develop and implement a plan to reassess the discharge planning process on an on-going basis. The hospital's failure to do so potentially contributed to the lack of a complete and accurately implemented discharge plan for Patient #1 and may have contributed to the same for other patients.

Findings include:

On 05/24/17, the hospital was provided with a written request for documentation. One requested item was for documentation that described how the hospital reassessed the discharge planning process.

-During interview on 05/24/17, at 11:40 am, Staff #4, the Manager of Case Management (Discharge Planning) was asked to describe the process the hospital used to evaluate the discharge planning process. The Manager was unable to identify a document that described how the hospital reassessed discharge planning, or to describe the process by which the hospital reassessed discharge planning.

-The hospital-wide Quality Assurance/Process Improvement (QAPI) plan was reviewed with the Director of Quality, who confirmed that there were no references to discharge planning in the hospital-wide QAPI plan.

-The department-specific QAPI plan, dated 1/2016 - 12/20/16, for Case Management/Utilization Review was reviewed with Staff #5, the Director of Case Management. The Director confirmed that the QAPI plan did not contain mention of discharge planning other than an identified quality issue of "coordination of care and discharge process".

-On 05/24/17, the department-specific QAPI plan was discussed with Staff #1, the Director of Quality Management. The Director stated that she was familiar with the plan and acknowledged that the plan had one stated goal, which was "decrease readmits 5%".