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Based on a review of medical records, facility's policies and procedures, and staff interviews, it was determined that the facility failed to provide a discharge planning evaluation in a timely basis for one patient (P) (P#1) of five patients (P#1, P#2, P#3, P#4, and P#5) reviewed to ensure the appropriate arrangements for post-discharge care before discharging P#1.


Findings included:


A review of medical records revealed that P#1 was admitted to the facility on 5/10/25 at 1:20 p.m. P#1 arrived via the facility's emergency department (ED) on 5/10/25.


A review of the documentation under the Patient Summary Report (Triage) on 5/10/25 at 11:01 a.m. revealed that P#1 was unkept and the odor of unbathed patient with stool and urine was all over him. Documentation revealed that P#1's clothes were saturated, and he had bloody stool and urine all over him and his clothes; his entire buttock was red and bleeding, the scrotal area was red and bleeding, and sores were noted to his arms, legs, and feet.


A review of P#1's medical record failed to reveal discharge planning evaluation documentation on admission. Initial discharge planning evaluation documentation was completed on 5/15/25, five days after P#1's admission.


A review of the Case Management documentation on 5/15/25 at 11:54 a.m. revealed that options for rehabilitation after discharge were discussed with P#1 and P#1's family member; however, P#1 was uninsured, and options were very limited. Documentation revealed that P#1's family member requested if P#1 could return to the hospital for outpatient therapy until coverage was available, and the social worker provided P#1's family member with an indigent (outpatient) packet to be completed and returned to the hospital's business office so a decision on coverage could be determined in a timely manner.


A review of the Case Management notes on 5/16/25 at 4:01 p.m. revealed that P#1's family member stated that she could not take P#1 home because he (P#1) was too much to handle in his condition. Documentation revealed that P#1's family member stated that P#1 needed to go to a skilled nursing facility (SNF) upon discharge.


A review of Doctor of Osteopathy (DO) FF's progress notes on 5/18/25 at 8:29 p.m. revealed that there was a meeting a day prior where P#1's family member agreed to the plan of P#1 going home with home health; however, P#1's family member was reluctant to go home.


P#1 was discharged home with self-care on 5/19/25 at 2:40 p.m.


A review of the facility's policy titled "Patient Rights," last reviewed 6/2024, revealed that the patient had the right to available, medically necessary treatment and accommodations without regard to race, ethnicity, national origin, religion, sex, age, current or anticipated mental or physical disability, sexual orientation, genetic information, or ability to pay.
The patient had the right to expect that, within its capacity, the hospital would make a reasonable response to the patient's request for services. The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case.


A review of the facility's policy titled "Discharge Planning Assessment," last reviewed 6/2024, revealed that each patient's needs for continuing care were assessed in an ongoing fashion by all members of the healthcare team. The discharge planning may begin prior to admission, but in no event later than at the time of the admission nursing assessment. The discharge planning function focused on meeting the patient's continuing healthcare needs after discharge. The purpose of discharge planning was to identify a patient's unique needs for continuing physical, emotional, housekeeping, transportation, social, and other needs and to arrange services to meet those needs.
As appropriate, discharge planning activities were integrated into the patient's Plan of Care.


A review of the facility's policy titled "Discharge of the Patient," last reviewed 2/2023, revealed that the facility required a discharge order from the patient's discharging physician to discharge an inpatient from the facility. The patient remained the responsibility of the facility until he/she left the hospital grounds.


An interview took place in the facility's conference room on 6/16/25 at 3:30 p.m. with Director, Case Management (DCM) AA, who stated that not all patients were seen by case managers on admission. DCM AA stated that discharge planning had to be requested by the patient, patient's family, physician, or the nursing team, especially if there was a trigger during the nursing assessment on admission.


An interview took place in the facility's conference room on 6/17/25 at 10:00 a.m. with Social Worker (SW) BB, who stated that during the discharge, P#1's family member had stated that she could not take care of P#1 at home, that it would be too much for her. SW BB stated she reached out to her superiors, and they concluded to refer P#1 to the Paramedicine program, which she (SW BB) also shared with P#1's family.
SW BB stated that P#1's family member had stated that one of P#1's children would also come to help out at home, but one of the children was annoyed that the facility was sending P#1 home without insurance, and P#1's family member had mentioned that they would just end up back in the emergency room.
SW BB also stated that the facility's indigent (outpatient) program was a process, but she did not know how long the process was, and not all patients qualify. SW BB further stated that the first trigger for P#1 on admission was that he did not have insurance, but she (SW BB) probably did not document it, which explained why her (SW BB) first documentation was five days after P#1 was admitted to the facility.


An interview took place in the facility's conference room on 6/17/25 at 10:40 a.m. with Paramedic (PM) DD, who stated that when he reviewed P#1's chart, he realized that P#1 did not qualify for the paramedicine program, and he (PM DD) did not assist patients with ADLs (activities of daily living). PM DD clarified that the paramedicine program was only for patients who had frequent readmissions (three or more within a month), and P#1 did not meet the criteria.


A telephone interview occurred in the facility's conference room on 6/17/25 at 11:00 a.m. with Registered Nurse (RN) EE, who stated that she was told in the report by the EMS (Emergency Medical Services) that P#1 lived in an unclean and hoarded house, and he (P#1) was found in his feces. RN EE stated that based on P#1's presentation on admission, there were some triggers on admission, which prompted her (RN EE) to contact the social worker, but she (RN EE) was unsure when the social worker came to see P#1.


An interview took place in the facility's conference room on 6/17/25 at 2:20 p.m. with Registered Nurse (RN) CC, who stated that she (RN CC) got the go-ahead from the physician and the social worker to discharge P#1, and he (P#1) was discharged home. RN CC further stated that she could not recall if P#1 went home with home health.