HospitalInspections.org

Based on document review and interview, staff failed to ensure complete and accurate documentation for follow through and communication for safe discharge plan for 1 of 10 MR's (Medical Record) reviewed. (Patient # 3).

Findings include:

1. Review of hospital policy titled: "Scope of Services - Case Management", policy number: Policy Stat ID 14346827, under procedures/functions on page 2, indicated, case management to document discharge plan of care, and assessment of abuse reporting; for safe discharge. Last revised 12/2023.

2. Review of Patient # 3 MR, indicated the following:
A. Patient; 85 year old, admitted to AH # 40 (Acute Care Hospital) to 4th floor - Medical unit on 2/15/2024;
with diagnosis(es) of Infected sacral decubitus, with necrotic tissue, diabetes, obesity.
B. Patient discharged to home with family and with HHC # 90 (Home health care) services on 2/22/2024.
C. Social worker note by S # 12 (Social Worker - Case Management) on 2/16/2024 at 12:38 pm, reflected S # 12 met with FM # 4 (family member) at beside to discuss DCP (discharge plan). Patient's daughters/sons live with her/him and provide care. FM # 4 stated that they have everything they need for DME (durable medical equipment). FM # 4 declined HHC (home health care) and SNF (skilled nursing facility) placement; even though it was strongly suggested since patient had very bad wounds. SW (social worker) and RN (Registered Nurse) have concerns after speaking with patient's family member, that patient may not be getting cared for properly at home. APS (Adult Protective Services) will be contacted to follow.
D. MR lacked any further documentation by Social Services - Case Management for the following:
1. Information for date/time APS contacted-report filed.
2. Any return call-contact from APS staff related to potential case; update on patient's status and discharge plan.
3. Any further call-contact to APS staff for follow through; prior to patient's discharge to home on 2/22/2024; for safe discharge home.

3. In interview on 3/19/2024 at approximately 1:20 pm, with S # 12, confirmed the following:
A. Forgot to document about patient #3 APS report filed on 2/16/2024.
B. Forgot to document call - contact with APS staff on 2/21/2024; that spoke with APS staff and that no case would be opened for patient #3.

4. In interview on 3/19/2024 at approximately 1:30 pm, with A # 2 (Manager - CM {Case Management}), A # 3 (Risk Specialist), and A # 7 (Clinical Informatics - Manager), confirmed that CM/SW notes lacked documentation for follow through with/for APS report and communication with APS prior to patient #3 discharge.