HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed regarding discharge planning, the hospital failed to ensure that the plan was updated.

Findings include:

1. On 11/25/2024, the hospital's document titled, "Inpatient Case Management Discharge Planning" (8/2023) included, " ... To provide guidance to the inpatient case management staff on discharge planning ... Procedure ... III. The discharge plan will be noted in the EMR (electronic medical record) ... The discharge plan is a fluid plan and will be updated when there are changes or additions to the plan based upon the patients' needs ..."

2. On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. On 7/25/2024, Pt. #1 was discharged to (Name of Skilled Nursing Facility). There was no documentation regarding re-evaluation of Pt. #1's mode of transportation upon discharge to (Name of Skilled Facility).

3. On 11/25/2024, the multidisciplinary discharge plan meeting notes on 7/24/2024 for Pt. #1 was reviewed and indicated, " ... (Case Manager) discharge plan: Tentative Discharge Date: 7/25/2024 ... Transitional Care ... (Pt. #1) will transfer from (Name of Skilled Facility) to (Name of Transitional Home A) once they open ..." The note did not include Pt. #1's mode of transportation.

4. On 11/25/2024 at approximately 2:09 PM, and on 11/26/2024 at approximately 9:30 AM, interviews were conducted with E #3 (Social Worker). Regarding the mode of transportation, E #3 stated, "the options were to: 1) send (Pt. #1) through ambulance, but (Pt. #1) was not approved (by the insurance); 2) (Z1/Pt. #1 DCFS Foster Parent) will go with (Pt. #1), but (Z1) lives 3 hours away; and 3) (Pt. #1's) insurance will make the arrangement and our employee will go with the patient. However, the transportation arranged by the insurance was too small, and was not wheelchair accessible. So, we call an Uber that was wheelchair accessible and have a staff accompanied (Pt. #1).

5. On 11/25/2024 at approximately 10:30 AM, an interview was conducted with E #8 (Pt. #1's Advance Practice Provider). E #8 stated that Pt. #1 was appropriate for discharge on 7/25/2024. However, E #8 stated that E #8 was not aware that there was an issue with Pt. #1's mode of transportation. E #8 stated that to ensure appropriateness of discharge planning, e.g., transportation issue, E #8 expects to be contacted.

Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed for discharge planning, the hospital failed to ensure that Pt. #1's placement was discussed/approved by Pt. #1's legal guardian.

Findings include:

1. On 11/25/2024, the hospital's policy titled, "Discharge Procedures" (5/2023) included, " ... to establish standards to inform and instruct the patient and caregiver of medical care related to health needs prior to discharge, to promote safe transition of patient to home or long-term care unit ..."

2. On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. The clinical record included:

- The face sheet indicating Z1 as Pt. #1's DCFS (Department of Childrens and Family Services) foster parent, case worker, and person to notify regarding Pt. #1's care.

- On 7/16/2024 at 3:19 PM, E #3 documented, " ... Discharge Planning. (E #3) spoke with DCFS worker (Z1) about (Name of Skilled Nursing Facility) transitional care. Per (Z1), (Pt. #1) was referred in the past and (was) denied. (Z1) will investigate again and update (E #3) to submit a referral, if needed."

- On 7/22/2024 at 8:43 AM, E #3 documented, "(Name of Skilled Nursing Facility) accepted (Pt. #1). Awaiting admission date."

- On 7/23/2024 at 8:28 AM, the covering case manager documented, " ... Discussed during (Discharge Plan Meeting) plan to transfer (Pt #1) to (Name of Skilled Nursing Facility) transitional care this week ..." There was no documentation that Pt. #1's placement was discussed/approved by Z1.

3. On 11/25/2024 at approximately 2:09 PM, and on 11/26/2024 at approximately 9:30 AM, interviews were conducted with E #3 (Social Worker)." E #3 stated that there was no documentation in the clinical record to indicate that Z1 agreed with the plan to transfer Pt. #1 to (Name of Skilled Facility).

A. Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed regarding discharge planning, the hospital failed to ensure that the personnel responsible for discharge confirmed that Pt. #1's urologic, wound, and bathing supplies were authorized/provided at (Skilled Nursing Facility) prior to Pt. #1's discharge.

Findings include:

1. On 11/25/2024, the hospital's policy titled, "Inpatient Case Management Discharge Planning" (8/2023) included, " ... To provide guidance to the inpatient case management staff on discharge planning ... Procedure ... III. The discharge plan will be noted in the EMR (electronic medical record) ... The discharge plan is a fluid plan and will be updated when there are changes or additions to the plan based upon the patients' needs ... g ... medical supplies are to be provided ..."

2. On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. The clinical record included:

- On 7/23/2024 at 5:15 PM, E #2 (Case Manager) documented, " ... Presenting Problem... DME (Durable Medical Equipment), Discharge Planning ... Notified this morning that (Pt. #1) was going to transfer to (Name of Skilled Nursing Facility) on Thursday (July 25, 2024) ... Reached out to (Name of Insurance Case Worker), asking for approved DME companies that can provide (Pt. #1's) wound care and urological needs ... I completed the orders and faxed them to (Name of DME Company). Will follow-up ... I also received an email from (Pt #1's) OT (Occupational Therapist) who requested that I order a tub transfer bench and over the toilet commode ... (Name of DME Company) cannot provide the supplies. I emailed (Name of Insurance Case Worker) asking what company they use ... currently awaiting a response..."

- On 7/25/2024 at approximately 8:30 AM, E #8's (Pt. #1's Advance Practice Provider) discharge plan, instructions, and summary, indicated, " ... Discharge Diagnosis: Muscle Weakness ... Discharge to: (Name of Skilled Nursing Facility) ... DME Company ... Bath Equipment Supplier ... Neurogenic Bladder: Continue (every 4 hours clean intermittent catheterization, allowing an 8-hour break overnight from 12 AM to 8:00 AM to promote sleep hygiene) ... Sacral Pressure Injury ... Remove old dressing. Cleanse wound with Vashe Wound Cleanser by saturating 4 x 4 gauze and placing in wound bed (for) 5-10 minutes ... Apply Sureprep (type of wound dressing) ... to protect the skin. Pack Calcicare Silver dressing to wound bed ... Cut rectangular piece of Hydrofera Blue (type of wound dressing) ... Change every three days or as needed for drainage or stool soilage..."

- The clinical record lacked documentation ensuring that the personnel responsible for discharge confirmed that the urologic, wound, and bathing supplies were authorized/provided to (Skilled Nursing Facility).

3. On 11/25/2024 at approximately 9:15 AM, an interview was conducted with E #2 (Case Manager). E #2 stated that E #2 handled arrangement of Pt. #1's urological, wound, and bathing needs. E #2 stated that there should be documentation that the urological and wound supplies were provided and authorized. E #2 could not provide documentation that urological, wound, and bathing supplies were provided to Pt. #1, along with confirmation that the supplies were authorized to be delivered to the facility.

B. Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed, it was determined that the hospital failed to document that Pt. #1's legal guardian understood the discharge instructions: Pt. #1's time of discharge, mode of transportation, and condition of Pt. #1.

Findings include:

1. On 11/25/2024, the hospital's policy titled, "Discharge Procedures" (5/2023) included, " ... The purpose of this policy is to establish standards to inform and instruct the patient and caregiver of medical care related to health needs prior to discharge ... Policy... B. The nurse is responsible for the discharge process..."

2. On 11/25/2024, the hospital's document titled, "Discharge Procedure" (undated) included, " ... 6. Document the discharge in the electronic medical record to include: A. The ... legal guardian's understanding of the discharge instructions ... C. Time Discharged. D. Mode of transportation ... E. Condition of patient. F. Person to whom the patient was discharged ..."

3.On 11/25/2024, the clinical record of Pt. #1 was reviewed. On 7/11/2024, Pt. #1 was admitted to the hospital due to muscle weakness. On 7/25/2024, Pt. #1 was discharged to (Name of Skilled Nursing Facility). The clinical record lacked documentation of Pt. #1's legal guardian's understanding the discharge instructions, Pt. #1's time of discharge, mode of transportation, and condition of Pt. #1.

4. On 11/26/2024 at approximately 9:47 AM, a telephone interview was conducted with E #1 (Pt. #1's Registered Nurse on 7/25/2024). E #1 stated that there should be discharge documentation in Pt. #1's clinical record.