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Based on interview and record review, the facility failed to arrange referral of 1 of 30 sampled patient (Patient 1) for outpatient admission to General Acute Care Hospital (GACH 2) for higher level of care, prior to discharge as per physician's order.

This deficient practice resulted to the delay of referral and care of Patient 1 to an appropriate outpatient service provider at the time of discharge.

Findings:

During a record review of Patient 1's electronic medical record (EMR) and interview with the Care Management Director (CMD) on 7/9/2024 at 2:45 p.m., the DCM stated that patient 1 had a discharge order with a condition that she will be referred for outpatient admission to General Acute Care Hospital (GACH 2) prior to discharge. The case manager on-call was not made aware of the order therefore the referral was not arranged at time of discharge. Patient 1 was discharged home on 7/9/2024 at 9:05 p.m. The discharge order was written afterhours and case manager on-call rely on nursing or provider communication of any case management need.

During a record review of Patient 1's electronic medical record (EMR) and interview with the Vice President of Regulatory Affairs (VPRA) on 7/9/2024 at 3:00 p.m., the VPRA stated that the nurse should have clarified Patient 1's discharge order with the provider.

During a record review of Patient 1's electronic medical record (EMR) and interview with the Vice President of Nursing operation (VPNO) on 7/9/2024 at 3:23 p.m., the VPNO stated that part of the discharge order was for case management to arrange outpatient admission to GACH 2. Expectation from the discharge nurse is to reach out to case management for any patient referral needs. The discharge order was written after hours, and the facility do have after hours case manager on call. For order clarification, nurse should reach out to the provider who wrote the order. There was a point of clarification to the written order, but the discharge nurse thought that the arrangement for outpatient admission to GACH 2 was already completed by case management. The patient was discharged home on 3/21/2024 at 9:05 p.m.

During a record review of Patient 1's electronic medical record (EMR) and interview with the Care Management Director (CMD) on 7/9/2024 at 4:00 p.m., the CMD stated that the discharge order indicated "Discharge pending arrangement for outpatient admission to [GACH 2] GI (Gastro-Intestinal) higher level of care." This part of the discharge order was for case management to make every effort to arrange Patient 1's referral to outpatient admission to GACH 2. If case management was unable to meet such orders, case management must follow up with the provider.

During a record review of Patient 1's electronic medical record (EMR) and interview with the Care Manager (CM) on 7/10/2024 at 10:38 a.m., the CM stated that her initial conversation with the provider on 3/21/2024 at 4:15 p.m. was to discharge patient home with plan for outpatient follow up. It was not a confirmed plan, there was no official discharge order at that time. Official discharge order was written on 3/21/2024 at 6:23 p.m., the order indicated discharge pending arrangement for outpatient admission to GACH 2. This was a conditional order that meant prior to discharging Patient 1, case management needs to arrange outpatient admission to GACH 2. This order was something case management will be able to do or at least make effort to initiate the referral to GACH 2.

During a review of the facility's policy and procedure (P&P) titled, "Discharge Planning" last revised March 2021, the P&P indicated the following:

1. Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient's identified post-discharge needs.

2. [Name of Facility] have established a policy and procedure to address the discharge planning process of patients who it determines would be at risk for adverse health consequences post-discharge without adequate discharge planning through assessment by nursing and physician.

3. The discharge planning process will include notification to the patient, family, and/or caregiver of the patient's continuing health care needs posthospitalization and provide the patient, family and/or caregiver the opportunity to participate and ask questions during the discharge planning process.