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UF HEALTH SHANDS HOSPITAL 1600 SW ARCHER RD GAINESVILLE, FL 32610 Nov. 20, 2019
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to honor patients' rights in the implementation of the discharge plan of care for 1 of 3 sampled patients. Patient # 6.

Findings:
Review of the initial discharge assessment completed by Staff P, a Registered Nurse Case Manager (RNCM) on 10/20/2019. Note read: CM( Case Manager) assumed care today. Wound care consulted for pressure injury. Patient receiving IV( Intravenous) antibiotic. Foley catheter in place. Unable to independently complete activities of daily living (ADL) and family has difficulty meeting his needs. Placement may be needed upon discharge. CM will review with patients' wife. Community resource information provided. Patient resides with spouse. After discharge place is undetermined currently. Patient is alert and oriented. Patient has capacity for decision making - respond was NO. Patient has capacity for self-care- NO. Patient requires maximum assist with ADL. Contact person for discharge are wife and son.
Admission nurses' assessment dated [DATE] revealed an orientation level x 3 to name, place and time, disoriented to situation. Cognition level was appropriate attention and concentration, follows command, and is cooperative.

During an interview on 11/19/2019 at 9:24 AM, with Staff L, Case Manager (CM)/ RN at the facility. The CM stated that she was on orientation during the incident. CM stated she had no prior conversation with family members. CM stated; "I was notified by the attending physician that he is ready for discharge today 10/29/2019". "I looked at the prior CM assessment and the placement. The family had chosen that particular place, I do not remember the name of the facility". "I called the facility to see that there was a bed available and notified the discharge facilitator to arrange for transport". "I provided the bedside RN of the discharge packet that consist of the time of the pick-up". At this time, CM stated she has not notified anyone else, no family members were notified. "I reviewed the hospital discharge process after the fact and aware that notification of family members is part of the discharge process".
Staff L / Case Manager stated that she met the patients' wife and his son the day after the discharge. The family stated that they were not aware of the discharge.

During an interview on 11/20/2019 at 10:11 AM, with the CM that she did not had any communication with the patient and or family members on the day of discharge. The CM completed the discharge communications electronically and communicated to the floor nurse.

During an interview on on 11/19/2019 at 10:20 AM, with the Accreditation Manager (AM)stated she was familiar with the incident. The Accreditation Manager stated that the family came in to visit the patient and was upset when they found the patient was not in his room.

During an interview on 11/19/2019 at 11:08 AM, with the Director of Quality who confirmed that the family members of Patient # 6 were not notified of the discharge to the nursing home. Director of Quality stated; " We owned that one".

Final discharge nurses; notes dated 10/29/2019 at 13:48 read: Patient discharged off unit by Life Care transport / stretcher. Discharge packet given to transporter. IV removed. Patient had hearing aid and glasses in possession. No signs and symptoms of [DIAGNOSES REDACTED]
Physician's discharge summary dated 10/29/2019 with diagnoses acute metabolic [DIAGNOSES REDACTED] due to delirium, possible dementia resolved.

Review of the facility's policy titled" Discharge Policy" Category: General Administrative.
Page 5 of 5 of the policy under discharge read:
2. Discharge planning and coordination is the primary responsibility of the patients' Registered Nurse. The RN collaborates with the patients' physician, social worker, pharmacist, dietitian, case manager and other providers, as necessary to meet the patients' post hospitalization care needs.
3. Patients and their families should receive teaching / specialized instructions for post hospital self-care / patient care.
Facility policy requires to get a verbal approval from responsible party prior to transfers. To hold discharge until family is verbally contacted and verbalizes understanding and approval.