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Based on interview and record review, the facility failed to implement their "Discharge Planning," policy, for one of 30 sampled patients (Patient 17), when a discharge planning assessment was not done within 48 hours of admission.

This failure had the potential for Patient 17 to not receive the necessary care after discharge from the facility.

Findings:

On April 22, 2025, at 11 a.m., a review of Patient 17's medical record was conducted with the Quality and Patient Safety Specialist (QPSS). A review of the facility document titled, "History & Physical (H&P)," dated February 14, 2025, indicated Patient 17 was admitted to the Emergency Department (ED) on February 13, 2025, from a skilled nursing facility. The diagnoses included recent femur (thigh bone) fracture, Chronic Obstructive Pulmonary Disease (COPD, (COPD-a chronic lung disease causing difficulty in breathing), and lung cancer which spread to the brain. Patient 17 was admitted to the facility for a Gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement.

A facility document titled, "Physician Discharge Summary," dated March 12, 2025, indicated, Patient 17 was stable for discharge to the skilled nursing facility with outpatient close follow-up with the primary care provider, general surgery and oncology (a physician who treats cancer).

During the review of Patient 17's medical record, there was no documented evidence that a discharge planning assessment was completed within 48 hours of Patient 17's admission.

On April 22, 2025, at 2:40 p.m., an interview was conducted with the Registered Nurse Case Manager (RNCM). The RNCM stated each patient is seen for a discharge planning assessment within 48 hours of admission to determine what the needs are. The RNCM stated, if the initial discharge planning assessment was not completed, the RNCM should continue to reach out to the patient or approved person involved in the patient's care, to complete the assessment.

On April 22, at 2:50 p.m., an interview was conducted with the Director of Case Management (DCM). The DCM stated, Patient 17 had a high lace score (a tool used in healthcare to predict the likelihood of hospital readmission within 30 days after discharge) triggered on admission. The DCM stated the goal is to re-evaluate the discharge plan if the lace score is high and the Case Manager should have followed up with a discharge planning assessment per facility policy.

A review of the facility policy and procedure titled, "Discharge Planning," dated August 3, 2021, indicated, "...The Hospital will identify, as soon as or as close to time of admission as possible, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning. Discharge planning shall be initiated upon admission through the initial Nursing Admission Assessment..."