HospitalInspections.org

Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure the availability of post-discharge services in accordance with facility policy.

Findings include:

Facility policy titled, "Discharge Planning," last reviewed 02/19/25 stated, " ... All patients admitted to the inpatient rehabilitation hospital receive discharge planning evaluations and discharge planning services provided by a case manager ... Discharge planning includes case management evaluation of the availability of appropriate post-discharge care and services and the patient's access to those services ... If the patient requests a specific HHA [home health agency] ... the case manager attempts to arrange post-hospital care to meet that request. If the case manager is unable to secure the requested provider arrangement (i.e., ... the HHA cannot provide the services needed) the reason the request could not be fulfilled is explained to the patient ..."

At 10:08 AM, Staff (S)3 was interviewed in the presence of S2. S3 stated that the initial case management evaluation is conducted within 24 hours of patient arrival to the facility. Case managers (CM) discuss home health vs outpatient services for patients.S3 stated that if a patient admitted to the facility had home health services in place prior to being hospitalized, then a new doctor's order would be needed. The CM would have to contact the providing home care agency and send a referral to reinstate services. CMs are responsible for confirming services before patients are discharged.

At 11:06 AM, S1 confirmed that Patient (P)1 is currently admitted to the facility. S1 indicated there was an incident on 07/07/25, where P1 was taken via ambulance to home, but P1's spouse would not let P1 into home and he/she had to be returned to facility. P1 is currently cleared for discharge but is waiting for an accepting home health agency due to the home environment being "smokey."

Medical record review conducted in presence of S5 revealed the following:

The "Encounter Information" revealed P1 was admitted to the facility on 06/21/25 at 9:54 PM.

The "History and Physical," entered on 06/22/25 at 8:58 AM by S8, revealed the following: " ... Chief Complaint: ... admitted from [sending medical facility] after [he/she] sustained a fall and was diagnosed to have a urinary tract infection ... PAST MEDICAL HISTORY: significant for arthritis ... depression, type 2 diabetes mellitus, hypertension, dementia, macular degeneration, AAA [abdominal aortic aneurysm] [enlarged heart blood vessel], history of major depressive disorder ... anxiety, depression, dementia ... tremor plus syndrome with moving toe syndrome, and mild anemia ... PERSONAL HISTORY: Currently lives with his wife ... PHYSICAL EXAMINATION: GENERAL: The patient is alert, awake ... not in acute distress. Forgetful ..."

The "Case Management - Initial Evaluation," entered on 06/22/25 at 09:10 AM by S9, revealed the following: " ... Emergency Contact Name [Family (F)1 (P1's daughter)] ... Met with patient. Introduced self and Case Management services. Reviewed acute rehab program, team conference process, Medicare guidelines and estimated length of stay. Discussed patient's goal for rehab and discharge plan. States [he/she] lives with [his/her] wife and son in a two story home ... Provided patient with name and phone number of assigned Case Manager for contact as needed. Patient in agreement with rehab plan at this time, no questions offered."

The "Case Management Ongoing Assessment," entered on 07/02/25 at 10:46 AM by S7, revealed the following: " ...Anticipated Discharge Date 07/07/2025 ... Met with patient to review team conference report, status, goals and plan for discharge home on 7/7 with reccomendations [sic] for 24/7 assistance. Patient confirms that [he/she] has [his/her] HHA [home health aide] from the VA [veterans affairs] ... Calls placed to his wife and daughter; messages left with discharge date, 24/7 reccomendations [sic] and request for return calls to confirm the discharge plans. Will continue to follow and assist with discharge planning..."

The "Case Management Ongoing Assessment," entered on 07/03/25 at 7:02 PM by S7, revealed the following: " ... Met with patient and spoke with [his/her] daughter ... to confirm the discharge plan for Monday 7/7 with home health services. REviewed reccomendations [sic] for 24/7 assistance, [F1] reported that they are having trouble finding over night care for [P1], provided contact information for [Home Care Agency] for their consideration. Confirmed referral made to [Home Care Agency] and transport arranged with OnTime with a 11 am pick up time. Patient and daughter in agreement with [sic] plans. Voicemail message left for [his/her] wife with request for return call. Will continue to follow and assist with discharge planning ..."

The "Case Management Ongoing Assessment," entered on 07/07/25 at 10:30 AM by S7, revealed the following: " ... Call placed to [S12 (Staff at Home Care Agency)] to confirm the discharge plan for today. [S12] reported that [his/her] agency is meeting today to discuss resuming [P1's] care as [P1] is high risk, having had 9 falls in the past few months. Informed [him/her] that patient's daughter had confirmed that they had care arranged for him as of 7/3 and was in agreement with discharge plan; patient's wife has not made a return call. [S12] will discuss with [his/her] team and will call back once they have a decision ..."

The "Case Management Ongoing Assessment," entered on 07/07/25 at 6:19 PM by S7, revealed the following: " ... Alerted by nursing that patient is being returned to the facility as [his/her] wife refused to accept [him/her] back home as she does not have care arranged. Call placed to [his/her] daughter ... voice mail message left with [his/her] current status and request for return call for further discharge planning. Call placed to [his/her] wife ... who stated that she did not know that he was coming home today... Reviewed discharge plan that was discussed with her daughter on Thursday 7/3 and that her daughter was in agreement with discharge plan for today. Offered again to provide contact information for private agency, wife agreeable. Referral made to [Home Health Agency]. Will continue to follow and assist with discharge planning ..."

The "Case Management Ongoing Assessment," entered on 07/07/25 at 6:32 PM by S7, revealed the following: " ... Received voice mail message from [S12] that they are working on getting [P1]'s case staffed ... Received a message from [S13 (Staff at Home Health Agency)] that [he/she] had a 2 hour call with paitent's [sic] wife and [S13] will follow up with the wife tomorrow morning ..."

On 07/16/25 at 1:56 PM, S5 confirmed that there is no documentation in the medical record that S7 received confirmation from the home health agency that they would begin services on 07/07/25. S5 confirmed that P1 was discharged from facility without home health services established.

At 2:20 PM, above findings reviewed with S1 and S5.