HospitalInspections.org

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Based on record review and interview, the facility failed to ensure through documentation that patient rights were protected by informing them in advance of plans to discontinue patient care for 7 of 7 patients.

Failure to do so created risk that patients may not have the necessary information to exercise their rights related to implemented discharge from the hospital including, but not limited to, appealing the discharge plan through the Office of Civil Rights in the applicable Department of Health and Human Services Regional Office.

Reference: 42 CFR 405.1205(c): requires standard patient notice with "An Important Message from Medicare" within 2 days of admission and with then a second delivery (per length of stay) not more than 2 calendar days before the patient discharge.

Findings included:

1. In review of facility policy titled, "Delivery of Important Message from Medicare from (IMFM) and Detailed Notice of Discharge form" (Revised 10/25/10) it addressed patient notification with the "Important Message from Medicare" per distribution to Patient Access (registration) staff , Care Management and Health Information Management staff. On the second page it stated that Care Management staff were responsible to deliver the second notice to patients/surrogates (no more than 2 days prior to discharge) 5 days a week and identified other hospital staff coverage after-hours and for the weekends. The procedure included initialing and dating by the patient/surrogate.

2. Review of the following medical records, for patients that had a hospital stay longer than 2 days, indicated that eligible (Medicare) patients did not receive delivery of a second notification from staff with standard information about their rights to appeal the discharge plan implemented by the hospital within 2 days of their discharge from their hospital stay.

Age Hospital Stay
Patient A 67 years old 05/03/18 to 05/07/18
Patient B 73 years old 05/02/18 to 05/06/18
Patient C 88 years old 04/26/18 to 05/08/18
Patient D 71 years old 04/22/18 to 05/03/18
Patient E 86 years old 04/30/18 to 05/08/18
Patient F 86 years old 04/28/48 to 05/03/18
Patient G 73 years old 04/30/18 to 05/05/18

3. On 01/25/19 at 2:30 PM, the System Manager of Care Management (Staff E) stated that staff only secured 1 signed IMM document for each patient and then re-used it if needed. However, it was discussed that there was no evidence in the medical records that patients that required more than one initialed and dated document had been provided with one for the required, timed information about their discharge rights.
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Item - #1 Patients Deemed High Risk by Age with Admission Screening and Care Management Evaluation Not Completed

Based on record review and interview, the facility staff failed to ensure evidence in the medical record that discharge evaluations were completed within 48 hours, or otherwise noted to be completed, so that appropriate post-hospital care could be arranged before discharge and/or to avoid unnecessary delays in discharge in 4 of 4 patients, deemed high risk by age.

Failure to do so created risk that post-hospital care would be implemented that was not adequate to meet patient needs and/or may result in patient harm.

Findings included:

1. a. In review of facility policy titled, "Discharge Planning" (#922.00; revised 11/2017) it defined the process for discharge planning for patients as including an assessment of the patient's post-discharge needs and development of plans necessary to meet those needs. It defined the unit nurses' role to screen patients for discharge needs upon admission under the "Discharge Plan Review" with seven different criteria. However, the computer system was designed to only require that the nurse obtain information on the first 2 criteria ("Patient living arrangement prior to hospitalization"and Current support systems") before automatically flagging that screening process as completed.

b. The facility policy further defined the process for discharge planning for patients as including an assessment of the patient's post-discharge needs and development of plans necessary to meet those needs. On page 3 of 10 it stated that care management staff will evaluate needs within 48 hours [of a completed screening referral].

c. 1. On page 2 of 10 it stated that "Nursing and the care management team will use high risk and evidence-based re-admission screening tools to augment their clinical knowledge and then referenced Appendix A and B.

c.2. On 01/03/19 at 11:00 AM, during an interview with the Social Worker Acute Care Supervisor (Staff A) he stated that staff at the facility did not use the Appendix B tool for patient services.

c.3. On 01/03/19 at 1:00 PM the RN Care Manager Supervisor (Staff B) stated that the care management staff did not perform screening functions for discharge planning, as was stated in the policy. She stated that only the unit nurses perform screening for discharge planning services.

d. 1. The high risk criteria outlined in Appendix A included psychosocial factors including, but not limited to, age 75 years or greater. Also, two positive screening questions indicated a need for a discharge evaluation and were described as follows: 1) Will a change in the patient's current living situation likely be required post discharge? 2) Does the patient lack significant others who can help with post-hospital care?

d. 2. On 01/25/19 at 10:00 AM, a nurse (Staff C) who completed admission assessments on patients for discharge planning needs was asked if she knew about the two specific screening questions that were asked of patients in determining their needs for care management. She stated did not know about those questions.

d. 3. On 01/25/19 at 2:45 PM, a complex care manager/social worker (Staff D) was asked if she knew abut the two specific screening questions that were asked of patients in determining their needs for care management. She stated did not know about those questions.

2. Record review indicated the following information:

-Patient C: high risk patient by age of 88 years old; 04-26-18 to 05-08-18. Admitting nurse completed partial screening on 04/26/18. A care management assessment was not completed by a social worker until 05/06/18. The patient was treated for poor lung function and was discharged with new order for home oxygen.

-Patient E: high risk patient by age of 77 years old; 04-20-18 to 05-03-18. Admitting nurse completed partial screening on 05/02/18. There was no assessment of discharge planning needs by care management staff. A RN care management note in the chart was entered on 04/27/18 but did not included evidence of a full assessment. The patient was treated for respiratory failure and was discharged to a nursing home with oxygen required.

-Patient F: high risk patient by age of 86 years old; 04/28/18 to 05/03/18. Admitting nurse completed partial screening on admission. A care management assessment was not completed by a social worker until 05/02/18. The patient was treated for an infection and discharged with new order for intravenous antibiotics.

-Patient H: high risk patient by age of 76 years old; 04/24/18 to 05/05/18. Admitting nurse completed partial screening on admission. A care management assessment was not completed by a social worker until 05/05/18. The patient was treated for a stroke and was discharged to a skilled nursing facility.

Item - #2 Patients Deemed High Risk by Homelessness with Admission Screening and Care Management Evaluation Not Completed

Based on record review and interview, the facility staff failed to ensure evidence in the medical record that discharge evaluations were completed within 48 hours, or otherwise noted, so that appropriate post-hospital care could be arranged before discharge and/or to avoid unnecessary delays in discharge in 2 of 3 patients, deemed high risk by homelessness.

Failure to do so created risk that post-hospital care would be implemented that was not adequate to meet patient needs and/or may result in patient harm.

Findings included:

1. a. In review of facility policy titled, "Discharge Planning" (#922.00; revised 11/2017) it defined the process for discharge planning for patients as including an assessment of the patient's post-discharge needs and development of plans necessary to meet those needs. It defined the nurses' role upon admission to screen patients for discharge needs under the "Discharge Plan Review" with seven different criteria. However, the computer system was designed to only require that the nurse obtain information on the first 2 criteria ("Patient living arrangement prior to hospitalization"and Current support systems") before automatically flagging that screening process as completed. Therefore, screening information about "Type of Residence" (i.e. homelessness) was not routinely included in the screening process.

2. In record review of admission screening for discharge planning needs (specifically homelessness) the following omissions were noted:

Patient I was admitted from 04/18/18 to 04/22/18 with dehydration, weakness and fatigue. She was treated with IV antibiotics and discharged on oral antibiotics. The screening admission questions for discharge planning were not completed upon admission (not since 01/28/18). The patient was homeless. Information about her homeless status and the related impact on her post-hospital needs from inpatient nursing and/or care management could not be located in the medical record. One nurse care manager note on 04/20/18 stated "No [discharge] barriers identified".

Patient J was admitted from 04/26/18 to 05/11/18 with a urinary tract infection, a wound infection, an acute kidney injury due to dehydration and other medical problems. Two of 10 screening questions per procedure were completed; the question related to homelessness was left blank. The patient was homeless. The next day a case manager noted that she was known to be homeless; subsequently a note on 05/04/18 addressed homelessness and limited community resources and referrals. An evaluation of discharge planning needs within 48 hours of admission per high risk status could not be located in the record.
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