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Based upon record review and interview, the facility failed to ensure patient #1's next of kin/medical power of attorney participated in the development and implementation of the discharge plan of patient #1.

Findings Included:
Intake received by Texas Department of Health and Human Services on 3/4/22 via email, the complainant stated the facility refused "to speak to family members when patient repeatedly asked for family to be involved."

Review of facilities "Patient Rights and Responsibilities" form noted that the patient "16 .... You have the right to be involved in the development and implementation of your discharge plan. Upon your request, a friend or family member may be provided this information also."

Review of the medical record for Patient ID #1 showed Patient ID #1 had listed his brother, as next of kin, and expressed desire on the admission patient acknowledgment form for his brother to be the "representative to make healthcare decisions for you." Further review of the medical record, failed to demonstrate any case management notes which included the patient or his family representative in discharge planning discussions. No documentation was found in the medical record that patient's brother was given notification of date and time of treatment team meetings or opporutnity to participate in meetings.

Interview with Director of Case Management Staff ID # 62 on 1/11/2023 at 0945 am, she stated that she knows that Case Manager staff ID #61 and herself had engaged the patient and family in discharge planning and written notes describing their involvement, however, she stated that she and the CNO Staff ID #51 could not locate the documentation in the patient's medical record.

Interview with CNO Staff ID #51 on 1/11/23 at 10:30 am, he confirmed they were unable to locate written evidence of case management involvement with patient and family for discharge planning.

Based on interviews and record review, the hospital failed to ensure 1 patient's (Patient ID #1) discharge plan was re-evaluated and updated to reflect the patient's change in his discharge status. As a result, the patient's family wasn't notified of his impending discharge and was denied their right to participate in the development and implementation of his discharge plan of care.

Findings included:

During an interview with Director of Case Management Staff ID #62 1/11/2023 at 09:45 am, she stated that she knows that Case Manager staff ID #61 and herself had engaged the patient and family in discharge planning and written notes describing their involvement, however, she stated that she and the CNO Staff ID #51 could not locate the documentation in the patient ID #1's medical record.

Interview with CEO, Staff ID #53 on 1/11/23 at 08:30 am, she stated she personally had spoken with family regarding concerns for discharge planning prior to patient's discharge. She stated she was aware of case manager Staff ID #61 and Director of case management Staff ID #62 had worked extensively with patient and patient's brother, however she acknowledged the facility had limited documentation confirming this in the medical record. She verified that the facility had paid for patient to receive home based oxygen services for 3 months post-discharge to assist with overcoming discharge barriers.

Record review of medical record for Patient ID #1 reveals no written "case management progress notes" or entries in the patients 7 volume paper medical record. This was verified by Director of Case Management Staff ID #62 and Chief Nursing Officer Staff ID #51. Case Management Tab in medical record included the "48 hour weekly/continued stay criteria forms dated 3/1/22, 2/22/22, 2/8/22, 2/1/22, 1/25/22, 12/14/21, 11/30/21) and "Inhouse coding summary" and a 2 page "Psychosocial History" completed by case manager Staff ID #61 on 10/29/21. The only documentation related to discharge was on the "48 hour weekly/continued stay form" dated 3/1/22 11:00 am by case manager Staff ID #61 which stated "Discharge to home expected this week."