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Based on review of medical records and hospital documents and interviews with staff, the hospital failed to ensure arrangement of needed post-hospital services, care and education was provided. This occurred in two of eight medical records (Records #2 and 3) reviewed.

Findings:

1. Patient #1 - the patient had multiple and complex wounds. Documents reviewed did not contain evidence the patient and or family member had been educated and was able and willing to provide the care for the patient. Other that than the physician's reference that the patient's sister would provide aftercare, the medical record did not contain any evidence of communication with family members or family visitation or teaching. The medical record contained documentation that Patient #1 was non-compliant with care and instructions: removing her wound dressings and placing her ungloved hands in the wound beds; pulling out her Foley Catheter twice; and refusing to bathe and allow activities of daily living to be performed.

2. Patient #3 was admitted to the hospital using oxygen by nasal cannula at 5 liters per minute. The patient was also treated at the hospital with oxygen by nasal cannula, bi-pap for sleep and regular respiratory therapy treatments. The physician ordered a sleep study to be scheduled for the patient post-discharge.

An advanced registered nurse practitioner documented shortly before the day of discharge that the patient would need continued respiratory support.

The patient's closed medical record was reviewed. There was no documentation of evaluation of the patient's at-home respiratory support needs. There was no documentation a sleep study was scheduled.

On the day of discharge, a registered nurse documented, "...Discussed use of O2 [oxygen] @ home. Pt. states she has tank and will use it if she needs it..." There was no other documentation of the hospital discharge planning activities in the medical record.

On 03/19/13, discharge planning staff (staff D) stated some of the discharge planning work was not documented or was in notes in the discharge planning office and not included in the medical record.

Based on review of medical records and hospital documents, and interviews with hospital staff, the hospital failed to reassess the patient's discharge plan when needed. This occurred in two of eight medical records (Records #2 and 3) reviewed.

Findings:

1. Patient #1 - The patient had a revision of the amputation of the left lower extremity "high" above the knee at another facility on 08/05/12. The patient was admitted with Stage II and Stage III pressure ulcers to buttocks, sacral and bilateral thighs, in addition to the nonhealing wound of the amputation. Admission diagnosis included morbid obesity, generalized debility, COPD (chronic obstructive pulmonary disease), peripheral artery disease, and history of Guillain Barre syndrome.

The initial discharge plan on 09/14/13 and the review on 09/17/13, documented the patient's disposition as home with family. The review on 09/17/13 recorded the "patient/caregiver able to learn care. No further update was performed. This was confirmed with Staff D and E on 03/19/13.
a. According to medical record review, the family did not visit the patient while Patient #1 was in the hospital, so teaching of wound care, or precautions was provided or ensured.
b. Multiple staff, physical therapy and nursing, documented Patient #1 was non-compliant with wound care precautions and nursing instructions; pulled off wound dressings; pulled out her Foley catheters; and found with ungloved hands in the wound beds.

The physician documented in his discharge summary that the Patient #1 was to be discharged home to family with a wound care appointment at another facility. Nursing notes reflected the patient was not released to family, but was taken (destination not documented) by a transportation company. The hospital did not provide a revision to the discharge plan when the patient had shown inability to care for self and family had not demonstrated ability or willingness to provide appropriate care.


2. Patient #3 was admitted on 02/22/13. There was no documentation of initial discharge planning on the pre-admission evaluation form as directed in the hospital's discharge planning policy and procedure.

The patient's clinical record documented the first evidence on discharge planning was done on 03/04/13, ten days after admission. The record documented, "... Discussed POC [plan of care] & DC [discharge] plan with patient. He agrees [with] POC and DC Plan. There was no detailed documentation of what discharge plan of care was discussed with the patient.

No other documentation of discharge planning was found in the clinical record.