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Based on document review and interview the facility failed to make arrangements to discharge patient to appropriate facility to meet patient needs in 1 of 10 MRs (Medical Records) reviewed. (P3)


The cumulative effect of this deficient practice prevented the facility from providing a safe discharge.

Based on document review and interview, the facility failed to make arrangements to discharge patient to appropriate facility to meet patient needs in 1 of 10 MRs (Medical Records) reviewed. (P3)

Findings include:

1. Facility policy titled Patient Discharge Planning and Discharge Procedure, Policy and Procedure No. 40-02 S, under II. Purpose: To identify a coordinated discharge planning process. To identify the appropriate discharge destination that meets the needs of the patient. To provide a smooth and safe transition from the hospital to the discharge destination.

2. Review of P3 MR indicated:
a. Patient admitted to the facility on 3/3/25 at 0830 hours with diagnosis of Nausea and Vomiting, Diarrhea and Debility. Patient was wheelchair bound.
b. On 3/3/25 at 1432 hours Case Management Note indicated RD1 (Homeless Shelter Regional Director) from F1 (Homeless Shelter) phoned Case Management and stated P3 is not able to return to F1 due to his/her inability to perform ADLs (Activities of Daily Living) on his/her own and requested P3 get some kind of higher level of care/rehabilitation.
c. On 3/4/25 at 0910 hours Occupational Therapy Assessment Note indicated P3 reported he/she does not feel strong enough to be able to perform all of his/her ADLs independently at this time and does not have anyone to help him/her. Assessment: decreased ADL status, decreased UE (upper extremity)strength, decreased activity tolerance, decreased self-care transfer, decreased high-level ADLs, decreased fine motor control. Recommendations: Patient would benefit from continued therapy at facility level.
d. On 3/14/25 at 1542 hours Provider Progress Note indicated P3 remained deconditioned/debilitated and working toward rehabilitation. Discharge delayed by difficulties securing placement for skilled care.
e. On 3/17/25 at 1149 hours Occupational Therapy Treatment Note indicated under Recommendations: Patient would benefit from continued therapy at a facility level, does not have assist needed for safe mobility/transfer and unable to complete basic hygiene.
f. On 3/18/25 at 1054 hours Provider Progress Note indicated P3 remains deconditioned and debilitated. Insurance requested peer to peer, provider called and left a message with no return call.
g. On 3/19/25 at 0848 hours Case Management Note indicated P3 aware he/she would be discharged back to the shelter. At 1020 hours N4 spoke with an employee at F1 and questioned if wheelchair was at F1 and if they would have it ready for P3. At 1042 hours F2 van to transport P3 at 1545 hours to F1.
h. On 3/19/25 at 1127 hours Discharge Summary indicated P3 was medically stable and would be discharged back to the community. Neurological examination indicated Diffusely weak lower extremities worse than upper.

3. In phone interview on 4/1/25 at approximately 1314 hours with RD1 (Homeless Shelter Regional Director), he/she indicated on 3/3/25 he/she called F2 and spoke with Case Management and told them P3 would not be able to return to F1 due to his/her inability to perform his/her ADLs (Activities of Daily Living) on his/her own. RD1 requested P3 be discharged to a higher level of care or rehabilitation facility. RD1 indicated F1 had P3's wheelchair and belongings and would keep them until P3 was discharged. RD1 also indicated F2 called F1 on 3/19/25 and spoke to an employee at the front desk asking if P3's wheelchair was ready, and employee told F2 it was. RD1 was under the impression F2 was just coming to pick up P3's wheelchair and belongings since he/she had called F1 upon admission indicating F1 could not take P3 back. N2 from F2 showed up later in the afternoon with P3, requested P3's wheelchair and dropped P3 off at F1. RD1 told N4 that he/she could not leave P3 at F1 due to the fact they were not equipped to care for P3, N4 would not answer any questions and left P3 at F1. RD1 then called transportation for P3 and sent him to F3 (Acute Care Hospital). RD1 indicated since that time F3 came to pick up P3's belongings and is unsure where P3 was discharged to.

4. In interview on 4/1/25 at approximately 1500 hours with A8 (RN Manager of Case Management), he/she confirmed when P3 came to the ER (Emergency Room) RD1 phoned Case Management at F2 and informed them P3 was not able to return to F1 due to his/her inability to perform ADLs on his own and requested that P3 get a higher level of care.

5. In interview on 4/1/25 at approximately 1330 hours with N2, he/she indicated P3 was alert and oriented and in a wheelchair. N2 arrived at F1, wheeled P3 in, and requested P3's wheelchair. Facility told N2 they could not take P3. Facility tried to ask N2 a lot of questions and he/she responded with I don't know. Facility found P3's wheelchair, N2 phoned F2's dispatch center and told them F1 could not take P3, Case Management was then paged and N2 was told to leave P3 at F1.