HospitalInspections.org

Based on record review, document review, policy review and interviews, the hospital failed to ensure the discharge planning process identified a patient likely to suffer adverse health consequences upon discharge and failed to provide discharge evaluation for 1 (Patient 1) of 3 discharged patient records reviewed. This deficient practices places patients at risk for inappropriate discharge, loss of continuity of care which could potentially cause harm to the patients and result in rehospitalization.

Findings Include:

Review of a hospital policy titled "Patient Assessments, Patient Identification, Plans of Care, and Discharge Planning" revised 02/10/22 showed " ...Discharge Planning, Dismissal of Patient" showed,

" ...A. Upon admission, registration staff gives the patient a copy of the patient's rights, including the rights for discharge planning.

B. Identification of patients needing discharge planning. Within 24-48 hours of admission, all inpatients are screened by nursing staff to identify those patients at risk upon discharge due to functional status, cognitive ability and family support tissues. These criteria are specific to the patient's capacity for self-care post hospitalization.

C. Reassessment of patient's discharge needs are evaluated and documented in the medical record on a daily basis. When possible, the anticipated discharge date should be written on the white board in the patient's room. The hospital must provide a discharge planning evaluation to the patients identified in the screening process. A discharge evaluation may also be initiated at the:

1. request of patient's physician
2. request of patient
3. request of a person acting on the patient's behalf
4. request of patient's physician. Upon the physician request, the discharge plan will be
developed and then shared with the patient/family and the physician.
5. request of patient's family; or
6. any member of the multidisciplinary team

D. Individuals who are qualified to develop or supervise the discharge planning evaluations include: Discharge planning is a multidisciplinary process and is not restricted to a particular discipline. Disciplines (physicians, physical, speech, occupational, respiratory therapists, dietitians, nurses) participate with care management to reassess the patient's discharge plan to identify if there are factors that may affect continuing care needs or the appropriateness of the discharge plan. Interdisciplinary planning is accomplished through collaboration and discussion with physician, nursing staff, rehabilitation staff, and the patient/patient family.

E. The discharge plan will be supervised by appropriately qualified personnel including the primary nurse caring for the patient and the care management associate.

1. As a team, the nurse and/or care management staff will discuss the discharge plan with the patient, family, or appropriate caregiver.

2. The primary nurse is responsible for coordinating the dismissal of the patient.

3. Care management associates have the knowledge of social and physical factors that affect functional status at discharge, and knowledge of community resources to meet post discharge clinical and social needs. Care Management responsibilities include:

a. Supervising the development and the evaluation of the discharge plan.
b. Arranging for the implementation of the plan.
c. Evaluating the likelihood of the patient's capacity for self-care or the possibility of patient being cared for in the environment from which he/she entered the hospital.
d. Discussing what steps are being taken with the patient or individual acting on his/her behalf ..."

Review of document titled "An Important Message From Medicare About Your Rights" revised 04/2015 showed " ...Planning For Your Discharge: During your hospital stay, the hospital staff will be working with you to prepare for your safe discharge and arrange for services you may need after you leave the hospital. When you no longer need inpatient hospital care, your doctor or the hospital staff will inform you of your planned discharge date if you think you are being discharged too soon: You can talk to the hospital staff and your managed care plan (if you belong to one) about your concerns ..."

Review of document titled "Job Description" as of July 31, 2023, showed " ...RN-Med Surg" (Registered Nurse Medical/Surgical) " ...Job Summary: Provides direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization. Responsibilities: Implements and monitors patient care plans. Monitors, records and communicates patient condition as appropriate. Serves as a primary coordinator of all disciplines for well-coordinated patient care. Notes and carries out physician and nursing orders. Assesses and coordinates patient's discharge planning needs with members of the healthcare team ..."

Review of document titled "Job Description" as of August 02, 2023, showed "Social Worker" " ...Job Summary: Investigates, assesses and plans interventions to help patients cope with social, emotional, economic and environmental problems. Responsibilities: Interviews patients, assesses priorities and documents case activity. Consults with team managers, statutory and voluntary agencies and patient's relatives to ensure compliance with patient's treatment plan. Assists clients/families with obtaining community assistance by referral to proper resources. Develops and maintains working relationships with community health, welfare and social agencies and
seeks creative means to assist the client with his/her needs. Supports management of concurrent review, discharge planning processes, social services, home care and other post discharge needs ..."

Patient 1

Review of Patient 1's discharged medical record showed a 63-year-old male was admitted on 06/24/23 for Cystitis (bladder infection), weakness, acute on chronic renal insufficiency (poor function of the kidneys).


Review of "List Patient Notes" dated 06/26/23 at 4:53 PM by Staff J, Case Manager (CM), showed " ...Patient ...states is too large to go into bathroom, reporting he has not showered in months. Patient reports not being able to ambulate in the community due to fatigue...Patient will be discharge home today."
Review of "Nursing Notes" dated 06/27/23 at 5:19 AM showed " ...Pt [patient] was incontinent (lack of voluntary control over urination and defecation) in bed x 2, but mostly due to obesity ...aware that the plan is for him to be discharge this morning."

Review of "OT [Occupational Therapy] Daily Note" dated 06/27/23 at 7:50 AM showed," Assessment: Pt [patient] tolerated OT tx [treatment] this date, secondary to increased weakness and difficulty advancing BLE's [Bilateral Lower Extremities] ...Discussed concerns w/ [with] d/c [discharge] at this time. Pt presents with decline in act. [activity] tolerance/strength/ADL's (Activities of Daily Living) and would benefit from continued OT services during stay. Pt likely needing post-acute rehab."

During an interview on 08/01/23 at 11:35 PM, Staff L, Occupational Therapist (OT), stated that She let everyone in the social work team know including the lead Social Worker and Staff J, CM that it was not a safe discharge, and that Patient 1 would not be able to get into car. She stated that they replied, they would call the ambulance to get him into house.

Review of "PT [Physical Therapy] Daily Notes" dated 06/27/23 at 8:33 AM showed, " ...Pt [patient] voices concerns about being discharged this morning. States he will have to walk ~100' to get into his apartment. Nursing notified ...Exercises completed ...Attempted STS [sit to stand] to bariatric 4 WW [four wheeled walker] with max asst [maximum assistance] X 2 without success ...It was decided it would not be safe to continue with TR [transfer] up to transfer chair with anything other than Hoyer lift (mechanical patient lift) ...Assessment: Pt [patient] continues to be too weak to functionally mobilize with 4 WW safely. SW [Social Worker] to work on other options for pt's discharge ..."

During an interview on 08/01/23 at 11:15 AM, Staff M, Physical Therapy Assistant (PTA), states, " ...Staff L, OT went and talked to social worker and nursing and informed them that it was not a good idea for him to go home since we could not get him out of bed into a chair ..."

Review of "Assessment-Shift" stated 06/27/23 at 8:38 AM by Staff K, Registered Nurse (RN), "showed, " ...Skin Integrity Location; Sacral/coccygeal (base of tailbone) area; Impairment: Normal/intact ..."

Review of "Nursing Notes" dated 06/27/23 at 8:44 AM Staff K, RN, showed, "pt [patient] resting in bed. PT [Physical Therapy] unable to get pt up to wheelchair. Pt to discharge this morning, social work setting up EMS (Emergency Medical Services) transportation ..."

Review of "Nursing Notes" dated 06/27/23 at 10:34 AM by Staff K, RN, " ... EMS here for pt [patient], transferred to stretcher ..."

Review of medical record showed patient 1 was discharged on 06/27/23 at 10:34 AM by EMS.

During an interview on 08/01/23 at 1:00 PM Staff K, Registered Nurse (RN), stated that the day Patient 1 discharged was the 1st day she took care of Patient 1. She stated that he had discharge paperwork from day before. Physical Therapy was in there that morning, and they said he was having trouble getting him up. After I dismissed him in the morning, Patient 1 returned a few hours later.

Review of "List Patient Notes" on 06/27/23 at 3:19 PM by Staff D, Director of Case Management, written after Patient 1 was discharged, showed ... "Social worker met with patient and also spoke to Patient 1's caregiver (Social Services Organization) that is in the home twice weekly from 8:30-11:30. Discharge plan is to return home this date and continue to work on nursing home placement. Worker provided education on nursing home placement. Patient states that he is open to nursing home placement ...ambulance was arranged, by social worker, to take patient home ...Worker spoke to CM4 (Insurance Company) and requested assistance with nursing home placement."

During an interview on 08/01/23 at 10:03 AM Staff D, Director of Case Management states " ...Patient 1 admitted on 06/24/23 and discharge home on 06/27/23 at 10:30 AM and returned later that day. We called 911 to bring him back as a direct admit ... We send patients home in the same condition they came in and CM1 was willing to take him back. Long term him being at home was concerning. We do a multi-disciplinary approach that is physician led, the physician takes in consideration of Physical Therapy, Occupational Therapy and nursing to make decision."

Review of Patient 1"s Ambulance Trip Report signed and 06/27/23 at 11:13 AM showed " ...Narrative ...dispatched to noted location for patient transfer from above-named Hospital back home ...Pt [patient] was needing transferred back home and needing transported via EMS due to not ambulatory and severe obesity. Pt was moved via slide board with assistance from multiple people onto EMS [ambulance] stretcher ... [Fire Department] was on scene to assist moving with patient. Patient was moved via tarp slid back into recliner where he wanted to go. Patient was rolled side to side to get tarp out from him ..."

During an interview on 08/02/23 at 8:07 AM, Emergency Medical Services (EMS), EMS4, stated, it was a transfer to home from above-named hospital. We were told Patient 1 was obese and non-ambulatory. There were several staff members in hall in anticipation to move him. The doctor told him to keep in the contact with Social Worker about nursing home placement and wish him the best of luck. His apartment was in a Highrise building on the 8th floor it was not optimal since the elevator was so small, we had to sit him up as high as we could so he could fit into elevator. He was only dressed in a gown and wanted to put undergarment and shorts on since he could not dress himself or even lean forward. His friend there was unable to help him, so we assisted dressing him.

During an interview on 08/02/23 at 8:00 AM, EMS3, stated that Patient 1 was a transfer from the hospital back home. He was lying hospital bed told us he was not able to move it took 8 people to move him to cot. When we arrived at his apartment his care giver was there to take care of cleaning of house and that hygiene would be on him. Since he was unable to assist it took total of 7 of us to do a total assist to move him to his recliner.

During an interview on 07/31/23 at 1:57 PM, Patient 1's Case Manager (CM1), with a Social Service Company, stated that Patient 1 was able to stand on his own with a walker with minimal assistance and then he had a urinary tract infection (UTI) and couldn't walk or stand on his own. She stated that he was scared about going home since he lived alone and doesn't have family or any other support system except 8 hours per week with CM1. She stated that Patient 1 tried to vocalize to hospital staff about not being able to stand up and wasn't safe for him to go home and that he was discharged home by an ambulance. She stated that Patient 1 called from his house, stating that he was sitting in his own feces and urine but didn't feel safe about going back to above-named hospital, so his case manager told him to call 911 ...


Review of Patient 1's Ambulance Report signed and dated 06/27/23 at 4:47 PM showed " ...Narrative ...Pt [patient] states he was having some lower back pain and is no longer mobile. Pt was previously admitted at the hospital earlier this morning and released at 10:30. Pt informs he spoke with his doctor about his reoccurring back pain just prior to calling 911 and that he was (sic) referred him to return to the hospital for evaluation ...With assistance from Fire Department patient is rolled into the titan tarp. During radio report to the hospital, EMS is given a direct room ..."

During an interview on 08/02/23 at 7:51 AM, EMS2, stated " ...Patient 1 was on the 8th floor highrise building found him in recliner had hospital bed sheet underneath and had fire department there to assist. Patient states he could not stand or help with transfer, so we put tarp under him and slid him on stretcher it was the 2nd ambulance transport that day for [Patient 1] just few hours after he was taken home from hospital. When we took him back to hospital there was a smell of feces and he had significant bed sore when we rolled him, and I let the nurses know."

Review of "History and Physical" readmission on 06/27/23 at 4:00 PM by Staff P, Physician Assistant (PA), showed, " ...Social History" "The patient lives at home independently. He uses walker at home to assist with ambulation ..." " ...Assessment and Plan" "63-year-old male with weakness and dysuria (painful or difficult urination)."

Review of "Adult Physical Exam" medical record on 06/27/23 at 6:06 PM showed, "Skin/Integumentary" " ...Location Sacral/Coccygeal area; impairment: blisters Describe: Right buttock, dressing applied ..."

Review of "Discharge Summery "on 07/25/23 at 9:40 AM, showed Patient 1 was dismissed 27 days after second admission and admitted to Long Term Care Facility.

During an interview on 08/01/23 at 2:04 PM with Staff J, Social Worker and Case Manager, stated that, Patient 1 came into hospital not being able to take care of himself at home. While working on discharging Patient 1, she called CM1 and asked what it looks like to discharge safely. We wanted to make sure he would be able to go to outpatient physical therapy appointments with utilizing Medicaid transport. She stated that CM1 told her that they help with equipment to get him down the elevator and a home aide was there 8-12 daily. We had communication with the doctor about discharge that day about the support at home.