HospitalInspections.org

Based on interview and record review the facility failed to document accurate and complete patient records for 2 (#1,3) of 8 selected patient records .

Findings:

1. Record review of Patient #1 's record revealed she was admitted to the hospital on 2/9/25 through the Emergency department. Diagnosis included a right open bimalleolar fracture and right ankle laceration. On 2/10/25 her surgeries included Irrigation/exicsional debridement of skin, subcutaneous tissue, muscle, fat and bone of right ankle fracture, open ankle traumatic areotomy and an Open Reduction Internal fixation right, open type IIIA PA-III bimalleolar ankle fracture, operative stabilization of right syndesmosis and repair in multilayered fashion of right ankle traumatic laceration, 10 centimeters in total length.

Pt. # 1's discharge disposition documented by the physician on the Discharge Summary read:
"...Per physical therapy recommendations, patient is independently ambulating with durable medical equipment (DME) and is cleared for discharge home. DME and home health care Physical Therapy ordered. Plan for discharge home today. "

Review of the Case Management notes documented on 2/12/25 documented discussion with patient and caregiver regarding the necessary DME and what was already in the home. There was no further documentation regarding patient needs or ordered home health physical therapy. There was no choice letter found in the record for selection of home care.

In an interview with the Quality Manager, Risk Manager and the Case Manager Manger at 12:30 on 4/2/25, they confirmed there was a physician order for home health care, for patient #1, however no documentation was in the record that documented the referral for home care had been made.


2. Record review reveled Patient # 3 was a 35 year old male admitted to the hospital on 1/29/25 through the Emergency department (ED.) Documentation revealed the patient was recently discharged from an acute care hospital in Charlotte North Carolina and arrived by a private ambulance company transportation. The patient was discharged from the hospital to go home and stay with family in Florida, however upon arrival they were not home and the ambulance company brought the patient to the hospital ED. Past medical history and present diagnosis was T-cell Lymphoma , pain, anemia, and failure to thrive. Documentation revealed the patient was bedbound and had chronic contractures of both lower extremities. The record reflected pertinent diagnostics and attempted medical care and treatment that was frequently refused by the patient, along with refusals of medications, and physical and occupational therapies. The patient accepted and received continued pain medications as ordered. The History and physical documented by the physician ordered and recommended a Case Management (CM) consult for placement. The physician discharge summary documented discharge instructions as: "Home Health with Plan of Care."

Documentation revealed the patient was discharged from the hospital, transported to a homeless shelter in another city, and refused entrance due to his disabilities and inability to walk or care for self.

In a group interview which included the Vice President of Quality/Risk Manager, the facility Medical Director, and the Director of Case Management at 12:30 PM on 4/2/25 revealed the case manager had spoken to the patient regarding the discharge to the homeless shelter and he was in agreement. They were informed there was no documentation in the legal record that supported the discussion with the patient or the agreement by the patient to be transferred to another city to a homeless shelter. They confirmed and agreed that the case management conversation with #3 regarding his discharge disposition was not documented.

Based on interview, record review, and review of hospital documents, the facility failed to ensure a safe and appropriate discharge plan was arranged and accomplished for 2 (#1, 3) of 8 sampled patients.

Findings:

1. Record review of Patient #1 's record revealed she was admitted to the hospital on 2/9/25 through the Emergency department. Diagnosis included a right open bimalleolar fracture and right ankle laceration. On 2/10/25 her surgeries included Irrigation/exicsional debridement of skin, subcutaneous tissue, muscle, fat and bone of right ankle fracture, open ankle traumatic areotomy and an Open Reduction Internal fixation right, open type IIIA PA-III bimalleolar ankle fracture, operative stabilization of right syndesmosis and repair in multilayered fashion of right ankle traumatic laceration, 10 centimeters in total length.

Pt. # 1's discharge disposition documented by the physician on the Discharge Summary read:
"...Per physical therapy recommendations, patient is independently ambulating with durable medical equipment (DME) and is cleared for discharge home. DME and home health care Physical Therapy ordered. Plan for discharge home today. "

Review of the Case Management notes documented on 2/12/25 documented discussion with patient and caregiver regarding the necessary DME and what was already in the home. There was no further documentation regarding patient needs or ordered home health physical therapy. There was no choice letter found in the record for selection of home care.

In an interview with the Quality Manager, Risk Manager and the Case Manager Manger at 12:30 on 4/2/25, they confirmed there was a physician order for home health care, for patient #1, however no documentation was in the record that documented the referral for home care had been made.


2. Record review reveled Patient # 3 was a 35 year old male admitted to the hospital on 1/29/25 through the Emergency department (ED.) Documentation revealed the patient was recently discharged from an acute care hospital in Charlotte North Carolina and arrived by a private ambulance company transportation. The patient was discharged from the hospital to go home and stay with family in Florida, however upon arrival they were not home and the ambulance company brought the patient to the hospital ED. Past medical history and present diagnosis was T-cell Lymphoma , pain, anemia, and failure to thrive. Documentation revealed the patient was bedbound and had chronic contractures of both lower extremities. The record reflected pertinent diagnostics and attempted medical care and treatment that was frequently refused by the patient, along with refusals of medications, and physical and occupational therapies. The patient accepted and received continued pain medications as ordered. The History and physical documented by the physician ordered and recommended a Case Management (CM) consult for placement. The physician discharge summary documented discharge instructions as: "Home Health with Plan of Care."

Occupational therapy notes documented with assistance, the patient was able to transfer from bed to chair and the hospital provided a wheelchair for the patient.
Nursing notes documented the patient was uncooperative with care and refused personal hygiene and linen changes frequently.

Review of the Case management notes for patient #3 revealed he requested skilled nursing facility placement while waiting to apply for Medicaid. There were multiple telephone calls by case management to the patient's family members, however, no family member would assist or care for him. Nearly on a daily basis case management notes documented referrals to area skilled nursing facility (SNF.) There were some accepted placements, however, upon finding results of patient's behaviors, refusing therapy and treatment, and refusals of care, the SNFs decline to accept him.

A case management note dated 2/11/25 documented "He is declined by multiple facilities for not meeting criteria...Met with patient and addressed behaviors and its impact with not having an accepted facility. Patient is aware that if no accepting facility today, he will need to be discharged to the community or to family. Patient is requesting a facility in Jacksonville because his family reside in the area..." Case management notes continued to document referrals to SNF and continued decline of acceptance.
On 2/14/25 case management notes documented the patient was brought a loaner wheelchair in case he needed it on discharge. Documentation also read the patient was denied a SNF level of care as patient was at baseline and has no skilled nursing needs.

A case management note dated 2/15/25 documented: ...Patient was informed we needed an address for transportation. Patient stated that "he will provide address once he can confirm placement. CM returned at 2:00 PM for address-CM received address at (address documented). CM was not provided with a name of contact nor contact # to confirm address..
.
CM placed a call to (name of transport company) and spoke to (name provided) in regards to this patient, CM was informed that transportation would be $605.00. CM provided this to leadership.

Per leadership due to inability to confirm address, patient to be placed in homeless shelter in St. Augustine. (address provided)
No other issues to report. Nursing and patient have been mode aware of arrangements."

Information provided revealed the patient was discharged from the hospital, transported to a homeless shelter in another city, and refused entrance due to his disabilities and inability to walk or care for self.


In a interview with the patient's Phrygian who documented the discharge order at 3:30 PM on 4/2/25 revealed upon patient #3's discharge she was unaware of where the patient was discharged to and was not contacted or called by a case manager to inform her that the parameter was not met or where the patient was discharged to.

A physician discharge order for patient #3 dated 2/8/25 documented: Discharge/Parameters:2/8/25 SNF (skilled nursing facility) bed.
Also documented , was to notify attending when discharge parameter met. Call if parameters not met. The physicians name and telephone number were included. The order also read: "Discharge to: Home Health with Plan of Care."

In a group interview which included the Vice President of Quality/Risk Manager, the facility Medical Director, and the Director of Case Management at 12:30 PM on 4/2/25 revealed the case manager had spoken to the patient regarding the discharge to the homeless shelter and he was in agreement. They were informed there was no documentation in the legal record that supported the discussion with the patient or the agreement by the patient to be transferred to another city to a homeless shelter. They confirmed and agreed that the case management conversation with #3 was not documented. They were also informed that the transfer to a homeless shelter was an inappropriate level of care for patient #3 as he was unable to ambulate or care for himself, and he was refused entrance/admission to the homeless shelter which resulted in the patient being transferred to an acute care hospital by the transportation company.


Review of the hospital policy entitled "Discharge Planning #17660951, Approved 2/26/2025" documented on page 1 under "POLICY" section;
(Name of hospital) provides discharge planning to promote a safe and timely discharge to an appropriate level of care."