The Critical Consequences of Poor Discharge Planning: When Oversights Turn into Medical Negligence

Imagine being the spouse of a patient hospitalized before Christmas. Let’s say your spouse had a significant illness and would need oxygen, home nursing, and physical therapy at discharge. Would you expect the hospital case manager or discharge planner to arrange this before discharge? If you think like me, the answer to that question is Yes. Unfortunately, the case managers at the facility failed to arrange home health. This led to the spouse navigating the health plan, the vendor approving home health services, hospital case managers, and the health plan case manager. The hospital case manager said they could do nothing since the patient was discharged. The vendor for the host Blues plan should never been involved. Neither Home Blues plan required preauthorization for home health. This led to the patient’s readmission and untimely death. I wish I could say the hospital assumed accountability for this. Risk Management for the hospital asked the spouse to speak with the Director of Case Management. When the spouse talked to her, she informed the spouse that she had discussed their lack of discharge planning with the staff. The Director of Case Management stated that her staff does not feel discharge planning should be part of their job; therefore, they do not do it. She asked the grieving spouse how to hold her staff accountable for doing their job. While grieving, the spouse gave the Director of Case Management leadership and management advice.

Imagine being the daughter of an eighty-six-year-old Mom with advanced Alzheimer’s and a ninety-year-old Dad. The Mom gets admitted to the intensive care unit with a urinary tract infection and acute kidney injury. The patient’s baseline function is walking with assistance. Level of function in the hospital, unable to walk. This indicates a decline in functioning attributed to hospitalization not advancing disease. There were four wounds to care for at home, two requiring wet-to-dry dressings. The discharge plan was home with no services. The daughter pushed back, requesting home health. The doctor agreed and wrote the order. The case manager entered the room and informed the daughter that her mom did not qualify for home services. What? Medicare covers skilled, short-term services in-home. These services help with recovery following an inpatient hospital stay. Home health care aims to return to the baseline level of function. Unfortunately, the case manager’s decision to ignore a physician’s order led to the patient’s readmission.

What is discharge planning? Who is responsible for discharge planning?

“Discharge planning is the process of transitioning a patient from one level of care to the next. Ideally, discharge plans are individualized instructions provided to the patient as they move from the hospital to home or instructions provided to subsequent healthcare providers as they move to a longer-term care facility. (Patel & Bechmann, 2024).” What is the goal of discharge planning? “The goal of adequate and efficient discharge planning is to improve a patient’s quality of life by ensuring continuity of care and reducing the rate of unplanned readmissions and/or complications, which may decrease the healthcare system’s financial burden (Patel & Bechmann, 2024).” Hospitals must meet federal regulations for discharge planning. “The hospital must have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions.(42 CFR 482.43 — Condition of Participation, n.d.),” The standard discharge planning process states that the hospital must identify discharge planning needs at an early stage of hospitalization, must be made at an early stage to arrange services prior to discharge, and discharge planning process requires regular re-evaluation throughout hospitalization. The discharge plan must be overseen by “a registered nurse, social worker, or other appropriately qualified personnel (42 CFR 482.43 — Condition of Participation, n.d.).”

According to a study from Johns Hopkins in 2016, “more than 250,000 people in the United States die every year because of medical mistakes (CNBC.com, 2018).” Medical errors are the third leading cause of death in the United States. The Institute of Medicine Committee on Quality of Health Care in the US defines medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”[5] Another definition identifies medical errors as a failure in care that may or may not result in patient harm (Rodziewicz et al., 2024).” Are discharge planning errors such as ignoring physician orders for home health or failing to arrange post-acute services before discharge considered medical errors? Yes. Can the hospital be sued for unsafe discharge planning as medical negligence? Yes.

I wish the examples shared were rare occurrences. It happens more frequently than case managers want to admit. To fix the problem, we must acknowledge there is a problem. Discharge planning currently happens when a discharge order is written or a doctor orders discharge planning. Should we require an order for discharge planning? No, discharge planning should start on day one. The admitting nurse can start the discussion during the admission assessment. Multi-disciplinary rounds should discuss discharge planning daily. Discharge planning should be a proactive process, not reactive. Patients, families, and caregivers should be involved in the discharge planning process starting on the day of admission. The change from reactive to proactive could have changed the patient outcomes for the two examples provided. Let us all remember that the code of ethics includes “to do no harm.”

42 CFR 482.43 — Condition of participation: Discharge planning. (n.d.). Retrieved October 13, 2024, from https://www.ecfr.gov/current/title-42/part-482/section-482.43

CNBC.com, R. S., special to. (2018, February 22). The third-leading cause of death in US most doctors don’t want you to know about. CNBC. https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html

Patel, P. R., & Bechmann, S. (2024). Discharge Planning. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557819/

Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024). Medical Error Reduction and Prevention. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK499956/