**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and procedure, resident and staff interview, the facility failed to follow the physician's discharge orders and ensure 1 (Resident #340) of 2 residents received home health services as ordered resulting in rehospitalization. The findings included: The facility policy, Resident Transfer and Discharge (revised 4/21/21) specified, Social Services will collaborate with the resident/ resident representative the Physician and the Interdisciplinary Team (IDT) to assist in planning the discharge care and services for the resident. Review of the clinical record showed Resident #340 was admitted to the facility on [DATE] after a hospitalization for acute respiratory failure and discharged home on 2/13/21, where he lived independently. The discharge summary created on 2/10/21 and completed on 2/18/21 noted Resident #340 lived alone and was discharged home with Home Health Services. Further review of the clinical record showed Resident #340 was admitted to the hospital on [DATE] for hemorrhagic shock and abdominal wound and discharged to the facility on 4/15/21. Review of the hospital record revealed a physician's progress note dated 3/26/21 that read . He was discharged from [hospital name] 2 months ago to rehabilitation for 2 weeks, then went home where he lives alone. Sustained a burn to his abdominal wall skin, at the large hernia site 2 weeks ago from hot ball . Started bleeding last night . On my exam, removing the abdominal binder that is soaked with large quantity of red blood, he has a 3 cm [3 centimeters] round necrotic wound with oozing blood . Home medications: 1. Warfarin (anticoagulant). Past medical history: 1. Atrial fibrillation/flutter, on anticoagulation with Warfarin. He could not afford the recently prescribed Eliquis when he was discharged from [hospital name] early February 2021, has had difficulty monitoring his Warfarin at home with a nonfunctioning machine. A facility IDT discharge summary completed on 4/24/21 noted Resident #340 was alert, oriented and lived alone. The Discharge Summary included a physician's order dated 4/20/21 to discharge home on 4/24/21 with home health care, registered nurse to draw PT/INR (lab test to measure how long it takes for your blood to clot) every Monday and Thursday and report results to primary care physician. The physician's orders included a wound care to abdomen, clean with normal saline, pat dry, apply calcium alginate, and cover with sacral foam dressing daily. Further review of the record showed Resident #340 was admitted to the hospital on [DATE] and discharged to the facility on 5/7/21. Diagnoses listed in the clinical record included a burn of unspecified degree of abdominal wall, repeated falls, hypertensive heart disease with heart failure, dilated cardiomyopathy, unspecified atrial flutter, presence of cardiac implants and grafts, non-rheumatic aortic valve, and tricuspid valve insufficiency, hypertension, anticoagulant use, peripheral vascular disease, type 2 diabetes, and chronic obstructive pulmonary disease. On 5/10/21 at 10:12 a.m., in an interview Resident #340 said this was his third admission to the facility in 4 months. Resident #340 said he was discharged home and was too weak to care for himself. He said he was bleeding from an abdominal wound and called 911. Resident #340 said he was supposed to receive Home Health services after each discharge but there was no follow through, and he did not receive it. Resident #340 said he lived alone, in a 1-bedroom apartment, on an upper floor, and required continuous oxygen. The resident said he needed the home health services and was not able to care for himself. Resident #340 said he called for emergency transport to the hospital and was admitted to the hospital on [DATE]. He said the hospital discharged him to the facility because I was too weak and could not do anything. On 5/12/21 at 8:30 a.m., in an interview Resident #340 said he had an abdominal wound when he was discharged home on 4/24/21. He said Home Health never came and he was doing his own wound care even though he was not taught how. On 5/11/21 at 1:30 p.m., in an interview, the Social Service Director (SSD) said Resident #340 was on his 3rd admission to the facility. The SSD said the resident's insurance informs the facility of the resident's last covered day. The SSD said she talked with the resident and set up home health. The SSD said Resident #340 did not want to apply for Medicaid during the last admission for fear of having to get rid of his possessions and lose control of his money to live in an assisted living facility. The SSD said Resident #340 filed and lost an appeal during his last admission and was discharged on 4/24/21. The SSD said she faxed the physician's order for Home Health to Home Health Agency (HHA) A and called to make sure they had received it. The SSD said the facility did not provide follow up once the resident was discharged to ensure the resident received home health services as ordered. She said she would not be aware of a resident needing community resources or additional health care services. The SSD said the resident's insurance company was responsible to determine if the resident was safe to discharge home. The SSD also confirmed she had no documentation she notified the HHA of Resident #340's discharge orders. On 5/12/21 at 11:30 a.m., in an interview, the Administrator said the facility was aware the HHA did not accept Resident #340's insurance upon discharge on [DATE] and did not refer the resident to another HHA that would accept his insurance. The Administrator said, Normally it is the home health agency that will refer the resident to another agency that accepts the insurance of the resident. On 5/12/21 at 1:00 p.m., in an interview, Resident #340 confirmed he never received a home health visit after his discharge on [DATE] or 4/24/21. Resident #340 said, They told me I would get help, but I never did get any visit from home health. Resident #340 said the SSD did not tell him the HHA did not accept his insurance. He said he did not receive information regarding community services that would have provided him with assistance after discharge. Resident #340 said, They are planning to discharge me on 5/14/21 and I don't know what I will do. I have no phone and relatives in the area that can help me. I need help, even taking a shower after 3 minutes feels like an eternity. I don't know what I'm going do, I can't take care of myself. On 5/12/21 at 1:08 p.m., in a telephone interview, the home health director for home health agency A said there was no record of Resident #340 being referred to the HHA. The Home Health Director said, Even if we do not accept the patient, we would still put the referral into the electronic record system but there is no record the patient was ever referred. The Home Health Director said if they did not accept a referral's insurance plan, they would contact the facility, but the facility usually knew before they even got a referral, whether the HHA would accept the insurance. The Home Health Director confirmed there was no record Resident #340 was referred to the HHA upon discharge on [DATE] and 4/24/21.