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Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) inpatient records reviewed for discharge planning, the Hospital failed to identify at an early stage of hospitalization a patient who was likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and complete a discharge evaluation.

Findings include:

1. The Hospital's policy titled, "Discharge Planning (10/6/2017)" was reviewed on 4/5/2021 and required, "Case finding is done as early as possible to identify patients in need of assistance with discharge planning to prevent adverse health consequences. ... A discharge planner assesses patients for potential discharge needs in the admission assessment and documents results in patient medical record."

2. The clinical record of Pt. #1 was reviewed on 4/5/2021. Pt. #1 was admitted to the Hospital on 1/4/2021 for elective neck surgery.

- The Physical Therapist's (PT - E#2) note, dated 1/5/2021 at 9:45 AM, included, "Recommendations following discharge: Home vs. SNF [skilled nursing facility] - (but patient prefers to go home with assist from daughter), needs a walker."
- The Occupational Therapist's (OT - E#3) note, dated 1/5/2021 at 5:53 PM, included, "Recommendations following discharge: Patient will benefit from continued therapy upon discharge, SNF. Patient indicates he plans to return home.
- Pt #1's clinical record lacked a discharge evaluation by the Discharge Planner/Case Manager.

3. During an interview on 4/6/2021 at 12:00 PM, the Lead Patient Navigator - Case Management (E#4) stated, "All inpatients should have a discharge evaluation, we call it an 'Open', within 48 hours of admission. Usually this evaluation of activities of daily living and support systems is completed on day one of the hospitalization. That way we have a better idea of patient needs at discharge, since length of stay in the hospital is much shorter these days." E#4 stated that there was no documentation in Pt. #1's record of any interaction with a patient navigator.

4. During an interview on 4/6/2021 at 3:00 PM., the Social Worker assigned to Pt #1 (E#7) stated that she did not recall completing a full assessment, as there was no documentation of the assessment being completed. E#7 stated, "If I had noted that PT/OT were recommending a SNF, I would have talked to the patient and/or family for their input. That conversation would be documented as well."

Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) inpatient records reviewed for discharge planning, the Hospital failed to ensure the discharge evaluation was included in the patient's medical record.

Findings include:

1. The Hospital's policy titled, "Discharge Planning (10/6/2017)" was reviewed on 4/5/2021 and required, "... A discharge planner assesses patients for potential discharge needs in the admission assessment and documents results in patient medical record."

2. The clinical record of Pt. #1 was reviewed on 4/5/2021. Pt. #1 was admitted to the hospital on 1/4/2021 for elective neck surgery.

- The Physical Therapist's (PT - E#2) note, dated 1/5/2021 at 9:45 AM, included, "Recommendations following discharge: Home vs. SNF [skilled nursing facility] - (but patient prefers to go home with assist from daughter), needs a walker."
- The Occupational Therapist's (OT - E#3) note, dated 1/5/2021 at 5:53 PM, included, "Recommendations following discharge: Patient will benefit from continued therapy upon discharge, SNF. Patient indicates he plans to return home.
- Pt #1's clinical record lacked a discharge evaluation by the Discharge Planner/Case Manager.

3. During an interview on 4/6/2021 at 12:00 PM, the Lead Patient Navigator - Case Management (E#4) stated. "[Pt. #1] was assigned to a social worker [E#7] for all discharge needs. Unfortunately, there is no documentation of any interactions about discharge planning in the clinical record. I would have expected there to have been."

4. During an interview on 4/6/2021 at 3:00 PM, the Social Worker (E#7) stated, "I can not explain why there is no documentation of the review or assessment. I should have done that. All interactions with each patient should be documented."