HospitalInspections.org

Based on review of facility policy and procedures, medical record review and staff interview it was determined the facility failed to ensure a discharge planning evaluation was documented in the patient's medical record for one (#5) of ten records sampled to use in establishing an appropriate discharge plan.

Findings include:

Review of the facility policy "Discharge Planning" last revised 1/2014, stated Procedure (A) Assessment (5) the case manager conducts discharge planning assessment within 48 hours of admission or within 24 hours of receipt of a referral for discharge planning; (6) the case manager monitors the needs of the patient on an ongoing basis throughout the hospital stay and prior to discharge to determine whether a change in the status of the patient and/or caregiver indicates a need to modify the discharge plan.

Patient #5 was admitted on 1/22/2015 and discharged on 1/28/2015 to the facility's in-house rehabilitation unit. Review of the record revealed no evidence a case manager completed a discharge plan evaluation.

Interview with the Director of Case Management on 5/27/2015 at approximately 4:40 p.m. confirmed the findings.