HospitalInspections.org

Review of facility documentation, medical records (MR) and staff interviews (EMP) revealed the facility failed to maintain an accurate medical record by not documenting that home care supplies were provided to patient on discharge for one of 20 medical records reviewed (MR1)
Findings Include:
Review of facility policy "Care of the Post Op Colon-Rectal Patient " dated April 2018 revealed " ...Upon discharge, please send a supply bag home with the patient to include the following supplies: (3) Pouches, (1) Stoma Paste, (3) Eakin Seal, (2) Transparent seal (1) Powder
Review of facility policy "Care Management Discharge/Transition Planning " last revised December 2017 revealed " ...Documentation of all activities involved in the discharge planning process must be maintained in the patient ' s medical record and must meet the standards of each discipline for content and timeliness ... "
Review of MRN1 discharge summary dated June 16, 2018, revealed "...patient was urgently taken to OR (operating room) for washout and ileostomy creation..."
Review of MR1 revealed patient was discharged from the facility with ostomy needs and was to be discharged to home with home care services on June 16, 2018. A review of MRN1 revealed no documentation that indicated patient was discharged with any supplies necessary to provide for ostomy needs at home.
During interview on August 2, 2018, at approximately 2:00 PM, EMP3 revealed remembering giving the patient ostomy supplies on discharge but could not confirm documentation was completed in the medical record.
During interview on August 3,2018, at approximately 12:00 PM EM1 confirmed the lack of documentation in MR1 that confirmed the patient received ostomy supplies on discharge.

Based on review of facility documentation, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure there was documented evidence in the medical record that the patient or his/her representative was provided freedom of choice (FOC) related to selection of either a Home Health Agency (HHA) or Skilled Nursing Facility (SNF) for ongoing care post-discharge for one of one medical record reviewed (MR1).
Findings include:
Review of facility policy and procedure "Freedom of Choice" last revised August 2018, revealed "D. Each patient and/or family is presented, with a generated list either through electronic means or manually, of relevant providers in their area and the patient chooses a provider(s). It is essential that the patient be informed as to which entities are affiliated with AHN. ... E. The receipt of the provider listing will be documented in the patient's medical record by the staff member who delivered the Freedom of Choice form."
Review of facility policy and procedure "Admission, Discharge, Reservation, and Transfer of Patients" last revised August 2016, revealed 16. The patient /representative will be presented with a list of post acute facilities/providers (i.e. skilled nursing facilities, acute rehabilitation providers, home health agencies, etc."
1) On August 2, 2018, at approximately 1:00 PM review of MR1 revealed the patient was admitted to the facility on May 31, 2018, and discharged with home health services on June 16, 2018. There was no FOC form identified on the medical record.
On August 3, 2018, at approximately 9:30 AM interview with EMP1 confirmed the above findings and revealed "There is no documentation in the chart."