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Based on interviews and record review the facility failed to communicate with both the patient and patient's representative the plan of discharge for 1 ( Patient # 9 ) of 10 patients reviewed.

The findings include:


1. On 12/31/2013 at 3:06 PM a social worker was interviewed. The social worker stated, the standard is to call the patient/family at home to tell them number and name of all medical equipment companies or insurance companies and information regarding discharge planning. The social worker added this should be written in the notes and someone should of visited with the patient/family to tell them of the discharge plan.


2. A review of Patient # 9 record review shows that patient was admitted to the facility for 12 days for the removal of an infected graft from left leg. A review of the discharge notes summary form show that on 11/08/2013 a discharge evaluation was started for Patient # 9. Further review of Patient # 9's discharge evaluation notes show that on 11/11/2013 medical equipment for this Patient #9 was to be delivered to the patient's home. No documentation that this was discussed with Patient #9 or Patient #9's representative. Patient #9 discharged home. There were no discharge evaluation notes that the discharged was discussed with patient or patient's representative. Further review of the discharge evaluation notes revealed that after Patient #9 was discharged the case manager had spoke to an insurance company, there is no documentation the facility to followed up with the Patient #9 or Patient #9's representative.

3. A review of the facility's policy/procedure for Case Management- Documentation number 8, page 2 (dated 10/22/2013) stated, documentation in the medical record will be made whenever new information pertinent to the management of the case is learned or a change in discharge plans occurs. At a minimum, the social worker or case manager will write progress note on each open case every 3 days, and more often as indicated. Each subsequent entry will clearly reflect the status of the plan. Patient/family inclusion discharge planning process will be documented. The patient/family understanding and agreement with the discharge plan will also be documented.

4. A review of policy/procedure for Case Management- Discharge Planning number 24, page 1 (dated 10/22/2013) under policy stated, All patients will be screened within 48 hours of admission. ( Patient # 9 admitted was not seen until eight (8) days after admission) On page 2, Discharge planning activities will be documented in the medical record using the CMS system (a computer system) or handwritten notes in the event that the computer system is non-operational or not in use by a specific department. Key issues regarding discharge planning are documented in physician's progress notes.

Based on interviews and chart review the facility failed to ensure that both the patient/family were counseled to prepare them for post hospital care prior to discharge for 1 (Patient # 9) of 10 patients reviewed.

Findings :


1. On 12/31/2013 at 3:06 PM a social worker was interviewed. The social worker stated, the standard is to call the patient/family at home to tell them number and name of all medical equipment companies or insurance companies and information regarding discharge planning. The social worker added this should be written in the notes and someone should of visited with the patient/family to tell them of the discharge plan.

2. A review of the facility's policy/procedure for Case Management- Documentation number 8, page 2 (dated 10/22/2013) stated, documentation in the medical record will be made whenever new information pertinent to the management of the case is learned or a change in discharge plans occurs. At a minimum, the social worker or case manager will write progress note on each open case every 3 days, and more often as indicated. Each subsequent entry will clearly reflect the status of the plan. Patient/family inclusion discharge planning process will be documented. The patient/family understanding and agreement with the discharge plan will also be documented.

3. A Review of policy/procedure for Case Management- Discharge Planning number 24, on page 1 under policy (dated 10/22/2013)revealed: The purpose of discharge planning is to identify a patient's unique needs for continuing physical, emotional, ADL ( Activites of Daily Living ), transportation, social and other needs to arrange services to meet those needs. Needed discharge services may include: medical equipment not provided by the associated hospital department for use after discharge.

4. A review of Patient # 9 record review shows that patient was admitted to the facility for 12 days for the removal of an infected graft from left leg. A review of the discharge notes summary form show that on 11/08/2013 a discharge evaluation was started for Patient # 9. Further review of Patient # 9's discharge evaluation notes show that on 11/11/2013 medical equipment for this Patient #9 was to be delivered to the patient's home. No documentation that this was discussed with Patient #9 or Patient #9's representative. Patient #9 discharged home. There were no discharge evaluation notes that the discharged was discussed with patient or patient's representative. Further review of the discharge evaluation notes revealed that after Patient #9 was discharged the case manager had spoke to an insurance company, there is no documentation the facility to followed up with the Patient #9 or Patient #9's representative.