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Tag No.: A0800
Based on record reviews, interviews, and review of the hospital discharge planning policy and procedures, the hospital failed to identify the patient's need for discharge planning for 2 of 28 concurrent patient charts reviewed for care and services. (Patient 11 and 14)
The findings are:
On 10/25/16 at 2:53 p.m., review of Patient 11's chart revealed the patient was admitted on 10/19/16 with Epilepsy. Further review of the patient's chart revealed a discharge order and a discharge summary both dated 10/25/16, but there was no documentation that the patient received a discharge screening and/or a discharge assessment. There was no other documentation available for review. On 10/26/16 at 10:41 a.m., the Clinical Informatic Analyst verified the findings, and acknowledged all patients should be screened. On 10/28/16 at 10:22 a.m., Registered Nurse 2, discharge planning, stated, "We screen all patients to see if they need a discharge plan within 24 hours of admission. This varies if the patient is admitted on the weekend. "
On 10/25/16 at 3:14 p.m., review of Patient 14's chart revealed the patient was admitted on 10/20/16 with an elevated Glucose level. The patient's chart revealed a physician discharge order and a physician discharge summary dated 10/25/16, but there was no documentation that the patient received a discharge screening and/or a discharge assessment. There was no other documentation available for review. On 10/26/16 at 10:32 a.m., the Clinical Informatic Analyst verified the findings, and acknowledged all patients should be screened. On 10/28/16 at 10:22 a.m., Registered Nurse 2, discharge planning, stated, "We screen all patients to see if they need a discharge plan within 24 hours of admission. This varies if the patient is admitted on the weekend."
Hospital policy and procedure, titled, "Discharge Planning ", reads, " .....The nurse case manager serves as the facilitator of the interdisciplinary team to assist the patient and family in developing and implementing an achievable discharge plan. Case management covers both the inpatient and outpatient (ambulatory care, same day surgery, observation, ED (emergency department) setting. All patients are assessed for discharge planning needs. Every patient is assessed for discharge planning needs ..... ".
Tag No.: A0820
Based on record reviews and interview, the hospital failed to ensure adequate counseling was provided to its patients for 1 of 28 concurrent patient charts reviewed for care and services related to the hospital's discharge process. (Patient 1)
The findings are:
On 10/25/16 at 1:30 p.m., review of Patient 1's chart revealed the patient was admitted on 9/27/16 with an infection. Review of the Case Manager's documentation dated 10/5/16 revealed, " .....Patient has questions about out of pocket expenses and how it would be paid. Left message for .....(potential transfer facility) and requested that he/she speak with patient. Nurse case manager will follow. Review of the Nurse Case Manager's notes dated 10/10/16, 10/11/16, 10/14/16, 10/18/16, 10/24/16 and 10/25/16 revealed there was no documentation of a follow up to the patient's concern related to out of pocket expenses. Review of the patient's chart revealed a physician discharge order and a discharge summary dated 10/25/16, but there was no documentation related to the patient's previous concern addressed. The hospital failed to ensure documentation of adequate counseling to this patient related to the patient's financial concerns.
Tag No.: A0837
Based on record reviews, interviews, and review of the hospital's discharge planning policy and procedures, the hospital failed to ensure the patient's medical information was sent to the receiving facility upon discharge (transfers/referrals) for 2 of 3 closed patient charts reviewed for care and services. (Patient 2 and 3)
The findings are:
On 10/25/16 at 11:21 a.m., review of Patient 2's chart revealed the patient was admitted on 8/27/16 with Weakness. Review of the patient's "Discharge Needs Assessment " form dated 8/29/16 revealed Referral Information/Admission Type: Inpatient and that transportation was available (Car; family or friend will provide). Review of the Case Manager documentation dated 9/10/16 revealed the patient was accepted for a charity acute rehabilitation bed. The Case Manager note dated 9/10/16 revealed,"Transfer packet given to 9 West Nurse Station". Review of the patient's chart revealed a physician discharge order and a discharge summary dated 9/10/16. Review of the discharge summary revealed: "Disposition: Home with assist." The hospital failed to ensure the correct disposition was noted in the patient's medical record. There was no other documentation available for review. The was no evidence that the patient's transfer documents were sent with the patient to the receiving facility. On 10/26/16 at 11:22 a.m., the Clinical Informatic Analyst verified the findings.
On 10/25/16 at 2:01 p.m., review of Patient 3's chart revealed the patient was admitted on 10/3/16 with Cerebrovascular accident (CVA), unspecified mechanism. Review of the patient's "Discharge Needs Assessment " form dated 10/5/16 revealed the need for transportation upon discharge since the family was unable to transport at this time. Review of the patient's chart revealed a physician discharge order and a discharge summary dated 10/18/16. The discharge summary revealed, "Disposition: Nursing Home / Skilled Nursing Facility." Review of the Case Manager's notes dated 10/18/16 revealed transportation was available via ambulance and " .....DC (discharge) packet prepared with highlighted areas for completion and given to the Charge RN (Registered Nurse) with a fax number to fax the discharge forms to the accepting facility. " Review of the nursing notes dated 10/18/16 revealed there was no documentation that the transfer forms were faxed to the receiving facility as directed. There was no other documentation available for review. There was no evidence that the patient's transfer documents were sent to the receiving facility with the patient. On 10/26/16 at 10:20 a.m., the Clinical Informatic Analyst verified the findings.
Hospital policy and procedure, titled, "Discharge Planning ", reads, " .....The Home Care Coordinator, in collaboration with other members of the interdisciplinary team, is responsible for overseeing the home health durable medical equipment (DME), infusion, and hospice referral process. Discharge orders and appropriate clinical information are sent to receiving agencies to ensure a safe transition to the next level of care ..... ".