HospitalInspections.org

Based on record review and interview, the facility failed to ensure patients and/or patient's representatives were included in discharge plans and documented in the patient's record, in 1 (patient #1) of 5 (patient's #1 through #5) patient records reviewed.

A review of patient #1's record revealed the following information:
Patient #1 was a 77 year old female with a history of chronic kidney disease. Patient #1 presented to the facility's Emergency Department (ED) on Thursday, 6/9/2016, with complaints of shortness of breath. At the time of admission to the facility, patient #1 was in the process of outpatient treatment, including hemodialysis and lived at home. Patient #1's hospital course was prolonged due to underlying comorbidities and progressive renal disease leading to a 13 day hospital stay. Patient #1 was discharged on Wednesday, 6/22/2016, to a local Long Term Acute Care (LTAC) facility. Patient #1's record contained minimal documentation by the Discharge Planning staff (Case Management staff). The documentation stated:

On 6/11/2016 at 5:21 AM, staff #8 documented the following in the electronic medical record:
" ...SPOKE WITH PT (patient) AND PT'S SON. PT LIVES IN ROSSTON, AR ALONE. HOWEVER, SON, AND SON'S EX WIFE AND SON ALSO LIVE ON PROPERTY VERY CLOSE TO PT. PMD IS (patient #1's son) ... I'ADLS (sic) AND DRIVES. NO HHS (home health services). RX (prescription) COVERAGE. ULT FX (sic). DC (discharge) PLAN HOME WITH SON/FAMILY. SON TO PROVIDE TX (sic). CM (Case Management) WILL CONTINUE TO FOLLOW ASSIST WITH DC NEEDS AND CARE."

On 6/16/2016 at 3:40 p.m., staff #5 documented the following in the electronic medical record:
" ...ltac (long term acute care) prompt placed on chart."

On 6/17/2016 at 3:18 p.m., staff #5 documented the following in the electronic medical record:
" ...chart reviewed. Noted that post acute medical (LTAC) liaison documented that pt has been approved for transfer to (LTAC) south campus on Monday 6-20-16. Accepting md is dr .... and dr ... will consult."
On 6/17/2016 at 10:30 a.m. a nurse from an inpatient rehab located on the facility's campus, documented the following statement in the physician's progress notes: " ...Patient seen for eval (evaluation) for inpatient rehab. Awaiting PT (Physical Therapy) eval then will submit ...."

On 6/21/2016, staff #7, documented an electronic physician progress note that included the following statement: " ....Patient's son also expressed concern with local (Long Term Acute Care) facility, telling me that there is nobody there to watch her heart. Her son tells me that he wishes to discuss with patient and with rest the (sic) family concerning plan going forward. Ultimately, patient has been accepted to (local Long Term Acute Care facility) and could be transferred there ...."

In summary, patient #1's discharge planning documentation, provided the following information:
Patient #1 admitted to the facility on 6/9/2016. An initial review of patient #1's living situation and care needs prior to admission was documented on 6/11/2016, and according to the facility's policy. Five days later, on 6/16/2016, an LTAC prompt was placed on the chart, which meant patient #1 was being evaluated for admission to the local LTAC facility. One day later, on 6/17/2016, at 10:30 a.m., the local inpatient rehab initiated an evaluation of patient #1 for discharge placement to rehab. There was no record of follow up on the rehab evaluation. Also on 6/17/2016, at 3:18 p.m., staff #5 documented patient #1 was approved to discharge to the local long term acute care facility. On 6/21/2016, patient #1's son expressed concerns with the patient going to the local LTAC at discharge and planned to discuss it with the patient and other family members. There was no record the facility followed up with the patient and/or son/family in regards to their concerns. There was no clear methodical documentation of patient #1's discharge plan or evidence the patient and/or the patient's representative were included in the discharge planning process.

A review of the facility's Discharge Planning Policy #CM-PP-16, revealed the following information:
" ...POLICY/PURPOSE:
...The patient and family shall have input to the discharge plan and are an integral part of options and decisions.
...ASSESSMENT:
...Reassessment (of discharge needs) is made by the RN, Case Manager as often as necessary or at least every 7 days for long length of stays, at time of patient condition change or when relocated to a new medical floor ....All patients within the facility are provided discharge planning options with the patient and or family. If patient unable (sic) to assist with a discharge plan then the family is approached as a spoke person for the patient ....
...IMPLEMENTATION:
...5. Referrals are made to outside agencies (i.e., Home Health, Hospice, etc.) if additional services are required after discharge. The patient's choice of provider is documented on Hospital's 'Transition of Care Choice Letter' and this is placed in the Medical Record ....
...9. Transfers are done as a Nursing and Case Management collaborative. Prior to transfer patient will sign a 'Transfer Agreement Form' ....
DOCUMENTATION:
1. Documentation by the case manager is in the computerized medical record listed under Other Reports and called Discharge Planning Summary and contains any pertinent discharge information or services arranged such as nursing home placement, home health and hospice services, durable medical equipment or any other referral information ....
5. Some discharge plans will be simple for the self-care patients and those requiring assistance will be more complex and each will be reflected in the documentation.
6. The discharge plan will reflect a thorough evaluation of the patient's post hospital care needs and must address the needs identified ...."

An interview conducted on 3/22/2017, with staff #3, #4 and #5 (Case Management) confirmed the discharge planning documentation was inadequate and contained no evidence patient #1 and/or patient #1's representative were included in the discharge planning process.