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Based on interview and record review it was determined the facility failed to include discharge planning evaluations in patients' medical records to establish appropriate discharge planning. Four (4) patients (Patient #44 and Patients #25, #26, and #29 on the medical intensive care unit-MICU ) from a sample of thirty-five (35) patients whose records were reviewed facility-wide had no documented evidence of evaluation for discharge planning nor documentation about the need for a plan.

The findings include:

Record review of Patient #44, admitted status post motor vehicle accident on 04/04/10, revealed no discharge planning evaluation in the medical record. Patient #44 was discharged on 04/07/10.

Interview with the the Registered Nurse (RN) #29 on 04/07/10 at 4:40pm revealed the nurse or the physician is responsible for informing social service if there is a need for discharge planning. According to RN #29, because Patient #44 was ambulatory, there was no need for discharge planning.

Review of the medical record of Patient #26 on 04/07/10 revealed the patient was admitted to the facility on 03/26/10 with a diagnosis of Metastatic Lymphadenopathy. The patient was being treated in the MICU. The record contained no evidence of evaluation for discharge planning.

Review of the medical record of Patient #25 revealed the patient was admitted to the facility on 04/01/10 with a diagnosis of Sepsis. The patient was being treated in the MICU. The record contained no evidence of assessment for discharge planning.

Interview with the Nurse Manager of the MICU on 04/07/10 at 10:10am revealed patient #25 was being transferred to a medical/surgical unit in the hospital. She said that staff did discharge notes in the progress notes of the patients' record and there should have been some documentation from the care coordinator on Patient #25's record regarding discharge planning. The manager explained that nurses doing initial assessments of patients upon arrival to the unit triggered a referral to social services in the computer if they saw need to do so. Otherwise, nurses did not document specifics about inability to initiate a discharge plan.

Review of the medical record of Patient #29 revealed the patient was admitted to the facility on 03/12/10 with complaints of bilateral ankle paint and elevated heart rate. The patient later needed ventilator support for breathing and continued to need it at the time of the survey. The patient was being treated in the MICU. There was no documentation of assessment for discharge planning in the patient's record.

Interview on 04/07/10 at 10:00am with the Social Worker responsible for discharge planning on the MICU revealed she had not had the chance to evaluate several patients on that unit because she had been off work due to illness during the previous week. The Social Worker stated that it was her understanding she did not have to see every patient on the unit but was to do so when a consult from nursing services was generated due to issues such as homelessness or substance abuse.

Interview on 04/07/10 at 10:40am with the Director of Case Management revealed that, unless patients were discharged home from the MICU, discharge planning was not done on the unit unless a social worker was involved in the case. A nurse could ask for a social work consult at any time. However, if a patient was on a ventilator, did not have insurance and was ineligible for Medicaid (as in the case of Patient #29), staff did not evaluate the patient for discharge planning until the patient was weaned from the ventilator. In further interview with the Director, she stated Patient #29 met no criteria for discharge planning because the patient was being maintained in a coma on Versed and Fentanyl.

Review of the hospital's policy and procedure entitled, "Discharge Planning" revealed the following:
"The Registered Nurse conducts an initial nursing assessment of the patient, including an initial assessment of discharge planning needs. Based on the assessment, the Registered Nurse may initial a referral to the Social Worker. Responses to urgent referrals will be within 24-48 business hours."




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