HospitalInspections.org

Based on review of documentation in 3 of 3 medical records of patients who were discharged to a SNF (Patients 4, 6 and 7), and review of policies and procedures it was determined that the hospital failed to fully develop and implement its policies and procedures to ensure that a list of available and geographically appropriate Medicare participating SNFs was provided to the patient or the patient's representative(s), and that it was documented in the patient's medical record that the list was provided.

Findings include:

1. The policy and procedure titled "Discharge" dated effective "01/29/2013" was reviewed and reflected "For those patients requiring the services of a...(SNF) a list of...SNFs that are available to the patient and...in the case of a SNF, in the geographic area requested by the patient or that are contracted to the managed care organization the patient may be enrolled in, will be provided..." The policy contained no information reflecting that the hospital would ensure that it was documented in the medical record that the list was presented to the patient or the patients' representative.

2. The medical record of Patient 4 reflected that the patient was admitted with a diagnosis of anoxic brain injury and hyponatremia on 10/03/2014 at 0715.

The RN CM notes dated 10/07/2014 at 0906 reflected "SW met with pt. and [family member] to discuss d/c plans...[patient's family member] was really in favor of SNF and they asked SW to reserve a room at [SNF]."

The RN CM notes dated 10/08/2014 at 1100 reflected "Discharge to...[SNF] DC Date: 10/8/14...SW checked in with pt. and [family member] and set up w/c transport at 1330..."

The record reflected the patient was discharged to a SNF on 10/08/2014.

There was no documentation in the record to reflect that the required list of SNFs had been provided to the patient or the patient's representative for consideration in their choice of a SNF.

3. The medical record of Patient 6 reflected that the patient was admitted on 01/08/2016 at 1308 with a diagnosis of altered mental status.

The RN CM notes dated 01/11/2016 at 1002 reflected "...family wants [SNF]. Pt will d/c tomorrow. [SW] confirmed bed at [SNF]...SW confirmed plan with pt...Plan: d/c to [SNF] tomorrow at 11 a.m...No further SW needs at this time."

The record reflected the patient discharged to a SNF on 01/12/2016 at 1059.

There was no documentation in the record to reflect that the required list of SNFs had been provided to the patient or the patient's representative.

4. The medical record of Patient 7 reflected that the patient was admitted on 01/08/2016 at 1401 with a diagnosis of abdominal pain and progressive weakness.

The RN CM notes dated 01/10/2016 at 1036 reflected "...Pt is requesting SNF at d/c due to living alone and feeling unstable in home...Plan: Pt will likely d/c to SNF 1/11/-1/12..."

The record reflected the patient discharged to a SNF on 01/11/2016 at 1705.

There was no documentation in the record to reflect that the required list of SNFs had been provided to the patient or the patient's representative.

5. On 01/14/2016 at 1645 the Director of CM confirmed there was no documentation to reflect that the required list of SNFs had been provided to Patients 4, 6 and 7.

Based on review of documentation in 3 of 3 medical records of patients who were discharged to a SNF (Patients 4, 6 and 7), and review of policies and procedures it was determined that the hospital failed to fully develop and implement its policies and procedures to ensure that a list of available and geographically appropriate Medicare participating SNFs was provided to the patient or the patient's representative(s), and that it was documented in the patient's medical record that the list was provided.

Findings include:

1. The policy and procedure titled "Discharge" dated effective "01/29/2013" was reviewed and reflected "For those patients requiring the services of a...(SNF) a list of...SNFs that are available to the patient and...in the case of a SNF, in the geographic area requested by the patient or that are contracted to the managed care organization the patient may be enrolled in, will be provided..." The policy contained no information reflecting that the hospital would ensure that it was documented in the medical record that the list was presented to the patient or the patients' representative.

2. The medical record of Patient 4 reflected that the patient was admitted with a diagnosis of anoxic brain injury and hyponatremia on 10/03/2014 at 0715.

The RN CM notes dated 10/07/2014 at 0906 reflected "SW met with pt. and [family member] to discuss d/c plans...[patient's family member] was really in favor of SNF and they asked SW to reserve a room at [SNF]."

The RN CM notes dated 10/08/2014 at 1100 reflected "Discharge to...[SNF] DC Date: 10/8/14...SW checked in with pt. and [family member] and set up w/c transport at 1330..."

The record reflected the patient was discharged to a SNF on 10/08/2014.

There was no documentation in the record to reflect that the required list of SNFs had been provided to the patient or the patient's representative for consideration in their choice of a SNF.

3. The medical record of Patient 6 reflected that the patient was admitted on 01/08/2016 at 1308 with a diagnosis of altered mental status.

The RN CM notes dated 01/11/2016 at 1002 reflected "...family wants [SNF]. Pt will d/c tomorrow. [SW] confirmed bed at [SNF]...SW confirmed plan with pt...Plan: d/c to [SNF] tomorrow at 11 a.m...No further SW needs at this time."

The record reflected the patient discharged to a SNF on 01/12/2016 at 1059.

There was no documentation in the record to reflect that the required list of SNFs had been provided to the patient or the patient's representative.

4. The medical record of Patient 7 reflected that the patient was admitted on 01/08/2016 at 1401 with a diagnosis of abdominal pain and progressive weakness.

The RN CM notes dated 01/10/2016 at 1036 reflected "...Pt is requesting SNF at d/c due to living alone and feeling unstable in home...Plan: Pt will likely d/c to SNF 1/11/-1/12..."

The record reflected the patient discharged to a SNF on 01/11/2016 at 1705.

There was no documentation in the record to reflect that the required list of SNFs had been provided to the patient or the patient's representative.

5. On 01/14/2016 at 1645 the Director of CM confirmed there was no documentation to reflect that the required list of SNFs had been provided to Patients 4, 6 and 7.