HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt. #2) open clinical records reviewed for discharge planning on 5 North Unit, the Hospital failed to ensure that the patient's condition was re-evaluated by the discharge planner to identify changes that require modification of the patient's discharge plan.

Findings include:

1. On 4/6/2021, the Hospital's policy titled, "Discharge Planning: Implementation and Documentation" (approved on 2/2021) was reviewed and included, "... Discharge planning services are provided to patients... 3. Care Management Assessment and Care Coordination... Care Management will reassess and document updates to the patient's discharge plans as interventions affect continuing care needs or the appropriateness of the discharge plan. Such reassessment and documentation shall occur no less than every 3 days during acute care hospitalization..."

2. On 4/6/2021 at approximately 11:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital on 2/9/2021 with a diagnosis of COVID-19. The clinical record indicated that Pt. #2 was evaluated by the discharge planner on 3/26/2020. However, as of survey date, 4/7/2021 (approximately 12 days), Pt. #2's condition has not been re-evaluated by the discharge planner to identify any changes that would require modification of Pt. #2's discharge plan.

3. On 4/7/2021 at approximately 9:30 AM, findings were discussed with E #2 (Director of Value-Based Acute Care Management). E #2 stated that the Care Management should have conducted and documented Pt. #2's re-evaluation every 3 days. E #2 was unable to provide documentation regarding a care management's re-evaluation for Pt. #2.