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Based on policy and procedure review and clinical record review, it was determined that the facility failed to evaluate the nursing care of patients in that one of one (#8) patient clinical records did not contain documentation of turning patient every two hours to assure the skin policy was followed. The failed practice affected Patient #8 and created the likelihood to affect any patient needing to be turned every two hours. Findings follow:

A. Review of Policy and Procedure titled "Skin Integrity Care of the Patient With or at Risk for Impairment" showed the following:

1) For pressure ulcers present on admission follow the above II. A above.

2) II. A: Turn patient every two hours, inspect pressure points for signs of redness.


B. Review of Patient #8's clinical record showed on 08/12/20 from 8:07 AM to 3:10 PM Patient remained in right side lying position.

C. Findings in A and B were verified by the Compliance Coordinator on 10/09/20 at 12:15 PM

Based on clinical record review , review of policy and procedure, review of the CDC ( Centers for Disease Control and Prevention) Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) Discharging Patients dated August 10, 2020, and interview it was determined that the facility failed to ensure the methods for controlling and preventing the transmission of infections between the hospital and the community were followed in that one of one COVID positive patient was discharged to an unknown location without instructions to quarantine. The failed practice had the potential to transmit contagious infectious disease to the community and had the likelihood to affect any patient discharged with a positive COVID diagnosis. See Tag A-749.

Based on clinical record review, review of policy and procedure, review of the CDC ( Centers for Disease Control and Prevention) Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) Discharging Patients dated August 10, 2020, and interview, it was determined the facility failed to ensure the methods for controlling and preventing the transmission of infections between the hospital and the community in that one of one (#4) COVID positive patient was discharged to an unknown location without instructions to quarantine. The failed practice had the potential to transmit contagious infectious disease to the community and had the likelihood to affect any patient discharged with a positive COVID diagnosis.

Findings:

A. Review of the clinical record for Patient #4 (PT #4) showed the following:

1) PT#4 was diagnosed with COVID infection on 09/13/20 at 11:30 AM, admitted to the hospital and placed on the COVID unit.

2) Review of the Admission History Text dated 09/14/20 at 1:19 PM, showed, "Living Situation: Homeless."

3) Review of the Admit-Discharge-Transfer Forms dated 09/14/20 at 1:10 PM, showed, "from group home with c/o (complaint of) of SI (suicidal ideations) with plan to walk into traffic."

4) Review of Physician #1's order dated 09/14/20 at 5:55 PM, showed, consult to Case Management "for discharge planning, pt (Patient) is medically stable for discharge tomorrow, needs help with dc (discharge) plans as he is COVID positive."

5) Review of Physician #1 order dated 09/14/20 at 5:56 PM, showed, Consult to physician, consult to: (Physician #2), Behavioral Health.

6) Review of the Social Work-Case-Management Forms dated 09/15/20 at 9:47 AM, showed, "will meet with (Physician #2) today. Final discharge disposition will be based off this meeting. CM/SW (Case Management/Social Work) will follow."

7) Review of History and Physical - Consultation dated 09/15/20 at 4:09 PM, from Physician #2 showed, "He would benefit from referral to group home or substance use treatment facilities while he is in COVID quarantine housing."

8) Review of Social Work - Case Management Forms dated 09/15/20 at 4:19 PM, showed, "Social Worker received call from Physician #1 who expressed that patient will discharge today and will need clarification on where he will discharge to and arrange transport for him to safely discharge. He stated he has a sister, he has an apartment, but then will express that he is homeless as well. Social Worker called (PT #4) to clarify with patient and he stated that the doctor mentioned to him that someone would arrange for him to go to a hotel. Social Worker expressed that was not conveyed to her and that a taxi could be arranged to transport him to his destination. Patient expressed what location he would like to be taken to."

9) Review of Physician #1's order dated 09/15/20 at 4:39 PM, showed, "consult to Case Management for discharge planning, pt medically stable for discharge-please evaluate for discharge."

10) Review of the Discharge Documentation on 09/15/20 at 5:18 PM, showed, "Discharge To: Home with ambulatory/outpatient follow-up."

11) Review of the Inpatient Discharge Instructions dated 09/15/20 at 5:40 PM, showed no documentation of instruction for PT #4 to be quarantined after discharge for his COVID positive diagnosis.

12) Review of the Discharge-Face Sheet dated 09/15/20 at 5:56 PM, from Physician #1 showed, "Psych saw the patient and considered him safe to be discharged home with family care."

13) Review of the Discharge-Face Sheet dated 09/15/20 at 6:31 PM, showed an addendum by Physician #1 that stated, "I spoke to the Case Manager to make sure that the patient's sister was agreeable to taking the patient home before we discharge him. She called the sister and she said she would not take him back but said the patient was from a facility. Case Manager got in touch with the facility and they were ready to take him back."


B. Review of policy and procedure titled "Infection Prevention: Communicable/Reportable Disease & Report of Infection Requiring Action received 09/30/20 showed, "To assure that all patients with infectious and/or reportable diseases have the appropriate follow up and isolation procedures are followed."


C. Review of the CDC (Centers for Disease Control and Prevention) Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) Discharging Patients dated August 10, 2020, showed, "For patients who are not severely immunocompromised and who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test." Review of "Disposition of Patients with SARS_CoV-2 Infection" showed, "If discharged home: the decision to send the patient home should be made in consultation with the patient's clinical care team and local or state public health departments. It should include considerations of the home's suitability for and patient's ability to adhere to home isolation recommendations."


D. During an interview with Nurse Manager on 10/01/20 at 10:46 AM, she stated that Patient #4 was COVID positive and was discharged via taxi to the patient's home to the address on his face sheet.


E. The above findings in A, B, C, and D were verified with the Vice President of Patient Care on 10/02/19 at 8:30 AM.

Based on clinical record review, policy and procedure review, and interview, it was determined that the facility failed to have an effective discharge planning process in that one of one COVID positive patient with previous suicide ideation was discharged by taxi to an unknown location. The failed practice did not ensure the patient's discharge destination was suitable for the patient's quarantine requirements and had the likelihood to affect any patient discharged with a positive COVID diagnosis.

Findings: See Tags A-800, A-802, A-805, and A-806)

A. Review of the clinical record for Patient #4 showed the following:

1) Patient #4 (PT#4) was diagnosed with Suicide Ideation (SI) and COVID infection on 09/13/20 at 11:30 AM, admitted to the hospital and placed on the COVID unit.

2) Review of the Admission History Text dated 09/14/20 at 1:19 PM, showed, "Living Situation: Homeless."

3) Review of the Admit-Discharge-Transfer Forms dated 09/14/20 at 1:10 PM, showed, "from group home with c/o (complaint of) of SI (suicidal ideations) with plan to walk into traffic."

4) Review of Physician #1's order dated 09/14/20 at 5:55 PM, showed, consult to Case Management "for discharge planning, pt (Patient) is medically stable for discharge tomorrow, needs help with dc (discharge) plans as he is COVID positive."

5) Review of Physician #1 order dated 09/14/20 at 5:56 PM, showed, Consult to physician, consult to: (Physician #2), Behavioral Health.

6) Review of the Social Work-Case-Management Forms dated 09/15/20 at 9:47 AM, showed, "will meet with (Physician #2) today. Final discharge disposition will be based off this meeting. CM/SW (Case Management/Social Work) will follow."

7) Review of History and Physical - Consultation dated 09/15/20 at 4:09 PM, from Physician #2 showed, "He would benefit from referral to group home or substance use treatment facilities while he is in COVID quarantine housing."

8) Review of Social Work - Case Management Forms dated 09/15/20 at 4:19 PM, showed, "Social Worker received call from Physician #1 who expressed that patient will discharge today and will need clarification on where he will discharge to and arrange transport for him to safely discharge. He stated he has a sister, he has an apartment, but then will express that he is homeless as well. Social Worker called (PT #4) to clarify with patient and he stated that the doctor mentioned to him that someone would arrange for him to go to a hotel. Social Worker expressed that was not conveyed to her and that a taxi could be arranged to transport him to his destination. Patient expressed what location he would like to be taken to."

9) Review of Physician #1's order dated 09/15/20 at 4:39 PM, showed, "consult to case Management for discharge planning, pt medically stable for discharge-please evaluate for discharge."

10) Review of the Discharge Documentation on 09/15/20 at 5:18 PM, showed, "Discharge To: Home with ambulatory/outpatient follow-up."

11) Review of the Inpatient Discharge Instructions dated 09/15/20 at 5:40 PM, showed no documentation of instruction for PT #4 to be quarantined after discharge for his COVID positive diagnosis.

12) Review of the Discharge-Face Sheet dated 09/15/20 at 5:56 PM, from Physician #1 showed, "Psych saw the patient and considered him safe to be discharged home with family care."

13) Review of the Discharge-Face Sheet dated 09/15/20 at 6:31 PM, showed an addendum by Physician #1 that stated, "I spoke to the Case Manager to make sure that the patient's sister was agreeable to taking the patient home before we discharge him. She called the sister and she said she would not take him back but said the patient was from a facility. Case Manager got in touch with the facility and they were ready to take him back."


B. Review of facility policy and procedure received 10/01/20 titled "Discharge Planning" showed the following:

1) Discharge Planning is multi-disciplinary in approach and is initiated at the time of admission and/or pre-admission testing.

2) Reassessment is an ongoing process with all patients.

3) Documentation of discharge instructions that were provided to the patient will be entered into the patient's medical record as appropriate.

C. During an interview with Nurse Manager on 10/01/20 at 10:46 AM she stated that Patient #4 was discharged via taxi to the patient's home the address on his face sheet.

D. During an interview with the Social Worker on 10/01/20 at 10:15 AM she stated she called Patient #4's sister and the sister informed her that he had a room rented until the end of the month.

E. The above findings in A, B, C, and D were verified with the Vice President of Patient Care on 10/02/19 at 8:30 AM.

Based on clinical record review and policy and procedure review, it was determined that the facility failed to identify at an early stage in one of one (PT #4) patient who were likely to suffer adverse health consequences upon discharge. The failed practice had the likelihood to affect all patients discharged with a COVID positive diagnosis.

Findings:

A. Review of the clinical record for Patient #4 showed the following:

1) Patient #4 (PT #4) was diagnosed with Suicidal Ideations and COVID infection on 09/13/20 at 11:30 AM, admitted to the hospital and placed on the COVID unit.

2) Review of the Admission History Text dated 09/14/20 at 1:19 PM, showed, "Living Situation: Homeless."

3) Review of the Admit-Discharge-Transfer Forms dated 09/14/20 at 1:10 PM, showed, "from group home with c/o (complaint of) of SI (suicidal ideations) with plan to walk into traffic."

4) Review of Physician #1's order dated 09/14/20 at 5:55 PM, showed, consult to Case Management "for discharge planning, pt (Patient) is medically stable for discharge tomorrow, needs help with dc (discharge) plans as he is COVID positive."

5) Review of Physician #1 order dated 09/14/20 at 5:56 PM, showed, Consult to physician, consult to: (Physician #2), Behavioral Health.

6) Review of the Social Work-Case-Management Forms dated 09/15/20 at 9:47 AM, showed, "will meet with (Physician #2) today. Final discharge disposition will be based off this meeting. CM/SW (Case Management/Social Work) will follow."

7) Review of History and Physical - Consultation dated 09/15/20 at 4:09 PM, from Physician #2 showed, "He would benefit from referral to group home or substance use treatment facilities while he is in COVID quarantine housing."

8) Review of Social Work - Case Management Forms dated 09/15/20 at 4:19 PM, showed, "Social Worker received call from Physician #1 who expressed that patient will discharge today and will need clarification on where he will discharge to and arrange transport for him to safely discharge. He stated he has a sister, he has an apartment, but then will express that he is homeless as well. Social Worker called (PT #4) to clarify with patient and he stated that the doctor mentioned to him that someone would arrange for him to go to a hotel. Social Worker expressed that was not conveyed to her and that a taxi could be arranged to transport him to his destination. Patient expressed what location he would like to be taken to."

9) Review of Physician #1's order dated 09/15/20 at 4:39 PM, showed, "consult to case Management for discharge planning, pt medically stable for discharge-please evaluate for discharge."

10) Review of the Discharge Documentation on 09/15/20 at 5:18 PM, showed, "Discharge To: Home with ambulatory/outpatient follow-up."

11) Review of the Inpatient Discharge Instructions dated 09/15/20 at 5:40 PM, showed no evidence of instruction for PT #4 to be quarantined after discharge for his COVID positive diagnosis.

12) Review of the Discharge-Face Sheet dated 09/15/20 at 5:56 PM, from Physician #1 showed, "Psych saw the patient and considered him safe to be discharged home with family care."

13) Review of the Discharge-Face Sheet dated 09/15/20 at 6:31 PM, showed an addendum by Physician #1 that stated, "I spoke to the Case Manager to make sure that the patient's sister was agreeable to taking the patient home before we discharge him. She called the sister and she said she would not take him back but said the patient was from a facility. Case Manager got in touch with the facility and they were ready to take him back."


B. Review of facility policy and procedure received 10/01/20 titled "Discharge Planning" showed the following:

1) Discharge Planning is multi-disciplinary in approach and is initiated at the time of admission and/or pre-admission testing.

2) Reassessment is an ongoing process with all patients.

3) Documentation of discharge instructions that were provided to the patient will be entered into the patient's medical record as appropriate.


C. The above findings in A and B were verified with the Vice President of Pateint Care on 10/02/20 at 8:30 AM

Based on clinical record review, and policy and procedure review, it was determined that the facility failed to regularly reevaluate the discharge plan for one of one (PT #4) COVID positive patient in that the discharge plan did not ensure the multidisciplinary team knew where the patient was going to be discharged to. The failed practice did not ensure that the discharge disposition was suitable for quarantine housing and had the likelihood to affect all patients discharged with a COVID positive diagnosis.

Findings:

A. Review of the clinical record for Patient #4 (PT #4) showed the following:

1) PT#4 was diagnosed with Suicidal Ideations and COVID infection on 09/13/20 at 11:30 AM, admitted to the hospital and placed on the COVID unit.

2) Review of the Admission History Text dated 09/14/20 at 1:19 PM, showed, "Living Situation: Homeless."

3) Review of the Admit-Discharge-Transfer Forms dated 09/14/20 at 1:10 PM, showed, "from group home with c/o (complaint of) of SI (suicidal ideations) with plan to walk into traffic."

4) Review of Physician #1's order dated 09/14/20 at 5:55 PM, showed, consult to Case Management "for discharge planning, pt (Patient) is medically stable for discharge tomorrow, needs help with dc (discharge) plans as he is COVID positive."

5) Review of Physician #1 order dated 09/14/20 at 5:56 PM, showed, Consult to physician, consult to: (Physician #2), Behavioral Health.

6) Review of the Social Work-Case-Management Forms dated 09/15/20 at 9:47 AM, showed, "will meet with (Physician #2) today. Final discharge disposition will be based off this meeting. CM/SW (Case Management/Social Work) will follow."

7) Review of History and Physical - Consultation dated 09/15/20 at 4:09 PM, from Physician #2 showed "He would benefit from referral to group home or substance use treatment facilities while he is in COVID quarantine housing."

8) Review of Social Work - Case Management Forms dated 09/15/20 at 4:19 PM, showed, "Social Worker received call from Physician #1 who expressed that patient will discharge today and will need clarification on where he will discharge to and arrange transport for him to safely discharge. He stated he has a sister, he has an apartment, but then will express that he is homeless as well. Social Worker called (PT #4) to clarify with patient and he stated that the doctor mentioned to him that someone would arrange for him to go to a hotel. Social Worker expressed that was not conveyed to her and that a taxi could be arranged to transport him to his destination. Patient expressed what location he would like to be taken to."

9) Review of Physician #1's order dated 09/15/20 at 4:39 PM, showed, "consult to Case Management for discharge planning, pt medically stable for discharge-please evaluate for discharge."

10) Review of the Discharge Documentation on 09/15/20 at 5:18 PM, showed, "Discharge To: Home with ambulatory/outpatient follow-up."

11) Review of the Inpatient Discharge Instructions dated 09/15/20 at 5:40 PM, showed no evidence of instruction for PT #4 to be quarantined after discharge for his COVID positive diagnosis.

12) Review of the Discharge-Face Sheet dated 09/15/20 at 5:56 PM, from Physician #1 showed, "Psych saw the patient and considered him safe to be discharged home with family care."

13) Review of the Discharge-Face Sheet dated 09/15/20 at 6:31 PM, showed an addendum by Physician #1 that stated, "I spoke to the Case Manager to make sure that the patient's sister was agreeable to taking the patient home before we discharge him. She called the sister and she said she would not take him back but said the patient was from a facility. Case Manager got in touch with the facility and they were ready to take him back."


B. Review of facility policy and procedure received 10/01/20 titled "Discharge Planning" showed the following:

1) Discharge Planning is multi-disciplinary in approach and is initiated at the time of admission and/or pre-admission testing.

2) Reassessment is an ongoing process with all patients.

3) Documentation of discharge instructions that were provided to the patient will be entered into the patient's medical record as appropriate.


C. The findings in A and B were verified with the Vice President of Patient Care on 10/02/20 at 8:38 AM.

Based on clinical record review, and review of policy and procedure, it was determined that the facility failed to ensure appropriate arrangements for post-hospital care was made before discharging the patient in that one of one (PT #4) COVID positive patient were discharged via taxi to an unknown location after Physician #2 recommended that the patient would benefit from group home or substance abuse treatment facilities while he is in COVID quarantine housing. The failed practice did not ensure that the discharge destination was suitable for COVID quarantine requirements.

Findings:

A. Review of the clinical record for Patient #4 (PT #4) showed the following:

1) PT#4 was diagnosed with COVID infection on 09/13/20 at 11:30 AM, admitted to the hospital and placed on the COVID unit.

2) Review of the Admission History Text dated 09/14/20 at 1:19 PM, showed, "Living Situation: Homeless."

3) Review of the Admit-Discharge-Transfer Forms dated 09/14/20 at 1:10 PM, showed, "from group home with c/o (complaint of) of SI (suicidal ideations) with plan to walk into traffic."

4) Review of Physician #1's order dated 09/14/20 at 5:55 PM ,showed, consult to Case Management "for discharge planning, pt (Patient) is medically stable for discharge tomorrow, needs help with dc (discharge) plans as he is COVID positive."

5) Review of Physician #1 order dated 09/14/20 at 5:56 PM, showed, Consult to physician, consult to (Physician #2), Behavioral Health.

6) Review of the Social Work-Case-Management Forms dated 09/15/20 at 9:47 AM, showed, "will meet with (Physician #2) today. Final discharge disposition will be based off this meeting. CM/SW (Case Management/Social Work) will follow."

7) Review of History and Physical - Consultation dated 09/15/20 at 4:09 PM, from Physician #2 showed, "He would benefit from referral to group home or substance abuse treatment facilities while he is in COVID quarantine housing."

8) Review of Social Work - Case Management Forms dated 09/15/20 at 4:19 PM, showed, "Social Worker received call from Physician #1 who expressed that patient will discharge today and will need clarification on where he will discharge to and arrange transport for him to safely discharge. He stated he has a sister, he has an apartment, but then will express that he is homeless as well. Social Worker called (PT #4) to clarify with patient and he stated that the doctor mentioned to him that someone would arrange for him to go to a hotel. Social Worker expressed that was not conveyed to her and that a taxi could be arranged to transport him to his destination. Patient expressed what location he would like to be taken to."

9) Review of Physician #1's order dated 09/15/20 at 4:39 PM, showed, "consult to Case Management for discharge planning, pt medically stable for discharge-please evaluate for discharge."

10) Review of the Discharge Documentation on 09/15/20 at 5:18 PM, showed, "Discharge To: Home with ambulatory/outpatient follow-up."

11) Review of the Inpatient Discharge Instructions dated 09/15/20 at 5:40 PM, showed no documentation of instruction for PT #4 to be quarantined after discharge for his COVID positive diagnosis.

12) Review of the Discharge-Face Sheet dated 09/15/20 at 5:56 PM, from Physician #1 showed, "Psych saw the patient and considered him safe to be discharged home with family care."

13) Review of the Discharge-Face Sheet dated 09/15/20 at 6:31 PM, showed an addendum by Physician #1 that stated, "I spoke to the Case Manager to make sure that the patient's sister was agreeable to taking the patient home before we discharge him. She called the sister and she said she would not take him back but said the patient was from a facility. Case Manager got in touch with the facility and they were ready to take him back."


B. Review of facility policy and procedure received 10/01/20 titled "Discharge Planning" showed the following:

1) Discharge Planning is multi-disciplinary in approach and is initiated at the time of admission and/or pre-admission testing.

2) Reassessment is an ongoing process with all patients.

3) Documentation of discharge instructions that were provided to the patient will be entered into the patient's medical record as appropriate.


C. The findings in A and B were verified with the Vice President of Patient Care on 10/02/20 at 8:38 AM.

Based on review of clinical records, and policy and procedure review, it was determined that the facility failed to provide a complete discharge evaluation that included the likelihood of a patient needing post hospital services, the availability of the services, and the likelihood of the patients capacity for self-care in that one of one (#4) COVID positive patient was discharged to an unknown destination that had not been assessed for its suitability for COVID quarantine requirements. The failed practice did not ensure the discharge disposition was suitable for COVID positive quarantine requirements and had the likelihood to affect all patients discharged with a COVID positive diagnosis.

Findings:

A. Review of the clinical record for Patient #4 showed the following:

1) Patient #4 (PT#4) was diagnosed with Suicidal Ideations and COVID infection on 09/13/20 at 11:30 AM, admitted to the hospital and placed on the COVID unit.

2) Review of the Admission History Text dated 09/14/20 at 1:19 PM, showed, "Living Situation: Homeless."

3) Review of the Admit-Discharge-Transfer Forms dated 09/14/20 at 1:10 PM, showed, "from group home with c/o (complaint of) of SI (suicidal ideations) with plan to walk into traffic."
,
4) Review of Physician #1's order dated 09/14/20 at 5:55 PM, showed, consult to Case Management "for discharge planning, pt (Patient) is medically stable for discharge tomorrow, needs help with dc (discharge) plans as he is COVID positive."

5) Review of Physician #1 order dated 09/14/20 at 5:56 PM, showed, Consult to physician, consult to (Physician #2), Behavioral Health.

6) Review of the Social Work-Case-Management Forms dated 09/15/20 at 9:47 AM, showed, "will meet with (Physician #2) today. Final discharge disposition will be based off this meeting. CM/SW (Case Management/Social Work) will follow."

7) Review of History and Physical - Consultation dated 09/15/20 at 4:09 PM, from Physician #2 showed, "He would benefit from referral to group home or substance abuse treatment facilities while he is in COVID quarantine housing."

8) Review of Social Work - Case Management Forms dated 09/15/20 at 4:19 PM, showed, "Social Worker received call from Physician #1 who expressed that patient will discharge today and will need clarification on where he will discharge to and arrange transport for him to safely discharge. He stated he has a sister, he has an apartment, but then will express that he is homeless as well. Social Worker called (PT #4) to clarify with patient and he stated that the doctor mentioned to him that someone would arrange for him to go to a hotel. Social Worker expressed that was not conveyed to her and that a taxi could be arranged to transport him to his destination. Patient expressed what location he would like to be taken to."

9) Review of Physician #1's order dated 09/15/20 at 4:39 PM, showed, "consult to Case Management for discharge planning, pt medically stable for discharge-please evaluate for discharge."

10) Review of the Discharge Documentation on 09/15/20 at 5:18 PM, showed, "Discharge To: Home with ambulatory/outpatient follow-up."

11) Review of the Inpatient Discharge Instructions dated 09/15/20 at 5:40 PM, showed no documentation of instruction for PT #4 to be quarantined after discharge for his COVID positive diagnosis.

12) Review of the Discharge-Face Sheet dated 09/15/20 at 5:56 PM, from Physician #1 showed, "Psych saw the patient and considered him safe to be discharged home with family care."

13) Review of the Discharge-Face Sheet dated 09/15/20 at 6:31 PM, showed an addendum by Physician #1 that stated, "I spoke to the Case Manager to make sure that the patient's sister was agreeable to taking the patient home before we discharge him. She called the sister and she said she would not take him back but said the patient was from a facility. Case Manager got in touch with the facility and they were ready to take him back."


B. Review of facility policy and procedure received 10/01/20 titled "Discharge Planning" showed the following:

1) Discharge Planning is multi-disciplinary in approach and is initiated at the time of admission and/or pre-admission testing.

2) Reassessment is an ongoing process with all patients.

3) Documentation of discharge instructions that were provided to the patient will be entered into the patient's medical record as appropriate.


C. The findings in A and B were verified with the Vice President of Patient Care on 10/02/20 at 8:38 AM.