HospitalInspections.org

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Based on medical record review, document review, and interview, in four (4) of seven (7) medical records reviewed, the facility failed to ensure Social Workers conducted timely evaluation of patients admitted to the inpatient unit.

Findings include:

Review of the facility's Clinical Resource Management Policy and Procedure Manual titled "Discharge Planning and the Continuum of Care (last reviewed and revised 09/27/2), Procedure # 6" states: The decision to discharge patients is based on the following: ...B. An appropriate assessment for discharge planning that involves a patient or health care proxies or surrogates has been conducted by the physician team and social worker. The purpose of this assessment is to identify potential interdisciplinary needs upon discharge (i.e., physical or occupational therapy, home health services, post-acute care center, etc.) as well as determining eligibility for needed services."

Review of the medical record of Patient #1 revealed a 66-year-old male with a past medical history of Rheumatoid Arthritis, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Osteoarthritis, Opioid use who was admitted on 08/19/22 at 7:18 PM for muscle weakness. On 8/22/22 at 10:54 AM, Case Manager documented: "Chart review completed, 66-year-old male with past medical history of Rheumatoid Arthritis, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Carpal Tunnel, Osteoporosis for, worsening pain and stiffness in multiple joints for two months. Case Manager will follow with team for discharge planning needs."

There was no documentation in the medical record of a Social Work initial evaluation as part of his Discharge Planning needs.

Patient #2, an 86-year-old female with a medical history of COPD, Hypertension, CVA (stroke) and heart block s/p pacemaker. The patient was taken by ambulance to the Emergency Department (ED) with a complaint of syncopal episode and unstable vitals. She was evaluated and admitted to the Medicine Cardiac Telemetry Unit on 11/25/22 at 9:37 AM. A Case Management evaluation was completed on 11/28/22 at 7:36 PM, 58 hours after arrival on the Unit.

There was no documentation in the medical record that the patient received an initial evaluation by a Social Worker as part of a complete Discharge Planning assessment.

Patient #3 was a 50-day old pediatric patient who arrived in the ED on 10/6/22 at 7:00 AM with a chief complaint of fever. He was admitted at 10:24 AM with a diagnosis of COVID 19. He was transferred to the PICU at 11:32 AM. The Case Manager documented an initial Case Management evaluation on 10/07/22 at 9:21 AM.

There was no documentation of an initial evaluation by a Social Worker as part of identification of discharge needs or specialized Discharge Planning. The patient was discharged on 10/9/22.

Patient #5, a 76-year-old female admitted on 11/08/22 at 10:07 AM with a brain mass. The patient had an initial Case Management assessment on 11/10/22 at 12:42 AM.

There is no documentation in the medical record of a Social Work initial assessment to identify discharge Planning needs of this patient.

Review of facility policy titled "Discharge Planning Process Policy #C-691" revised 12/08/2019 states: All patients admitted to The Brooklyn Hospital have the right to receive individualized assessment of their needs that will assure continuity of quality health care services transitioning from hospital to the community or to an alternate level of care that is appropriate to meet their needs ...
Responsible Staff:
Social Work:
A. Receives and reviews referrals from care team.
B. Reviews medical records, interview the patient and/or family and collaborate with interdisciplinary team to complete a psychosocial work assessment.
C. Complete Social Work assessments within 48-72 hours on referred and high-risk patients ...
G. Document in the patient's Medical Record as often as necessary assessment/reassessment of the patient's tentative plans, any change(s) in plan(s) and impediments to timely discharges.

At interview on 12/1/22 at approximately 11:30 AM, Staff B, Director of Case Management stated: "The patient was admitted on the holiday Thanksgiving, and it was during the holiday weekend. We have staffing challenges for Social Workers."

During interview on 12/2/22 at 11:05 AM, Staff G, Director of Social Work stated: "They are supposed to put in an assessment within 48 hours of admission or sooner."

The finding was acknowledged by Staff B Director of Case Management on 12/1/22 and Staff G, Director of Social Work on 12/2/22