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The facility was determined to be out of compliance with 42 CFR 482.43 Conditions of Participation for Discharge Planning based on the facility ' s failure to: 1) provide an adequate discharge plan , 2) complete a discharge planning evaluation , 3) provide qualified personnel to develop, and supervise the development of the discharge plan and the evaluation , 4) provide an appropriate discharge for sample patient #2 who needed post-hospital services. refer to A-0800, A-0806, A-0807, A-0808, and A-0818.

Based on interview and record review The facility failed to identify and provide an adequate discharge plan for 1 of 13 sample patients ( #2) who had a high potential to suffer an adverse health consequence upon discharge to an ALF.

Findings include:
Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from the assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change.


Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "

The Living Environment Factors form found in sample patient #2 medical record was blank. This form is used per the facility's policy, for interdisciplinary care conference / discharge planning .

The Discharge Summary of sample patient #2 addresses patient education for stroke and the discharge medications. The discharge planning stated that anticipated discharge was to an assisted living facility with nursing, wound care and occupational therapy.

There are no nursing, wound care or occupational therapy discharge orders written. The discharge order reads " D/C [discharge] to ALF [assisted living facility] social worker to arrange transportation " . The discharge prescription dated 10/18/11 is for oral medications only, with no wound care orders or medications. The case manager documented on 10/18/11 at 3:09 pm " called the ALF [assisted living facility] and notified pt [patient] dc [discharge] today; transport done for 4 p.m.; pt ' s [patient ' s] son notified about dc [discharge];. " The discharge summary from the attending physician stated the patient came to the facility with decubitus ulcers in both heels but does not mention anything further about the ulcers at discharge or care after discharge.

Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge.

During interview with the Director of the 2nd floor Medical Surgical unit on February 2, 2012 at 5 pm she stated that case management is responsible for following the physician order for discharging a patient. The Director stated that the case manager should be able to know the stage of the ulcer because it is in the patient ' s chart and the case manager should know the diagnosis at discharge. The Director went on to state that the nurses on the floor would be aware of the discharge location but would not know the rule that patient ' s with greater than a stage 2 ulcer cannot go to an assisted living facility.
The facility's policy states that the case manager/social worker will complete an initial assessment. Continual assessment of changes in the patient's status/responses to treatment will be documented in the medical record and reflected on the Case Management/ Discharge Planning form.

There were no documented evidence in the medical record that the above policy was implemented for sample patient #2.

Based on record review and interview the facility failed to provide a discharge planning evaluation for one of 13 sample patients ( #2).

Findings include :

Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from the assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change.


Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "

The Living Environment Factors form found in sample patient #2 medical record was blank. This form is used per the facility's policy, for interdisciplinary care conference / discharge planning .


Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge.

The facility's policy " Interdisciplinary Care Conference/Discharge Planning " states that the case manager/social worker will complete an initial assessment. Continual assessment of changes in the patient's status/responses to treatment will be documented in the medical record and reflected on the Case Management/ Discharge Planning form. The case manager / social worker and the assigned nurse will assess the patient's anticipated discharge and continuing care needs within 24 hours of admission, or 72 hours or next working day.
There were no documented evidence in the medical record that the above policy was implemented for sample patient #2.

Based on record review and interview the facility failed to provide qualified personnel to develop, and supervise the development of an appropriate discharge plan and evaluation for 1 of 13 sample patients ( #2) who had post discharged needs.

Findings include:


Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from the assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change.


Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "

The Living Environment Factors form found in sample patient #2 medical record was blank. This form is used per the facility's policy, for interdisciplinary care conference / discharge planning and for the initial discharge assessment and planning .


Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge.

The facility's policy " Interdisciplinary Care Conference/Discharge Planning " states that the case manager/social worker will complete an initial assessment. The policy also states that continual assessment of changes in the patient's status/responses to treatment will be documented in the medical record and reflected on the Case Management/ Discharge Planning form. The case manager / social worker and the assigned nurse will assess the patient's anticipated discharge and continuing care needs within 24 hours of admission, or 72 hours or next working day. The case manger/social worker will also plan for appropriate disposition upon discharge and will provide discharge planing instructions, to the patient.

There were no documented evidence in the medical record that the above policy was implemented for sample patient #2.

Based on record review and interview the facility failed to complete an adequate discharge planning evaluation for 1 of 13 sample patients (#2) who needed post-hospital services.

Findings include:

Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from the assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change.


Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "

The Living Environment Factors form found in sample patient #2 medical record was blank. This form is used per the facility's policy, for interdisciplinary care conference / discharge planning .

The Discharge Summary addresses patient education for stroke and the discharge medications. The discharge planning stated that anticipated discharge was to an assisted living facility with nursing, wound care and occupational therapy.

There are no nursing, wound care or occupational therapy discharge orders written. The discharge order reads " D/C [discharge] to ALF [assisted living facility] social worker to arrange transportation " . The discharge prescription dated 10/18/11 is for oral medications with no wound care orders or medications. The case manager documented on 10/18/11 at 3:09 pm " called Dora Home ALF [assisted living facility] and notified pt [patient] dc [discharge] today; transport done for 4 p.m.; pt ' s [patient ' s] son notified about dc [discharge];. " The discharge summary from the attending physician stated the patient came to the facility with decubitus ulcers in both heels but does not mention anything further about the ulcers at discharge or care after discharge.


Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge. . The Director stated that discharge planning begins upon entrance in to the facility with the case manager seeing the patient.

Policy and procedure " Interdisciplinary Care Conference/Discharge Planning " reads " the case management/social worker will complete an initial assessment including patient ' s support system, environmental, and equipment needs, and accessibility to needed resources. Continual assessment in the changes in the patient ' s status/responses to treatment will be documented in the medical record and reflected in the " Case Management/Discharge Planning " form. Furthermore the policy reads " the case manager/social worker, physician, nursing staffs, other appropriate member of the health care team, and patient/significant other will plan for appropriate disposition upon discharge. "

Based on record review and interview the facility failed to provide an appropriate discharge for 1 of 13 (sample patient #2) sampled patients.

The findings include:

Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from an assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change. The wound care documentation noted that 2 photographs of the wounds were taken but there are no photographs found in the record. Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "
The Living Environment Factors form found in the record was blank. The Discharge Summary addresses patient education for stroke and the discharge medications. The discharge planning stated that anticipated discharge was to an assisted living facility with nursing, wound care and occupational therapy. There are no nursing, wound care or occupational therapy discharge orders written. The discharge order reads " D/C [discharge] to ALF [assisted living facility] social worker to arrange transportation " . The discharge prescription dated 10/18/11 is for oral medications with no wound care orders or medications. The case manager documented on 10/18/11 at 3:09 pm that she called the ALF and notified them of the patient's discharge for today, that transportation would be for 4 p.m and that the patient's son was notified of the discharge plan. The discharge summary from the attending physician stated the patient came to the facility with decubitus ulcers in both heels but does not mention anything further about the ulcers at discharge or care after discharge. The final discharge is signed off that sample patient #2 returned to her previous assisted living facility.

Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge.

During interview with the Director of the 2nd floor Medical Surgical unit on February 2, 2012 at 5 pm she stated that case management is responsible for following the physician order for discharging a patient. The Director stated that the case manager should be able to know the stage of the ulcer because it is in the patient ' s chart and the case manager should know the diagnosis at discharge. The Director went on to state that the nurses on the floor would be aware of the discharge location but would not know the rule that patient ' s with greater than a stage 2 ulcer cannot go to an assisted living facility.


Policy and procedure " Interdisciplinary Care Conference/Discharge Planning " reads " the case management/social worker will complete an initial assessment including patient ' s support system, environmental, and equipment needs, and accessibility to needed resources. Continual assessment in the changes in the patient ' s status/responses to treatment will be documented in the medical record and reflected in the " Case Management/Discharge Planning " form. Furthermore the policy reads " the case manager/social worker, physician, nursing staffs, other appropriate member of the health care team, and patient/significant other will plan for appropriate disposition upon discharge. "

The facility was determined to be out of compliance with 42 CFR 482.43 Conditions of Participation for Discharge Planning based on the facility ' s failure to: 1) provide an adequate discharge plan , 2) complete a discharge planning evaluation , 3) provide qualified personnel to develop, and supervise the development of the discharge plan and the evaluation , 4) provide an appropriate discharge for sample patient #2 who needed post-hospital services. refer to A-0800, A-0806, A-0807, A-0808, and A-0818.

Based on interview and record review The facility failed to identify and provide an adequate discharge plan for 1 of 13 sample patients ( #2) who had a high potential to suffer an adverse health consequence upon discharge to an ALF.

Findings include:
Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from the assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change.


Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "

The Living Environment Factors form found in sample patient #2 medical record was blank. This form is used per the facility's policy, for interdisciplinary care conference / discharge planning .

The Discharge Summary of sample patient #2 addresses patient education for stroke and the discharge medications. The discharge planning stated that anticipated discharge was to an assisted living facility with nursing, wound care and occupational therapy.

There are no nursing, wound care or occupational therapy discharge orders written. The discharge order reads " D/C [discharge] to ALF [assisted living facility] social worker to arrange transportation " . The discharge prescription dated 10/18/11 is for oral medications only, with no wound care orders or medications. The case manager documented on 10/18/11 at 3:09 pm " called the ALF [assisted living facility] and notified pt [patient] dc [discharge] today; transport done for 4 p.m.; pt ' s [patient ' s] son notified about dc [discharge];. " The discharge summary from the attending physician stated the patient came to the facility with decubitus ulcers in both heels but does not mention anything further about the ulcers at discharge or care after discharge.

Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge.

During interview with the Director of the 2nd floor Medical Surgical unit on February 2, 2012 at 5 pm she stated that case management is responsible for following the physician order for discharging a patient. The Director stated that the case manager should be able to know the stage of the ulcer because it is in the patient ' s chart and the case manager should know the diagnosis at discharge. The Director went on to state that the nurses on the floor would be aware of the discharge location but would not know the rule that patient ' s with greater than a stage 2 ulcer cannot go to an assisted living facility.
The facility's policy states that the case manager/social worker will complete an initial assessment. Continual assessment of changes in the patient's status/responses to treatment will be documented in the medical record and reflected on the Case Management/ Discharge Planning form.

There were no documented evidence in the medical record that the above policy was implemented for sample patient #2.

Based on record review and interview the facility failed to provide a discharge planning evaluation for one of 13 sample patients ( #2).

Findings include :

Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from the assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change.


Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "

The Living Environment Factors form found in sample patient #2 medical record was blank. This form is used per the facility's policy, for interdisciplinary care conference / discharge planning .


Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge.

The facility's policy " Interdisciplinary Care Conference/Discharge Planning " states that the case manager/social worker will complete an initial assessment. Continual assessment of changes in the patient's status/responses to treatment will be documented in the medical record and reflected on the Case Management/ Discharge Planning form. The case manager / social worker and the assigned nurse will assess the patient's anticipated discharge and continuing care needs within 24 hours of admission, or 72 hours or next working day.
There were no documented evidence in the medical record that the above policy was implemented for sample patient #2.

Based on record review and interview the facility failed to complete an adequate discharge planning evaluation for 1 of 13 sample patients (#2) who needed post-hospital services.

Findings include:

Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from the assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change.


Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "

The Living Environment Factors form found in sample patient #2 medical record was blank. This form is used per the facility's policy, for interdisciplinary care conference / discharge planning .

The Discharge Summary addresses patient education for stroke and the discharge medications. The discharge planning stated that anticipated discharge was to an assisted living facility with nursing, wound care and occupational therapy.

There are no nursing, wound care or occupational therapy discharge orders written. The discharge order reads " D/C [discharge] to ALF [assisted living facility] social worker to arrange transportation " . The discharge prescription dated 10/18/11 is for oral medications with no wound care orders or medications. The case manager documented on 10/18/11 at 3:09 pm " called Dora Home ALF [assisted living facility] and notified pt [patient] dc [discharge] today; transport done for 4 p.m.; pt ' s [patient ' s] son notified about dc [discharge];. " The discharge summary from the attending physician stated the patient came to the facility with decubitus ulcers in both heels but does not mention anything further about the ulcers at discharge or care after discharge.


Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge. . The Director stated that discharge planning begins upon entrance in to the facility with the case manager seeing the patient.

Policy and procedure " Interdisciplinary Care Conference/Discharge Planning " reads " the case management/social worker will complete an initial assessment including patient ' s support system, environmental, and equipment needs, and accessibility to needed resources. Continual assessment in the changes in the patient ' s status/responses to treatment will be documented in the medical record and reflected in the " Case Management/Discharge Planning " form. Furthermore the policy reads " the case manager/social worker, physician, nursing staffs, other appropriate member of the health care team, and patient/significant other will plan for appropriate disposition upon discharge. "

Based on record review and interview the facility failed to provide an appropriate discharge for 1 of 13 (sample patient #2) sampled patients.

The findings include:

Record review of sample patient # 2 revealed the patient presented to the emergency department on October 13, 2011 via emergency medical services transportation with shortness of breath. The record revealed the patient was brought to the emergency room from an assisted living facility where she resides. Furthermore the emergency room physical examination by the house physician revealed " decubitus ulcer bilateral ankles. " On October 14, 2011 the wound care physician documented excisional debridement of left heel ulcer and right heel ulcer daily dressing change. The wound care documentation noted that 2 photographs of the wounds were taken but there are no photographs found in the record. Clinical Documentation revealed that on October 15, 2011 at 3:47 p.m. the wounds were assessed as right heel " stage III pressure ulcer. " On October 18, 2011 (the day of discharge) at 12:17 p.m. the wound assessment reads " right heel stage III pressure ulcer " and at 1:59 p.m. the wound assessment was documented as right heel " unstageable. "
The Living Environment Factors form found in the record was blank. The Discharge Summary addresses patient education for stroke and the discharge medications. The discharge planning stated that anticipated discharge was to an assisted living facility with nursing, wound care and occupational therapy. There are no nursing, wound care or occupational therapy discharge orders written. The discharge order reads " D/C [discharge] to ALF [assisted living facility] social worker to arrange transportation " . The discharge prescription dated 10/18/11 is for oral medications with no wound care orders or medications. The case manager documented on 10/18/11 at 3:09 pm that she called the ALF and notified them of the patient's discharge for today, that transportation would be for 4 p.m and that the patient's son was notified of the discharge plan. The discharge summary from the attending physician stated the patient came to the facility with decubitus ulcers in both heels but does not mention anything further about the ulcers at discharge or care after discharge. The final discharge is signed off that sample patient #2 returned to her previous assisted living facility.

Interview with the discharge planner on February 2, 2012 at 10:30 a.m. revealed that she has been working in case management at the facility for 6 years. Furthermore she stated that she has a bachelor ' s degree but is not a nurse or social worker. She stated that her responsibility is to coordinate discharge for patients. She stated she works with the health care team to place the patient in an appropriate setting upon discharge. Furthermore she contacts the facility once one is decided on to make sure a bed is available. The discharge planner stated she also is responsible for contacting the family to inform them of the discharge and disposition and to set up transportation for the patient at discharge should they need it. The discharge planner was asked by the surveyor if she was aware of any rules/regulations that would make a patient unable to go to an assisted living facility. The discharge planner mentioned patients that required more than assistance to daily living and patients with a pressure ulcer greater than a stage 2. The surveyor showed the discharge planner the discharge for sample patient #2 and asked if this was a patient she assisted with discharge. The discharge planner replied " yes " . The surveyor asked the discharge planner how she would know if this patient had a pressure ulcer. The discharge planner replied that she would know if the patient had any pressure ulcers greater than a stage 2 because the physician would have ordered home health after discharge for wound care. The discharge planner stated she is not clinical so she would not know that the patient had an ulcer or what stage it was if the doctor or nurse did not inform her. The discharge planner stated that the doctor orders the placement of the patient at discharge and that is the order she follows. The discharge planner has reviewed the physician ' s discharge order and is unable to locate any indication that sample patient #2 has a pressure ulcer or that wound care orders were written for after discharge.

During interview with the Director of the 2nd floor Medical Surgical unit on February 2, 2012 at 5 pm she stated that case management is responsible for following the physician order for discharging a patient. The Director stated that the case manager should be able to know the stage of the ulcer because it is in the patient ' s chart and the case manager should know the diagnosis at discharge. The Director went on to state that the nurses on the floor would be aware of the discharge location but would not know the rule that patient ' s with greater than a stage 2 ulcer cannot go to an assisted living facility.


Policy and procedure " Interdisciplinary Care Conference/Discharge Planning " reads " the case management/social worker will complete an initial assessment including patient ' s support system, environmental, and equipment needs, and accessibility to needed resources. Continual assessment in the changes in the patient ' s status/responses to treatment will be documented in the medical record and reflected in the " Case Management/Discharge Planning " form. Furthermore the policy reads " the case manager/social worker, physician, nursing staffs, other appropriate member of the health care team, and patient/significant other will plan for appropriate disposition upon discharge. "