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Based on medical record review, staff interview, and review of facility policies/procedures, the facility failed to ensure that hospital personnel completed a discharge planning evaluation in a timely manner in five (sample patients #16, #17, #20, #22, and #25) of twenty records reviewed. This failure had the potential to cause unnecessary delays in patient discharge.

The findings were:

Medical record review on 9/20/2010, revealed the following:

Sample patient #16, was a 53 year old admitted to the hospital on 9/14/2010, for viral meningitis and dehydration. The record did not contain any discharge planning documentation.

Sample patient #17, was a 51 year old admitted to the hospital on 9/15/2010, for Chron's disease. The record did not contain any discharge planning documentation.

Sample patient #20, was a 75 year old admitted to the hospital on 9/19/2010, for generalized weakness and urinary tract infection. The record indicated that a discharge planning consult was requested. The record, however, did not contain any discharge planning documentation.

Sample patient #22, was a 62 year old admitted to the hospital on 9/7/2010, for generalized weakness and bronchitis. The record did not contain any discharge planning documentation. Upon further review on 9/22/2010, it was found that documentation of interdisciplinary rounds contained a section for the case management to give updates. This section indicated issues related to Utilization Review and barriers to discharge planning. However, there was no documentation of a preliminary discharge plan or revisions to such a plan in the patient's record.

Sample patient #25, was a 70 year old admitted to the hospital on 9/18/2010, for abdominal pain and hypertensive urgency. The record indicated that a discharge planning consult was requested on 9/18/2010. The record did not contain any discharge planning documentation. Upon further review on 9/21/2010, at approximately 9:18 a.m., no documentation for discharge planning existed. Review of the record on 9/22/2010, at approximately 10:00 a.m., revealed that discharge planning had been documented after interview with the Director of Case Management on 9/21/2010.

On 9/20/2010, at approximately 4:00 p.m., an interview with the Director of Case Management was conducted. S/he had confirmed that there was no documentation of discharge plans on sample patients #16, #17, and #20. S/he stated that in the case of sample patient #16, that s/he had "been in and out of his/her room, but have not made any charting". S/he stated that in the case of sample patient #17, that when it comes to the "younger population" that the case manager would see the patient when "they are closer to discharge". S/he stated that in the case of sample patient #20, that the interdisciplinary team meets for care conferences on Tuesdays and Thursdays at 1:00 p.m., and that the patient would be discussed there. The Director of Case Management also stated that she had read the patient's charts, but had not made attempts to speak to the patients as the patients had been "really sick."

On 9/21/2010, at approximately 9:15 a.m., an interview with the Director of Case Management was conducted. She stated that discharge planning was triggered on pathways and patients were identified for discharge needs during interdisciplinary rounds and upon admission assessment. S/he stated that once a request was received, that the case manager would see the patient within 24 hours, except on the weekend. S/he also confirmed that there was no documentation of discharge plans on sample patients #22 and #25. S/he stated that the discharge plan was an "informal process" and that documentation would be in the case management notes in the computer documentation.

A review of a facility policy titled "Case Management - Discharge Planning" revealed the following, in pertinent parts:

"...Policy:
A. All patients will be evaluated by the admitting nurse for case management/discharge planning needs within 24 hours of admission and referred to case management as indicated.
B. All patients will be reviewed by Case Manager for appropriate level of services.
C. All patients will have the benefit of discharge planning available at any point during their stay...
...E. All case management and discharge needs will be documented in Meditech and will be accurate and thorough...
...4. The Case Manager/Discharge Planner will document:
1. All information regarding case management and discharge planning in a thorough and accurate manner in the "Case Management Note" section of the patient's computer record;
a. All updated and/or re-evaluations as necessary..."

Based upon staff interview, review of facility documents and a review of the hospital's policies/procedures, the hospital failed to reassess the discharge planning process periodically, including reviewing discharge plans to ensure that the plans were responsive to the patient's discharge needs.

The findings were:

A hospital policy titled: "Case Management - Discharge Panning" was reviewed. The policy did not have any mention of reassessment of the hospital's discharge planning process, including reviewing discharge plans to ensure that the plans were responsive to the patient's discharge needs.

On 9/21/2010, at approximately 9:00 a.m., an interview with the Director of Case Management was conducted. S/he stated that the Performance Improvement Council would be where the hospital would review the discharge planning process.

Minutes for the Performance Improvement Council were reviewed for a period of approximately one year. Three meeting's minutes contained mention of Utilization Review/Discharge Planning (8/26/10, 1/28/10, 8/27/2009), however, the reports contained in the minutes did not mention a review of the discharge planning process, rather the reports reflected Utilization Review information.

On 9/22/2010, at approximately 10:00 a.m., an interview with the Director of Case Management was conducted. When asked if s/he could show how the hospital had reviewed the discharge planning process in the meeting minutes that s/he had earlier indicated would contain the review, s/he was unable to do so.