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Based on record review and interview, the facility failed to provide adequate reassessment of the patients needs for discharge when the patients needs changed from the initial assessment in 1 of 10 records reviewed (Pt #1). This deficiency affected Pt #1 and has the potential to affect all other patients being discharged from this facility.

Findings include:

Review of facility policy # CM-08, titled "Discharge Screening/Planning" states, "2) a) A patient's health and/or mental status can change during the course of hospitalization. Because of this, the assessment of the patient's care needs is on ongoing and continuing process."

Review of Pt #1' MR on 4/1/15 at 10:30 AM revealed the following documentation:

Activity during hospitalization:

Pt #1 was independent with ambulation and activities of daily living upon admission to this facility on 12/20/2014 and Pt #1 used a prosthesis and a walker to get around prior to admission. The following activity was documented for Pt #1 during the initial seven day hospital stay:
12/31/14 = Up with stand by assistance and a walker with O2 on, up to chair
1/1/15 = Up in chair most of the shift
1/2/15 = Slept in chair for the night
1/3/15 = Slept in chair most of the night
1/4/15 = Up in chair using urinal, Up with two assist to the bathroom.
1/5/15 (day of discharge) = Up with assistance of one and a walker to chair, "short of breath with mild exertion, 02 at 3L." Also documented, "using commode at bedside."

Pt #1 MR shows documentation of active range of motion exercises (exercises done for immobile patients) 12/31/14 through 1/5/15.

Review of Pt #1's discharge documentation dated 1/5/15 revealed "discharge comment: up with 1-2 assist and walker, tol general diet, no further shortness of breath or difficulty breathing since neb (nebulizer) given around 1:15 PM... discharged with family via wheelchair at 6:10 PM"

Review of Pt #1's MR revealed Physical Therapy (PT) added a note to Pt #1's chart on 1/5/15 at 1:37 PM, day of discharge, stating Pt #1 would benefit from PT. Per interview with Dir of Medical/Surgical F, at the time of chart review, F stated PT does evaluations on almost every patient on admission and stated "I'm surprised they didn't do it until the day of discharge."

Discharge planning:

CM D conducted an initial assessment with Pt #1 on the 2nd day of admission (12/31/2014) and noted "Initial discharge assessment Plan/Intervention - CM available as needed."

CM did not document any further contact until day of discharge for Pt #1, on 1/5/2015 at 4:49 PM. The documentation states "Met with patient. He will be returning home today... States his wife may need some help as he was her helper. List of agencies that provide in home services given as well as the Fond du lac County Seniors booklet. He will give to his wife to review and decide if she wishes to arrange any of the services listed." There is not documentation related who will assist Pt #1 with activities of daily living as the previous documentation stated Pt #1 was up with assist of 1-2 and no longer independent. There is not documentation on Pt #1's potential need for physical therapy as indicated in previous documentation.

Review of Pt #1 MR revealed Pt #1 was discharged from the facility on 1/5/2015 and readmitted for a second admission dated 1/6/15 at 1:35 PM. CM D documented "Call received early this AM from patient's daughter... Stated patient is unable to get up from chair and has required use of wife's O2 during night. Does not feel family is able to provide as much care as patient is needing at home. Advised her that if she felt patient needed urgent intervention to call ambulance and return to ED. She feels patient needs rehab/SNF (skilled nursing facility) placement. Has familiarity with Lutheran Home... and would prefer that facility if available. Phone contact with Lutheran Home. Paperwork from yesterdays discharge faxed. Spoke with (ED Dr.)...is willing to complete needed paperwork if cleared from ED. Patient admitted from ED to medical floor. Patti at Lutheran home advised. Phone contact with daughter... Number given for ... Customer relations." Case Management continued to have contact with Pt #1 and Pt #1's family throughout the second admission until day Pt #1's death on 1/17/15.

Per Interview with Care Transitions Manager (CTM) E on 4/1/15 at 11:30 AM, CTM E stated CM D indicated on the initial assessment of Pt #1 that there were no needs for discharge and Pt #1 would return home. It is not required for CM to continue to follow Pt #1 because there were no discharge needs indicated. Per CTM E, if the patients needs change it would be communicated through a referral to case management by the physician or nursing. Case Management is involved in "Interdisciplinary Rounds" daily where patients progression and needs are discussed. Per CTM E this is a conversation and not documented in the medical record. CMT E confirmed CM D documented Pt #1 was given community resource booklets and information on the day of discharge. Per CTM E, this is a private pay service and it would be up to the patient to contact the agency and set up services if they want to. Per CTM E, Case management would only help set up services that qualified for reimbursement. CMT E stated PT was not address as an outside or outpatient service because PT was never ordered by the physician and only a screening for PT needs had occurred. CTM E stated when patients are readmitted within 30 of the last discharge it should be documented in the admission assessment noted by case management.

Reviewed documentation of admission assessment for Pt #1 dated 1/6/15 at 4:52 PM (the second admission) with CTM E at the time of interview on 4/1/15 at 11:30 AM. It states "See CM notes from 12/31/14 for CM assessment... Referral has been made to the Lutheran Home, will need to get prior authorization for SNF stay once pt has been medically stabilized." A full assessment did not occur for the second admission and the previous assessment was not adequate because of the patients increased needs. CMT E agreed a full assessment should have been done at the time of the second admission dated 1/6/15 and the previous admission was no longer applicable as Pt #1's discharge needs changed.