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Based on record reviews and interviews, the hospital failed to ensure that each patient's discharge planning evaluation assessed whether home or physical environment modifications would be necessary prior to discharge for 2 (#F10, #F11) of 2 rehab patients' records reviewed for discharge planning from a total of 7 (#F1, #F2, #F3, #F8, #F9, #F10, #F11) patient records reviewed for discharge planning from a total sample of 11 patients (#F1 - #F11).
Findings:

Review of the hospital's policy titled "Patient Assessment and Reassessment" revealed that discharge planning focuses upon the patient's assessed needs at the time of
admit. Discharge planning will begin during the admission phase and is
interdisciplinary. An assessment will be made of patient care needs and/or
deficits and the ability of the patient and/or significant other to provide care post
discharge. Referrals will be made to appropriate support services based on
these identified needs. Discharge planning is an ongoing process that wi ll be
completed at the point of discharge. Criteria for discharge may vary according to
treatment setting. Further review revealed that all patients admitted to the Rehabilitation Unit will have a functional, nutritional, social service assessment upon admission to the unit. A social service evaluation is performed with analysis of data collected to determine the state of patient needs and the need for further psychosocial care resources. Patients are reassessed on an ongoing basis depending on the patient's needs.

Patient #F10
Review of Patient #F10's medical record revealed he was a 49 year old male admitted on 03/17/15 with diagnoses of CVA (Cerebrovascular Accident), Hypertension, and Arthritis. He was discharged on 04/07/15.

Review of Patient #F10's History and Physical (H&P) performed on 03/18/15 revealed he came in with a CVA with left dense hemiparesis and increase in tone and left-sided hemineglect. Further review revealed it appeared to be a dysarthritic speech and hemorrhagic due to hypertensive urgency and hypertensive episode. Further review revealed Patenit #F10 was living in a single-story home with 3 steps to enter. He was completely independent for activities of daily living (ADLs) and ambulation and active in the community. He was set up for supervision with eating, minimal assist for grooming, moderate assist for transfers, maximum assist for upper body dressing, bathing, and toileting, and total assist for lower body dressing. He was doing supine to sit with moderate assist, edge of bed unsteady, and required verbal cues for upright posturing.

Review of Patient #F10's OT (Occupational Therapy) Evaluation conducted on 03/18/15 revealed he had poor safety awareness (fail minus at discharge), poor activity tolerance (fair plus at discharge), left upper extremity was flaccid with mixed tone (same at discharge). Further review revealed he had no equipment at home, and a quad cane was documented at discharge.

Review of Patient #F10's PT (Physical Therapy) Evaluation revealed it was conducted on 03/18/15. Further review revealed Patient #F10 lived in a single-story with 3 steps with bilateral hand rails, was independent with mobility, and was working offshore with a sandblasting company prior to hospitalization. Review of PT notes documented on 04/07/15 (day of discharge) revealed he was discharged home to continue with outpatient PT, needed caregiver assistance with transfers, stand-by assist with wheelchair use, and ambulated 100 feet twice with a straight cane with caregiver assistance.

Review of SF8Case Mgr.'s (Manager) notes documented on 03/18/15 at 8:30 a.m. revealed Patient #F10 was admitted with a diagnosis of CVA. Further review revealed that prior to hospitalization, Patient #F10 resided at home alone and was independent with all ADLs. He presently had flaccid upper extremity with poor safety awareness and was very impulsive. Patient #F10's goal was to return back home to his prior level of function. SF8Case mge. spoke with him about his goal possibly being a challenge due to his CVA. SF8Case Mgr. documented in her Psychosocial Assessment that Patient #F10 would need a walker and shower chair.

Review of SF8Case Mgr.'s documentation on 03/31/15 at 3:48 p.m. revealed that according to Patient #F10's sister, Patient #F10 would be going to his father's home at discharge, and his sisters would take turns staying with him there. Further review revealed a wheelchair and bedside commode will be ordered for Patient #F10.

Review of Patient #F10's "IRU Staffing & (and) Plan of Care", signed by the interdisciplinary team on 03/18/15, 03/25/15, and 04/01/15 revealed a section titled "Equipment Needs (Check all that apply) If needs have not yet been determined, check here:" Further review of this section revealed no equipment needs were checked, and the box next to "If needs have not yet been determined, check here" was not checked.

Review of SF6MSW's (Medical Social Worker) documentation on 04/06/15 revealed Patient #F10's sister verified by phone that his family could transport him to outpatient therapy. Further review revealed Patient #F10's sister was informed that he would be discharged on 04/07/15 at 11:00 a.m.. SF6MSW faxed the equipment order to the durable medical equipment (DME) company.

Review of SF6MSW's documentation on 04/07/15 revealed Patient #F10 was discharged home with his family, and orders for his outpatient therapy was faxed to the agency that would be providing his care.

Review of Patient #F10's "Social Services - Discharge Summary" signed by SF6MSW on 04/07/15 at 11:00 a.m. revealed a referral had been made to the DME company for a wheelchair, quad cane, and a tub bench.

Review of all documentation in Patient #F10's medical record revealed no documented evidence that an assessment of whether home modifications would be needed for Patient #F10 to return home with a wheelchair, quad cane, and tub bench or that a reassessment of his discharge needs was done regarding home modifications when it was determined that Patient #F10 would be dischrged to his father's home rather than his home. There was no documented evidence of the type of home (single story, multi-story, steps to enter) in which his father lived.

In an interview on 04/09/15 at 9:10 a.m., SF6MSW indicated SF8Case Mgr., who had documented the conferences she had with Patient #F10 and his sister, was off this week and unavailable to be interviewed. SF6MSW indicated where she formerly worked the Physical Therapist usually did a home evaluation if one was necessary. After reviewing the social service documentation, SF6MSW confirmed she didn't see any documentation of an assessment of Patient #F10's home environment or his father's home environment to determine if modifications would be needed to accomodate a wheelchair and tub bench.

Patient #F11
Review of Patient #F11's medical record revealed he was a 67 year old male admitted on 04/01/15 with a diagnosis of Right Hip Fracture.

Review of Patient #F11's "H&P/Post Admission Physician Evaluation" conducted on 04/02/15 revealed prior to hospitalization Patient #F11 lived in a single-story house with no steps and reported complete independence with ADLs and dressing. Further review revealed he currently was ambulating about 3 feet with a lot of pain and muscle spasms. Patient #F11 was set up for eating and grooming, was minimal assist for upper body dressing, toileting, and toilet tub transfers, functioning moderate assist for transfers and bathing, and maximum assist for lower body dressing. His other medical history included Hypoglycemia, Acute Renal failure, and Hypertension.

Review of SF8Case Mgr.'s documentation on 04/02/15 at 11:00 a.m. revealed Patient #F11 hada Right Intertrochanteric Fracture and underwent a Right Gamma Nail on 03/30/15. Prior to hospitalization he resided at home with his wife and was independent with all ADLs. Patient #F11 was interested in outpatient therapy after discharge and DME would be ordered prior to discharge.

Review of SF6MSW's documentation on 04/08/15 at 2:35 p.m. revealed an interdisciplinary staffing conference was held to discuss Patient #F11's status and progress. Further review revealed Patient #F11 was scheduled to be discharged on 04/10/15 to return home with his wife.

Review of Patient #F11's medical record revealed no documented evidence that an assessment was made to determine whether home modifications would be necessary to accommodate Patient #F11 post hip surgery.

In an interview on 04/09/15 at 9:55 a.m., SF6MSW indicated she usually spoke with the Physical Therapist the day before a patient's discharge to determine what DME needed to be ordered. After reviewing Patient #F11's medical record, she confirmed there was no documentation of any equipment needed by Patient #F11 after discharge. After having left the interview, SF6MSW returned to say that Patient #F11 had access to a walker at home, and she asked that the family bring it at the time of discharge, so it could be adjusted for his height. SF6MSW indicated she spoke with Patient #F11's family after the interdisciplinary conference on 04/08/15, but she hadn't documented their discusssion.

In an interview on 04/09/15 at 10:00 a.m., SF7Director of Rehab indicated Patient #F11's wife had assisted him (Patient #F11) with a shower using a tub bench. SF7Director of Rehab further indicated he didn't know if Patient #F11 had a tub bench at home. He confirmed, after reviewing Patient #F11's medical record, that there was no documented evidence of an assessment of Patient #F11's bathing needs after discharge and if home modification would be needed to accommodate the use of a tub bench in the bathroom.

Based on record reviews and interviews, the hospital failed to ensure that each patient's discharge plan was reassessed when there was a change in the patient's condition or in the location to which the patient was being transferred for 1 (#F10) of 2 rehab patients' records reviewed for discharge planning from a total of 7 (#F1, #F2, #F3, #F8, #F9, #F10, #F11) patient records reviewed for discharge planning from a total sample of 11 patients (#F1 - #F11).
Findings:

Review of the hospital's policy titled "Patient Assessment and Reassessment" revealed that discharge planning focuses upon the patient's assessed needs at the time of
admit. Discharge planning will begin during the admission phase and is
interdisciplinary. An assessment will be made of patient care needs and/or
deficits and the ability of the patient and/or significant other to provide care post
discharge. Referrals will be made to appropriate support services based on
these identified needs. Discharge planning is an ongoing process that will be
completed at the point of discharge. Criteria for discharge may vary according to
treatment setting. Further review revealed that all patients admitted to the Rehabilitation Unit will have a functional, nutritional, social service assessment upon admission to the unit. A social service evaluation is performed with analysis of data collected to determine the state of patient needs and the need for further psychosocial care resources. Patients are reassessed on an ongoing basis depending on the patient's needs.

Patient #F10
Review of Patient #F10's medical record revealed he was a 49 year old male admitted on 03/17/15 with diagnoses of CVA (Cerebrovascular Accident), Hypertension, and Arthritis. He was discharged on 04/07/15.

Review of Patient #F10's History and Physical (H&P) performed on 03/18/15 revealed he came in with a CVA with left dense hemiparesis and increase in tone and left-sided hemineglect. Further review revealed it appeared to be a dysarthritic speech and hemorrhagic due to hypertensive urgency and hypertensive episode. Further review revealed Patient #F10 was living in a single-story home with 3 steps to enter. He was completely independent for activities of daily living (ADLs) and ambulation and active in the community. He was set up for supervision with eating, minimal assist for grooming, moderate assist for transfers, maximum assist for upper body dressing, bathing, and toileting, and total assist for lower body dressing. He was doing supine to sit with moderate assist, edge of bed unsteady, and required verbal cues for upright posturing.

Review of Patient #F10's OT (Occupational Therapy) Evaluation conducted on 03/18/15 revealed he had poor safety awareness (fail minus at discharge), poor activity tolerance (fair plus at discharge), left upper extremity was flaccid with mixed tone (same at discharge). Further review revealed he had no equipment at home, and a quad cane was documented at discharge.

Review of Patient #F10's PT (Physical Therapy) Evaluation revealed it was conducted on 03/18/15. Further review revealed Patient #F10 lived in a single-story with 3 steps with bilateral hand rails, was independent with mobility, and was working offshore with a sandblasting company prior to hospitalization. Review of PT notes documented on 04/07/15 (day of discharge) revealed he was discharged home to continue with outpatient PT, needed caregiver assistance with transfers, stand-by assist with wheelchair use, and ambulated 100 feet twice with a straight cane with caregiver assistance.

Review of SF8Case Mgr.'s (Manager) notes documented on 03/18/15 at 8:30 a.m. revealed Patient #F10 was admitted with a diagnosis of CVA. Further review revealed that prior to hospitalization, Patient #F10 resided at home alone and was independent with all ADLs. He presently had flaccid upper extremity with poor safety awareness and was very impulsive. Patient #F10's goal was to return back home to his prior level of function. SF8Case Mgr. spoke with him about his goal possibly being a challenge due to his CVA. SF8Case Mgr. documented in her Psychosocial Assessment that Patient #F10 would need a walker and shower chair.

Review of SF8Case Mgr.'s documentation on 03/24/15 at 10:36 a.m. revealed Patient #F10 was interested in outpatient therapy and would have transportation available to him.

Review of SF8Case Mgr.'s documentation on 03/31/15 at 3:48 p.m. revealed that according to Patient #F10's sister, Patient #F10 would be going to his father's home at discharge, and his sisters would take turns staying with him there. Further review revealed a wheelchair and bedside commode will be ordered for Patient #F10.

Review of Patient #F10's "IRU Staffing & (and) Plan of Care", signed by the interdisciplinary team on 03/18/15, 03/25/15, and 04/01/15 revealed a section titled "Equipment Needs (Check all that apply) If needs have not yet been determined, check here:" Further review of this section revealed no equipment needs were checked, and the box next to "If needs have not yet been determined, check here" was not checked.

Review of SF6MSW's (Medical Social Worker) documentation on 04/06/15 revealed Patient #F10's sister verified by phone that his family could transport him to outpatient therapy. Further review revealed Patient #F10's sister was informed that he would be discharged on 04/07/15 at 11:00 a.m.. SF6MSW faxed the equipment order to the durable medical equipment (DME) company.

Review of SF6MSW's documentation on 04/07/15 revealed Patient #F10 was discharged home with his family, and orders for his outpatient therapy was faxed to the agency that would be providing his care.

Review of Patient #F10's "Social Services - Discharge Summary" signed by SF6MSW on 04/07/15 at 11:00 a.m. revealed a referral had been made to the DME company for a wheelchair, quad cane, and a tub bench.

Review of all documentation in Patient #F10's medical record revealed no documented evidence that an assessment of whether home modifications would be needed for Patient #F10 to return home with a wheelchair, quad cane, and tub bench or that a reassessment of his discharge needs was done regarding home modifications when it was determined that Patient #F10 would be discharged to his father's home rather than his home. There was no documented evidence of the type of home (single story, multi-story, steps to enter) in which his father lived.

In an interview on 04/09/15 at 9:10 a.m., SF6MSW indicated SF8Case Mgr., who had documented the conferences she had with Patient #F10 and his sister, was off this week and unavailable to be interviewed. SF6MSW indicated where she formerly worked the Physical Therapist usually did a home evaluation if one was necessary. After reviewing the social service documentation, SF6MSW confirmed she didn't see any documentation of an assessment of Patient #F10's home environment or his father's home environment to determine if modifications would be needed to accommodate a wheelchair and tub bench.

In an interview on 04/09/15 at 9:55 a.m., SF6MSW indicated she usually would get with the Physical Therapist the day before a patient's discharge to discuss what DME needed to be ordered.