HospitalInspections.org

Based on policy review, credential file review, and interview, the Governing Body failed to assume responsibility and provide oversight of the Medical staff credentialing process to ensure evidence was available for the recommendations of Medical Staff privileges.

The findings included:

1. The Governing Body failed to hold Medical Staff accountable for granting privileges and credentialing.
Refer to A 049.

2. The Governing Body failed to ensure credentialing information was current.
Refer to A 050.

Based on policy review, credentialing file review, and interview, the Governing Body failed to ensure the Medical Staff was held accountable and followed the hospital policies for the granting of medical staff privileges for 3 of 3 (Medical Provider #1, #2, and #3) Medical Provider credentialing files reviewed.

The findings included:

1. The facility's "Governing Body" policy revealed, "...Medical staff. The governing body will...Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff...Ensure the criteria for selection are individual character, competence, training, experience, judgement..."

2. Review of the Credentialing file for Medical Provider #1 revealed no evidence of recommendations from existing members of the Medical Staff.

3. Review of the Credentialing file for Medical Provider #2 revealed no evidence of recommendations from existing members of the Medical Staff.

4. Review of the Credentialing file for Medical Provider #3 revealed no evidence of recommendations from existing members of the Medical Staff.

5. In an interview in the conference room on 7/17/19 at 12:01 PM, the Regional Director of Quality Improvement and Assurance verified there was no other credential information available for Medical Providers #1, #2 and #3.

Based on policy review, credentialing file review, and interview, the Governing Body (GB) failed to ensure the Medical Staff was accountable to the GB and provided the GB updated and current information in order for the GB to verify that the Medical Staff applicants were qualified to be credentialed as part of the hospital's Medical Staff for 3 of 3 (Medical Providers #1, #2, and #3) credential files reviewed.

The findings included:

1. The facility "Medical Staff Credentialing and Privileging" policy revealed, "...Providers are recredentialed every two years. Expiration dates are tracked and monitored...a query of the National Practitioner Data Bank for all providers every two years...DEA [Drug Enforcement Agency] registration...Professional Liability Insurance Certificate...The completed and verified applicant packet, along with the recommendation regarding credentialing and clinical privileges, will be forwarded to the Medical Director, Administrator, and medical staff for review. The Medical Director will then forward the application for approval or denial of credentialing and clinical privileges to the hospital board of directors...The hospital board of directors reviews the application and will approve or deny credentialing and clinical privileges..."

2. Review of the credentialing file for Medical Provider #1 revealed no documentation of a statement of health, letters of recommendation, the Medical Staff's approval, or approval by the Governing Body.

3. Review of the credentialing file for Medical Provider #2 revealed there was no documentation of a DEA registration, Data Bank inquiry, Professional Liability Insurance Certificate, letters of recommendation, statement of health, the Medical Staff's approval, or approval by the Governing Body.

4. Review of the credentialing file for Medical Provider #3 revealed there was no documentation of a statement of health, Professional Liability Insurance Certificate, letters of recommendation, the Medical Staff's approval, or approval by the Governing Body.

5. In an interview in the conference room on 7/17/19 at 12:00 PM, the Regional Director of Quality Improvement and Assurance verified there was no other credentialing information available for Medical Providers #1, #2 and #3.

Based on medical record review and interview, the facility failed to ensure an informed consent was obtained upon admission and signed by the patient or the patients representative for 4 of 20 (Patient #1, 2, 12, and 14) patient records reviewed.

The findings included:

1. Medical record review for Patient #1 revealed an admission date of 7/14/19 with a diagnosis of Alzheimer's dementia with behavioral disturbance. There was no documentation in the medical record of an informed consent.

In an interview on 7/16/19 at 9:30 AM, the Director of Nursing verified there was not an informed consent for Patient #1.

2. Medical record review for Patient #2 revealed an admission date of 7/10/19 with a diagnosis of Major Depressive Disorder. There was no documentation in the medical record of an informed consent.

In an interview on 7/16/19 at 9:30 AM, the Director of Nursing verified there was not an informed consent for Patient #2.

3. Medical record review for Patient #12 revealed an admission date of 4/21/19 with a diagnosis of Dementia with behavioral disturbance. There was no documentation in the medical record of an informed consent.

In an interview on 7/16/19 at 9:30 AM, the Director of Nursing verified there was not an informed consent for Patient #12.

4. Medical record review for Patient #14 revealed an admission date of 3/30/19 with a diagnosis of Dementia with behavioral disturbance.

In an interview on 7/16/19 at 9:30 AM, the Director of Nursing verified there was not an informed consent for Patient #14.

5. In an interview in the conference room on 7/17/19 at 2:59 PM, the Director of Nursing stated she was unable to locate an informed consent policy.

Based on document review and interview, the facility's Quality Assessment and Performance Improvement Program (QAPI) failed to ensure the Governing Body (GB) participated in the establishment of the frequency and detail of quality indicator data to be collected for measuring, analyzing and tracking the hospital's performance and failed to ensure the hospital's GB determined the number of distinct quality improvement projects to be conducted annually.

The findings including

1. QAPI failed to ensure the GB participated in determining the frequencies and details of specified data to be collected.
Refer to A 273

2. QAPI failed to ensure the GB participated in the determination of performance improvement projects to be conducted annually.
Refer to A 309

Based on document review and interview, the facility failed to ensure the Governing Body (GB) participated in the determination of the frequency and the detail of the data to be collected in order for the Quality Assessment Performance Improvement comittee to measure, track, and trend the data.

The findings included:

1. Review of the Governing Body meeting minutes for 2019 revealed there was no QAPI oversight by the Governing Body
to determine the overall program scope for QAPI.

There was no documentaion the Governing Body had been involved in the frequency and detail of data collection had been specified for the QAPI to review, analyze, track and trend.

2. In an interview on 7/17/19 at 11:24 AM, the Regional Director of Quality Improvement and Assurance stated the hospital selects the frequency and detail of data collection not the Governing Body. The facility was unable to provide documentation the Governing Body was involved with the selection and frequency of data collection.

Based on document review and interview, the facility's Quality Assessment Performance Improvement (QAPI) comittee failed to ensure the Governing Body participated in the facility's QAPI program and ensure that the QAPI program indicators were selected by the GB, and the frequency of data collection was approved by the GB to address all areas of patient care and safety.

The findings included:

1. Review of the Governing Body meeting minutes for 2019 revealed there was no evidence the Governing Body participated in the selection of and approved the QAPI program's quality indicators, and no evidence the frequency and specifics of data collection was determined and approved by the Governing Body.

2. In an interview on 7/17/19 at 11:24 AM, the Regional Director of Quality Improvement and Assurance verified the Governing Body had not participated in the selection of the QAPI program's quality indicators, and had not approved QAPI program indicators and had not participated in or approved the frequency and specifics of data collection.

Based on policy review, medical record review observation and interview, the facility failed to follow physician orders for wound care, perform assessments of the wounds and document a description of the wounds for 1 of 1 (Patient #7) sampled patients with wounds.

The findings included:

1. Review of the facility's "Wound Care" policy revealed, "...Procedure...Admission Skin Assessment...A thorough inspection of the patient's skin must be accomplished within the first 24 hours of admissions/ read mission to the facility...Documentation of findings on the admission note should include any reddened areas, scratches, skin etc...Orders for wound care must be completed...Once a pressure injury is identified, an assessment must be documented. This must reflect that the physician and family were notified and what treatment/interventions were initiated...The Weekly Wound Progress Note must be initiated by the nurse. The Date of the Onset and the Location must be documented. This will be completed weekly and PRN [as needed]...Weekly documentation is to be recorded on a Weekly Wound Progress Not. A separate form must be completed for each wound. Complete an assessment block for each weekly assessment...Location- Describe using appropriate terms and body parts...Staging- for pressure ulcers stage according to clinical practice guidelines... Wound measurement...should include length, width, depth...."

2. Medical record review for Patient #7 revealed an admission date of 7/11/19 with an admitting diagnosis that included Major Depression.

Review of the nursing admission Skin Assessment anatomical drawing form dated 7/11/19 revealed Patient #7 had skin tears to the right hand and right elbow and a sacral wound. There was no documentation under the title "pressure ulcer" to indicate the stage of the wounds, the size of the wound, or the appearance and if there was drainage or odor of the wound. There was no documentation under the title "skin tear" to indicate the location, size, appearance and drainage/odor of the skin tear(s).

There was no documentation of a Weekly Wound Care Progress Note initiated by the nurse for 7/11/19 which described the appearance, shape, size and measurements of the patient's wounds.

The physician's History and Physical dated 7/12/19 revealed the physician documented, "...2 sacral ulcers, 1 [one] is a stage 2 [two] the other is unstageable at this time..."

Review of physician orders dated 7/12/19 at 4:48 PM revealed, "... Daily AM [morning], Clean sacral wound with normal saline daily and apply Hydrocolloid dressing..."

Review of the nursing progress notes dated 7/12/19 revealed RN #3 documented, "...dressing change to sacral area and to abrasions on legs and arms...colloid dressings were applied..." There was no documentation of the description or appearance of the wounds. There was no documentation the physician had ordered colloid dressing for the patient's skins tears on the patient's right arm.

There was no documentation of a Weekly Wound Care Progress Note by the nurse that described the appearance, shape, size and measurements of the patient's wounds for 7/12/19.

Review of the nursing progress notes dated 7/13/19 revealed RN #2 documented, "...changed dressing with hydrolloid..." There was no documentation of what wound site the dressing change was performed on, or a description or size of the wound.

There was no documentation of a Weekly Wound Care Progress Note by the nurse that described the appearance, shape, size and measurements of the patient's wounds for 7/13/19.

Review of the nursing Weekly Wound Care Note dated 7/14/19 at 11:08 revealed, "...Unstageable wound to sacral. No slough present inside wound and around wound, 2.5 cm [centimeters] x [by] .7 cm. Assessed by [named physician], continue dressing changes daily using the AG [Allevyn AG]dressing cover with padded dressing ..." There was no documentation of a physician's order for the Allevyn AG dressing. There was no documentation the nurse assessed the patient's right hand and elbow skin tears or performed any treatment to the patient's right hand/elbow wounds. There was no documentation of the appearance, shape of the sacral wound.

Review of the nursing note 7/14/19 at 3:00 PM revealed, "...Sacral wound cleaned with wound cleanser (DermaKlenz), pat dry with 4x4, Calcium Alginate applied to first wound, covered with Allevyn Ag Sacrum dressing, skin tears to right wrist and elbow, cleaned with DermaKlenz , pat dry with 4x4, triple ointment applied, covered with border gauze, aseptic technique used, patient tolerated well...date of onset: 7/11/19, Present on Admission: yes..." There was no documentation of physician's orders for the wound cleanser DermaKlenz, Calcium Alginate and Allevyn Ag to be applied to the patient's sacral wound or the patient's right hand/elbow wounds.

Observations in Patient #7's room on 7/15/19 at 1:30 PM during wound care revealed Registered Nurse (RN) #1 performed wound care to Patient #7's right elbow and right hand. The dressings on right elbow and right hand were dated 7/13/19. The sites were cleaned with DermaKlenz and triple antibiotic cream was applied. The skin tear was covered with gauze. There was no documentation of physician's orders for DermaKlenz and triple antibiotic cream to be applied to the patient's wound on the patient's right elbow and hand.

Further observations on 7/15/19 at 1:30 PM revealed Licensed Practical Nurse (LPN) #1 performed wound care to Patient #7's sacral area. LPN #1 cleaned the wound with DermakKlenz and patted it dry with a 4x4, then applied Calcium Alignate to the wound bed and covered the wound with Allevyn Ag Sacrum dressing. The LPN failed to follow physician orders dated 7/12/19. There was no documentation of physician's orders for the DermakKlenz, Calcium Alignate and Allevyn AG.

Review of the nursing Progress notes dated 7/15/19 revealed LPN #1 documented the above wound care as, "...performed wound care to sacral area, right upper posterior arm and wrist. Cleaned all areas with wound cleanser, pat dry and applied calcium AG [Allevyn AG] dressing to sacral wound, applied triple antibiotic to skin tears to right wrist and upper arm...". There was no documentation of the description or appearance of the wounds.

On 7/15/19 at 3:13 PM, after the surveyor had observed the wound care, nursing obtained physician's order to use the DermakKlenz, Calcium Alignate and Calcium Alignate to the patient's sacrum wound.

In an interview on 7/16/19 at 12:15 PM, the Assistant Director of Nursing (ADON) verified there were no physician orders for the wound care for skin tears on the patient's right elbow and right hand and no orders to change wound care to the sacral area until 7/15/19 at 3:13 PM. The ADON stated the skin assessment form should be completed upon admission by the nurse and should have correct and complete documentation on the form. The ADON stated a wound care note should have been completed on 7/11/19. The ADON verified the wound care note was not completed on 7/11/19, 7/12/19 and 7/13/19.

Based on review of the Food and Drug Administration (FDA), manufacturer's instruction, observation, and interview, the facility failed to ensure measures to prevent the potential spread of infection when 1 of 2 (Registered Nurse (RN) #3) nurses observed during medication administration failed to clean the glucometer according to manufacturer's instructions.

The findings included:

1. Review of a FDA (an organization that provides oversight of the manufacturing and distribution of medical devices ect...) letter to the Manufacturers dated 8/23/10 revealed for the cleaning of medical devices such as glucometers, " ...the disinfection solvent you choose should be effective against HIV [Human Immunodeficiency virus], Hep. C, [Hepatitis C] and Hep B [Hepatitis B] virus ...please note that 70% ethanol solutions are not effective against viral blood borne pathogens ...".

2. The manufacturer's instructions provided by the hospital for the glucometer revealed, "...The meter should be cleaned and disinfected after use on each patient...may be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed...The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens...A variety of the most commonly used EPA [Environmental Protection Agency]-registered wipes have been tested and approved for cleaning and disinfecting....have been approved...[named brand]..."

3. Observations in room 406 on 7/16/19 at 11:49 AM revealed, RN #3 completed a blood glucose reading on Patient #6 using a glucometer. RN #3 then cleaned the glucometer with an alcohol wipe and placed the glucometer in a storage bag.

4. In an interview at the nurses station on 7/16/19 at 12:00 PM, the Director of Nursing stated the glucometer should be cleaned with antibacterial soap and water or alcohol wipe.

In an interview in the conference room on 7/16/19 at 12:40 PM, the Assistant Director of Nursing verified the glucometer should be cleaned with the EPA approved wipes as in the manufacturer's instructions.

Based on policy review, medical record review and interview, the facility failed to ensure staff followed its Discharge Planning and Aftercare Planning policy and its Interdisciplinary Discharge Summary/Transition Planning policy and performed complete, timely and accurate discharge plans 20 of 20 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20) sampled patients reviewed for discharge planning.

The findings included:

1. The facility failed to ensure a discharge planning evaluation/assessment was performed to determine the patients' post discharge needs.
Refer to A 806

2. The facility failed to ensure they had a process to ensure discharge planning evaluations/assessments were completed timely.
Refer to A 810

3. The facility failed to ensure the discharge planning evaluation/assessment was documented in the patient's medical record.
Refer to A 812

Based on policy review, medical record review and interview, the facility failed to follow their policy and ensure a discharge planning assessment/evaluation was performed to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care for 20 of 20 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20) sampled patients reviewed for discharge planning.

The findings included:

1. Review of the facility policy "Interdisciplinary Discharge Summary/Transition Planning" revealed, "It is the policy of [facility name] to initiate the process of transition/discharge planning as early in a patients treatment plan as possible ...will occur within the initial assessment upon entry into programming [hospital stay]. Through the process of assessing the patient's or legal representative's expectations of participation in programming and overall goals and objectives, an initial plan of care that will result in a successful experience in treatment is determined ...The original transition/discharge plan will be placed in the record...Transition/Discharge plans will be develeoped for all patients...Components of a Transition/Discharge Plan [include] Date of program admission...needs...preferences..Referrals to assist in supporting continued maintenance or progress toward meeting goals...Assist with maintaing the continuity and coordination of needed services...".

2. Medical record review for Patient #1 revealed an admission date of 7/14/19 with a diagnosis of Alzheimer's dementia with behavioral disturbance. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 9:00 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #1 in the patient's medical record. The Discharge Planner stated information was located in various places throughout the electronic medical record, but the Discharge Planner was unable to provide documents which included the required information upon initiating the discharge planning process.

3. Medical record review for Patient #2 revealed an admission date of 7/10/19 with a diagnosis of Major Depressive Disorder. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #2 documented in the medical record.

4. Medical record review for Patient #3 revealed an admission date of 7/12/19 with a diagnosis of Major Depression. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #3 documented in the medical record.

5. Medical record review for Patient #4 revealed an admission date of 7/9/19 with a diagnosis of Major Depression.
The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #4 documented in the medical record.

6. Medical record review for Patient #5 revealed an admission date of 6/26/19 with a diagnosis of Schizophrenia.
The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #5 documented in the medical record.

7. Medical record review for Patient #6 revealed an admission date of 7/13/19 with a diagnosis of Schizophrenia.
The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #6 documented in the medical record

8. Medical record review for Patient #7 revealed an admission date of 7/11/19 with a diagnosis of Major Depression. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #7 documented in the medical record.

9. Medical record review for Patient #8 revealed an admission date of 7/13/19 with a diagnosis of Schizophrenia. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #8 documented in the medical record.

10. Medical record review for Patient #9 revealed an admission date of 7/4/19 with a diagnosis of Dementia with behavioral disturbance. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #9 documented in the medical record.

11. Medical record review for Patient #10 revealed an admission date of 6/17/19 with a diagnosis of Dementia with behavioral disturbance. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #10 documented in the medical record.

12. Medical record review for Patient #11 revealed an admission date of 6/6/19 with a diagnosis of Dementia with behavioral disturbance. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #11 documented in the medical record.

13. Medical record review for Patient #12 revealed an admission date of 4/21/19 with a diagnosis of Dementia with behavioral disturbance. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #12 documented in the medical record.

14. Medical record review for Patient #13 revealed an admission date of 6/12/19 with a diagnosis of Mood Disorder. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 10:40 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #13 documented in the medical record.

15. Medical record review for Patient #14 revealed an admission date of 3/30/19 with a diagnosis of Dementia with behavioral disturbance. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 10:40 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #14 documented in the medical record.

16. Medical record review for Patient #15 revealed an admission date of 6/26/19 with a diagnosis of Mood Disorder. Patient #15 was discharged to a nursing facility on 7/11/19. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no discharge planning assessment for Patient #15 documented in the medical record.

17. Medical record review for Patient #16 revealed an admission date of 5/22/19 with a diagnosis of Vascular Dementia with mood disturbance. Patient #16 was discharged to a nursing facility on 6/12/19. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 8:25 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #16 documented in the medical record.

18. Medical record review for Patient #17 revealed an admission date of 5/2/19 with a diagnosis of Alzheimer's Dementia. Patient #17 was discharged to an assisted living facility on 6/14/19. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 9:24 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #17 documented in the medical record.

19. Medical record review for Patient #18 revealed an admission date of 7/6/19 with a diagnoses of Schizophrenia and Vascular Dementia with behaviors. Patient #1 was discharged to another hospital on 7/12/19. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 10:15 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #18 documented in the medical record.

20. Medical record review for Patient #19 revealed an admission date of 4/10/19 with a diagnosis of Alzheimer's Dementia. Patient #19 was discharged home on 5/10/19. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 10:55 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #19 documented in the medical record.

21. Medical record review for Patient #20 revealed an admission date of 4/15/19 with a diagnosis of Dementia. Patient #20 was discharged home on 5/1/19. The medical record contained no evidence of the discharge planning assessments to determine the likelihood of a patient needing post-hospitalization care or to determine the likelihood of a patient's capacity for self-care.

In an interview in the Discharge Planner's office on 7/16/19 at 10:43 AM, the Discharge Planner verified there was no discharge planning assessment for Patient #20 documented in the medical record.

22. In an interview in the conference room on 7/15/19 at 2:18 PM, the Discharge Planner stated the discharge plan was started a few days before discharge. He further verified the facility did not perform a screening process, that all patients received discharge planning.

In an interview in the Discharge Planner's office on 7/16/19 at 8:30 AM, the Discharge Planner stated, "We don't have a discharge planning evaluation per say, we only have a transition plan for each patient. He further verified there was no way to tell when the transition plans were initiated based on the documentation.

The facility failed to ensure a documented discharge planning evaluation process to asses patients ability for self care, need for specialized medical equipment and need for home modifications, and level of care at discharge.

Based on policy review, medical record review and interview the facility failed to ensure a process was in place to complete discharge planning evaluation to ensure appropriate arrangements are made before discharge and to avoid any unnecessary delays in discharge for 20 of 20 ((Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20) sampled patients reviewed for discharge planning.

The findings included:

1. Review of the facility policy, "Interdisciplinary Discharge Summary/Transition Planning" revealed, "It is the policy of [facility name] to initiate the process of transition/discharge planning as early in a patients treatment plan as possible...Initial Assessment- Transition/Discharge planning will occur within the initial assessment upon entry into programming [hospital stay]..."

Review of the facility's policy, "Discharge and Aftercare Planning" revealed, "...Discharge Planning begins at the time of admission..."

2. Medical record review for Patient #1 revealed an admission date of 7/14/19 with a diagnosis of Alzheimer's dementia with behavioral disturbance. The medical record revealed no documentation of a discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 9:00 AM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

3. Medical record review for Patient #2 revealed an admission date of 7/10/19 with a diagnosis of Major Depressive Disorder. The medical record revealed no documentation of a discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

4. Medical record review for Patient #3 revealed an admission date of 7/12/19 with a diagnosis of Major Depression. The medical record revealed no documentation of a discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

5. Medical record review for Patient #4 revealed an admission date of 7/9/19 with a diagnosis of Major Depression. The medical record revealed no documentation of a discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

6. Medical record review for Patient #5 revealed an admission date of 6/26/19 with a diagnosis of Schizophrenia. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

7. Medical record review for Patient #6 revealed an admission date of 7/13/19 with a diagnosis of Schizophrenia. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

8. Medical record review for Patient #7 revealed an admission date of 7/11/19 with a diagnosis of Major Depression. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

9. Medical record review for Patient #8 revealed an admission date of 7/13/19 with a diagnosis of Schizophrenia. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

10. Medical record review for Patient #9 revealed an admission date of 7/4/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

11. Medical record review for Patient #10 revealed an admission date of 6/17/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

12. Medical record review for Patient #11 revealed an admission date of 6/6/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

13. Medical record review for Patient #12 revealed an admission date of 4/21/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

14. Medical record review for Patient #13 revealed an admission date of 6/12/19 with a diagnosis of Mood Disorder. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:40 AM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

15. Medical record review for Patient #14 revealed an admission date of 3/30/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

16. Medical record review for Patient #15 revealed an admission date of 6/26/19 with a diagnosis of Mood Disorder. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

17. Medical record review for Patient #16 revealed an admission date of 5/22/19 with a diagnosis of Vascular Dementia with mood disturbance. Patient #16 was discharged to a nursing facility on 6/12/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 8:25 AM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

18. Medical record review for Patient #17 revealed an admission date of 5/2/19 with a diagnosis of Alzheimer's Dementia. Patient #17 was discharged to an assisted living facility on 6/14/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 9:24 AM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

19. Medical record review for Patient #18 revealed an admission date of 7/6/19 with a diagnoses of Schizophrenia and Vascular Dementia with behaviors. Patient #1 was discharged to another hospital on 7/12/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:15 AM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

20. Medical record review for Patient #19 revealed an admission date of 4/10/19 with a diagnosis of Alzheimer's Dementia. Patient #19 was discharged home on 5/10/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:55 AM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

21. Medical record review for Patient #20 revealed an admission date of 4/15/19 with a diagnosis of Dementia. Patient #20 was discharged home on 5/1/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:43 AM, the Discharge Planner verified there was no documentation to support the discharge planning process was started as soon as the patient was admitted to the facility.

22. In an interview in the conference room on 7/15/19 at 2:18 PM, the Discharge Planner stated the discharge plan was started a few days before discharge.

In an interview on 7/16/19 at 8:25 AM, the Discharge Planner stated the facility policy didn't have a time frame on when the discharge planning process had to be initiated.

The facility failed to ensure the discharge planning process was initiated as soon as possible and documented in the medical record to ensure adequate time time after completion to allow arrangements for post-hospital care.

Based on policy review, medical record review and interview, the facility failed to ensure the discharge planning evaluation was included in the patient's medical record for use in establishing an appropriate discharge plans for 20 of 20 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20) sampled patients reviewed for discharge planning.

The findings included:

1. Review of the facility policy "Interdisciplinary Discharge Summary/Transition Planning" revealed, "It is the policy of [facility name] to initiate the process of transition/discharge planning as early in a patients treatment plan as possible...will occur within the initial assessment upon entry into programming [hospital stay]...The original transition/discharge plan will be placed in the record...The [discharge plan] will be kept under the Social Services tab in the chart until discharge...".

2. Medical record review for Patient #1 revealed an admission date of 7/14/19 with a diagnosis of Alzheimer's dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 9:00 AM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #1.

3. Medical record review for Patient #2 revealed an admission date of 7/10/19 with a diagnosis of Major Depressive Disorder. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #2.

4. Medical record review for Patient #3 revealed an admission date of 7/12/19 with a diagnosis of Major Depression. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #3.

5. Medical record review for Patient #4 revealed an admission date of 7/9/19 with a diagnosis of Major Depression. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #4.

6. Medical record review for Patient #5 revealed an admission date of 6/26/19 with a diagnosis of Schizophrenia. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #5.

7. Medical record review for Patient #6 revealed an admission date of 7/13/19 with a diagnosis of Schizophrenia. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #6.

8. Medical record review for Patient #7 revealed an admission date of 7/11/19 with a diagnosis of Major Depression. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #7.

9. Medical record review for Patient #8 revealed an admission date of 7/13/19 with a diagnosis of Schizophrenia. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #8.

10. Medical record review for Patient #9 revealed an admission date of 7/4/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #9.

11. Medical record review for Patient #10 revealed an admission date of 6/17/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #10.

12. Medical record review for Patient #11 revealed an admission date of 6/6/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #11.

13. Medical record review for Patient #12 revealed an admission date of 4/21/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #12.

14. Medical record review for Patient #13 revealed an admission date of 6/12/19 with a diagnosis of Mood Disorder. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:40 AM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #13.

15. Medical record review for Patient #14 revealed an admission date of 3/30/19 with a diagnosis of Dementia with behavioral disturbance. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #14.

16. Medical record review for Patient #15 revealed an admission date of 6/26/19 with a diagnosis of Mood Disorder. Patient #15 was discharged to a nursing facility on 7/11/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the conference room on 7/16/19 at 2:15 PM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #15.

17. Medical record review for Patient #16 revealed an admission date of 5/22/19 with a diagnosis of Vascular Dementia with mood disturbance. Patient #16 was discharged to a nursing facility on 6/12/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 8:25 AM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #16.

18. Medical record review for Patient #17 revealed an admission date of 5/2/19 with a diagnosis of Alzheimer's Dementia. Patient #17 was discharged to an assisted living facility on 6/14/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 9:24 AM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #17.

19. Medical record review for Patient #18 revealed an admission date of 7/6/19 with a diagnoses of Schizophrenia and Vascular Dementia with behaviors. Patient #1 was discharged to another hospital on 7/12/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:15 AM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #18.

20. Medical record review for Patient #19 revealed an admission date of 4/10/19 with a diagnosis of Alzheimer's Dementia. Patient #19 was discharged home on 5/10/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:55 AM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #19.

21. Medical record review for Patient #20 revealed an admission date of 4/15/19 with a diagnosis of Dementia. Patient #20 was discharged home on 5/1/19. The medical record revealed no documented discharge planning evaluation.

In an interview in the Discharge Planner's office on 7/16/19 at 10:43 AM, the Discharge Planner verified there was no documented discharge planning evaluation for Patient #20.

22. In an interview in the Discharge Planner's office on 7/16/19 at 9:00 AM, the Discharge Planner stated information was located in various places of the electronic medical record, but he was unable to provide documents that included the required information to initiate the discharge planning process.

The facility failed to ensure a discharge planning process to include a discharge planning evaluation was kept in each patients' medical record in order for it to guide the development of the patients' discharge plan and facilitate communication among members of the patient's healthcare team to develop and implement an effective discharge plan.