HospitalInspections.org

Based on review of clinical records, policy and procedure review and interview, the Facility failed to address discharge planning for four (#7-10) of four acute care clinical records. Failure to address discharge planning did not ensure adequate planning was performed to enhance the patient's ability to go to the appropriate level of care at discharge and prevent re-admission. The failed practice affected four (#7-#10) of four acute care patients. Findings follow:

A. Review of the policy and procedure titled Discharge Planning, received from the Quality Services Director at 1345 on 12/01/14 revealed the following under standards 1. All patients admitted to this institution should be screened for the necessity for discharge planning within 24 hours of admission. ... 3. Follow-up documentation should be made at least every seventy-two (72) hours.

B. Review of the clinical records of Patients #8 and #10 revealed no evidence of discharge planning. The above was verified by the Swing Bed Coordinator on 12/02/14.

C. Review of the clinical records of Patients #7 and #9 revealed no evidence of discharge planning. The above was verified by the Director of Medical Records on 12/02/14.

Based on interview, policy and procedure review and clinical record review, it was determined the Facility failed to supervise and evaluate the nursing care of each swing bed patient in that a Registered Nurse (RN) did not observe the patient each shift. Failure to ensure each patient was observed by a RN each shift did not allow the patient's needs to be evaluated and care adjusted in response to that evaluation. The failed practice affected six (#1-6) of six (#1-6) Swing Bed patients. Findings follow:

A. Review of the clinical record of current Patient #1 revealed no RN observations for 26 of 52 shifts from 09/26/14 through 11/16/14. This included two full days of no RN observations at all.
B. Review of the clinical record of current Patient #2 revealed no RN observations for 2 of 34 shifts sampled from 11/11/14 through 11/29/14.
C. Review of the clinical record of current Patient #3 revealed no RN observations for 7 of 32 shifts sampled from 10/03/14 through 10/19/14.
D. Review of the clinical record of current Patient #4 revealed no RN observations for 8 of 33 shifts sampled from 10/29/14 through 11/15/14. This included one full day of no RN observations at all.
E. Review of the clinical record of current Patient #5 revealed no RN observations for 5 of 21 shifts sampled from 11/21/14 through 12/01/14. This included one full day of no RN observations at all.
F. Review of the clinical record of current Patient #6 revealed no RN observations for 7 of 54 shifts sampled from 11/04/14 through 12/01/14. This included one full day of no RN observations at all.
G. Review of the policy and procedure received from the Quality Services Director at 0930 on 12/02/14 revealed the following: #2. A critical assessment should be performed by a Registered Nurse or a Licensed Practical Nurse (LPN) on each patient at least every twelve (12) hours. This 12 hour assessment, if completed by an LPN, the RN will observe the patient and document every twelve (12) hours. Critical assessment included all factors relating to current patient problem(s). The implementation date was 01/13 and the revision date was 02/14.