HospitalInspections.org

Based on record review, policy review, patient and staff interviews, the facility failed to complete a discharge plan for 2 (#s 2 and 3) out of 4 records reviewed. Findings include:

1. Patient #2 was admitted to the hospital on 7/9/12 with shortness of breath, acute respiratory failure, and healthcare-associated pneumonia.
On 7/3/12 at 8:15 a.m., record review of patient #2's closed medical record was completed. The Nursing Assessment documented that a care management referral was needed, but the surveyor could not locate an initial discharge plan. The patient was discharged on 7/18/12.

On 7/31/12 at 9:30 a.m., the discharge planning manager stated that all inpatients should have an initial discharge plan completed within 24 hours.

According to the Discharge Planning Policy and Procedure, "All patients receive an initial discharge plan evaluation (DPE) from the case managers in collaboration with the primary nurse and the patient's physician."

2. Patient #3 was admitted to the facility on 7/23/12 with diagnosis including recurrent left leg cellulitis and chronic renal failure.

On 7/30/12 at 12:10 p.m., staff member G, a registered nurse (RN) was interviewed. She stated she was responsible for the care of patient #3 for today. The RN stated the discharge plans for patient #3 were difficult, as the patient was in need of an amputation but had refused. The patient wanted to go home and think about it. To complicate things further, the spouse stated he was unable to care for the patient at home and asked that nursing home placement be found. The patient was in two nursing homes prior and had an outstanding balance. The RN stated that those nursing homes refused to accept the patient. At the time of the interview, the RN was unclear what the discharge plans were for patient #3. The RN further stated a case manager would be able to provide more information on the discharge plan.

The discharge planning notes were requested and reviewed on 7/30/12 at 12:30 p.m. The most recent note on 7/27/12 by a RN case manager documented, " . . . She has made the decision that she will have an amputation. Both realize that he is unable to care for her and she will need SNF [skilled nursing facility]. Unable to contact [facility name] . . . will f/u [follow up] Monday . . . "

On 7/30/12 at 1:00 p.m., patient #3 was interviewed. She stated she decided to have the amputation and spoke with the physician last week. She was told the prior week that a RN case manager was looking into placement after her surgery. She expected to hear today (7/30/12) on placement, but no one had been in to discuss it with her. She further stated she only wanted to go home because she did not feel she could afford to live in the nursing home. She had financial concerns and a case manager had not discussed the possibility of applying for assistance.

On 7/30/12 at 2:00 p.m., staff member F, a RN case manager was interviewed. She was not the case manager that worked with patient #3 on Friday. She stated she was unaware that patient #3 agreed to the amputation. She further stated that she was not aware the patient was needing assistance with financial concerns, although she was aware the patient needed nursing home placement and she had outstanding bills with the nursing home.

The RN and RN case manager responsible for patient #3 were both unaware of the change in discharge plans. The RN case manager was not aware of the need to follow up that day, per the discharge plan, on nursing home placement. Further, the patient and her spouse were concerned about finances and whether they could afford nursing home placement. The discharge plan documented these concerns, but the staff had not acted upon these concerns by offering to assist with qualifying for financial assistance.

Based on record review and staff interview, the facility failed to reassess discharge planning for one (#1) of 4 sampled patients. Findings include:

Patient #1 was admitted to the hospital on 7/26/12 with diagnosis of right upper abdominal pain.

On 7/30/12 at 12:15 p.m., Staff member D, a RN case manager, stated that she had not met with patient #1 as of 7/30/12, but would make a point to meet with her. The RN case manager stated she was not aware that patient #1 was going to be discharged that day. The chart lacked documentation of communication regarding the reassessment of patient #1's discharge on 7/30/12. At 12:30 p.m., the RN case manager stated that she checked with the charge nurse and patient #1 was not going to be discharged until the next day.

On 7/30/12 at 3:30 p.m., patient #1's medical record was reviewed and lacked documentation of ongoing discharge planning for patient #1's discharge. According to the record, the RN case manager documented at 2:13 p.m., that the discharge to go home was planned for 7/31/12.

Based on staff interviews and record review, the facility failed to incorporate discharge planning into the Quality Assurance (QA) program. Findings include:

On 7/30/12 at 3:00 p.m., the QA Manager stated that he did not look at the discharge planning process in QA. Re-admissions for diagnoses of heart failure, myocardial infarction, and pneumonia, were reviewed after the information was received from the Utilization Review Committee. The Peer Committee reviewed those re-admissions. A contracted service reviewed re-admissions and submitted a report to the facility. The QA manager stated, "There has not been a problem reported to me regarding re-admissions."

On 7/31/12 at 9:30 a.m., a review of the re-admissions documented for February, March, April, and May 2012, was completed. The QA manager stated he was unsure what the outcome was of the peer review for 10 of 14 re-admissions documented on the QA form as the QA form was incomplete.

On 7/31/12 at 9:30 a.m., staff member B, the Case Management manager stated that discharge planning was not monitored in the QA program. Furthermore, the discharge plan process did not look at high risk patients which may become a re-admission. The facility's protocol was to look at re-admissions when they occur.