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Based on medical record review, policy review, and interview, the facility failed to provide a discharge planning screening for one patient (#4) of four patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the hospital on May 10, 2012, with diagnosis of Dislocated Right Total Hip. Further review of the medical record revealed the patient was discharged home on May 11, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Medical record review revealed Patient #4 was re-admitted to the hospital on May 16, 2012, with diagnosis of Dislocated Right Hip Prosthesis. Further review of the medical record revealed the patient was discharged home on May 17, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Review of facility policy titled, "Discharge Planning", number 01.07, reviewed November 2006, revealed, "Assessment of discharge planning needs begins at the time of admission...The case manager follows the patient concurrently throughout the hospitalization to assist in identification of any discharge planning needs..."

Interview with Director of Case Management, on July 10, 2012, at 10:00 a.m., in the administration conference room, confirmed a Discharge Planning Assessment had not been completed for Patient #4, prior to discharge on May 11, 2012 or prior to discharge on May 17, 2012.

Based on medical record review, policy review, and interviews, the facility failed to assess insurance coverage of post hospital care for one patient (#2) and failed to provide a discharge planning evaluation for one patient (#4) of four patients reviewed.

The findings included:

Review of current census revealed Patient #2 was an inpatient at the hospital during the survey. Review of the current medical record revealed the patient had been re-admitted to the hospital on July 8, 2012, with diagnosis of Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) (four day after last discharge).

Further review of the medical records revealed Patient #2 had a previous admission on July 2, 2012, with diagnoses of COPD, and was discharged on July 4, 2012, with a referral for home health services and a prescription for prednisone (a medication to reduce inflammation in the airway).

Review of the re-admission history and physical, dated July 8, 2012 revealed the patient, "...did not get the prednisone prescription filled..."

Review of the Discharge Planning Summary dated July 4, 2012, revealed Patient #2 had been referred to a home health agency for "medication assistance".

Review of the patient's Discharge Planning Assessment and Discharge Planning Summary revealed no documented assessment of insurance coverage for the referred home health services and prescribed medications to verify insurance payment for requested services.

Interview with Patient #2, in the patient's room, on July 9, 2012, at 1:45 p.m., revealed the patient had not received the prednisone or the home health services because neither were covered by the patient's insurance.

Interview with the Director of Case Management, on July 9, 2012, at 2:30 p.m., in the Administration Conference Room, confirmed there was no documentation of Patient #2's insurance coverage verification for home health services or medications being assessed.


Medical record review revealed Patient #4 was admitted to the hospital on May 10, 2012, with diagnosis of Dislocated Right Total Hip. Further review of the medical record revealed the patient was discharged home on May 11, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Medical record review revealed Patient #4 was re-admitted to the hospital on May 16, 2012, with diagnosis of Dislocated Right Hip Prosthesis. Further review of the medical record revealed the patient was discharged home on May 17, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Review of facility policy titled, "Discharge Planning", number 01.07, reviewed November 2006, revealed, "Assessment of discharge planning needs begins at the time of admission...The case manager follows the patient concurrently throughout the hospitalization to assist in identification of any discharge planning needs..."

Interview with Director of Case Management, on July 10, 2012, at 10:00 a.m. in the administration conference room, confirmed a Discharge Planning Assessment had not been completed for Patient #4, prior to discharge on May 11, 2012 or prior to discharge on May 17, 2012.



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Based on medical record review, policy review, and interview, the facility failed to complete, prior to discharge, a discharge planning screening for one patient (#4) of four patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the hospital on May 10, 2012, with diagnosis of Dislocated Right Total Hip. Further review of the medical record revealed the patient was discharged home on May 11, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Medical record review revealed Patient #4 was re-admitted to the hospital on May 16, 2012, with diagnosis of Dislocated Right Hip Prosthesis. Further review of the medical record revealed the patient was discharged home on May 17, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Review of facility policy titled, "Discharge Planning", number 01.07, reviewed November 2006, revealed, "Assessment of discharge planning needs begins at the time of admission...The case manager follows the patient concurrently throughout the hospitalization to assist in identification of any discharge planning needs..."

Interview with Director of Case Management, on July 10, 2012, at 10:00 a.m. in the administration conference room, confirmed a Discharge Planning Assessment had not been completed for Patient #4, prior to discharge on May 11, 2012 or prior to discharge on May 17, 2012.

Based on medical record review, policy review, and interview, the facility failed to document a discharge planning evaluation for one patient (#4) of four patients reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the hospital on May 10, 2012, with diagnosis of Dislocated Right Total Hip. Further review of the medical record revealed the patient was discharged home on May 11, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Medical record review revealed Patient #4 was re-admitted to the hospital on May 16, 2012, with diagnosis of Dislocated Right Hip Prosthesis. Further review of the medical record revealed the patient was discharged home on May 17, 2012, with no documentation of the patient's discharge planning needs having been assessed.

Review of facility policy titled, "Discharge Planning", number 01.07, reviewed November 2006, revealed, "Assessment of discharge planning needs begins at the time of admission...The case manager follows the patient concurrently throughout the hospitalization to assist in identification of any discharge planning needs..."

Interview with Director of Case Management, on July 10, 2012, at 10:00 a.m. in the administration conference room, confirmed a Discharge Planning Assessment had not been completed for Patient #4, prior to discharge on May 11, 2012 or prior to discharge on May 17, 2012.

Based on facility policy review, medical record review, and interview, the facility failed to ensure arrangements were made for post-hospital care and needed services for four patients (#1, #2, #3 and #4) of four patient records reviewed.

The findings included:

Review of the facility policy "Discharge Planning", policy #01.07, dated as reviewed November 2011, revealed "...ensure that hospital personnel perform the hospital function of discharge planning...Case Management staff works with the interdisciplinary team to identify patient needs at discharge...Assessment of discharge needs begins at admission...Nursing staff assesses the patient on admission and referrals are made to case management department as needed...case manager follows the patient concurrently throughout hospitalization...as discharge planning needed or referrals are identified, the patient and family are given an option of the ancillary provider they wish to use...Referrals can be generated via the physician, patient, family, or any healthcare provider...documentation of the discharge planning assessment and referrals can be found on the Discharge Planning Assessment form completed by the case management department or in the nurses' notes if nursing makes the arrangement for patient..."

Patient #1 was admitted to the facility from home on June 26, 2012, with diagnoses to include Hepatic Encephalopathy and Stage 2 Sacral Ulcer.

Medical record review of the Case Management Note, dated June 26, 2012, revealed the patient had home health services in progress prior to admission; had a neighbor come to help during the day; and had a significant other available in the evenings. Continued review revealed on July 6, 2012, the patient had refused Skilled Nursing Facility care at discharge as had been recommended.

Medical record review of the Wound Care Nurse's Note, dated June 27, 2012, revealed the patient's Sacral Ulcer was evaluated as Stage 2 and orders for dressing initiated. Continued review revealed the wound was still present as a Stage 2 and dressings ongoing on July 9, 2012.

Medical record review of the Physician's Progress Note, dated July 7, 2012, revealed the patient was possibly ready for discharge after Physical Therapy evaluation was completed.

Interview at 3rd floor nursing station with the Nurse Manager on July 9, 2012, at 3:00 p.m., confirmed the patient or the patient's significant other's ability to care for the Sacral Ulcer had not been addressed in the discharge plan and would have been expected to be addressed as a discharge care need.

Interview at the 3rd floor nursing station with the Chief Quality Officer on July 9, 2012, at 3:00 p.m., confirmed the patient's discharge need for wound management had not been met.



Medical record review revealed Patient #2 was admitted to the hospital on July 2, 2012, with diagnoses to include Chronic Obstructive Pulmonary Disease. Further review of the medical record revealed the patient was discharged on July 4, 2012, with new medications that included: DuoNeb by Nebulizer (medicated mist for inhalation generated by a machine called a nebulizer), Potassium Chloride (an electrolyte supplement), and Prednisone Dose-Pak (a steroidal drug given in a series of dosages to reduce inflammation and swelling of the airways). Review of the Medication Reconciliation form and the Discharge Planning Summary revealed no documentation of the patient being educated on the new medications or use of the nebulizer.



Patient #3 was admitted to the facility from home on May 22, 2012, with diagnoses to include Bronchial Pneumonia and Status Post (S/P) Amputation of 5th Toe of Right Foot.

Medical record review of the Wound Care Nurse's Note, dated May 24, 2012, revealed a photograph of the suture line with sutures in place on the patient's right foot. Continued review revealed "S/P amputation of fifth toe". Continued review revealed a notation of "sutures intact" on a diagram of the patient's right foot. Continued review revealed no documentation the sutures had been removed prior to the patient discharge to home on May 27, 2012.

Review of the Case Management Discharge Planning Assessment, dated May 22, 2012, revealed the patient had been assessed to have family support; had a walker; had a wheelchair; and had a bedside commode at home. Continued review revealed no further discharge needs were identified prior to discharge on May 27, 2012.

Review of the patient's closed medical record, dated as admitted on May 17, 2012, for Amputation of the 5th toe of the Right foot, revealed the patient was discharged on May 18, 2012, with a follow-up appointment with the surgeon on May 23, 2012 (one day prior to admit of May 22, 2012).

Review of the Physician's Progress Note, dated May 25, 2012, revealed the patient was to follow-up with the surgeon in one week.

Review of the Discharge Instructions, dated May 27, 2012, did not reveal a need for a follow up appointment with the patient surgeon after discharge.

Interview in the conference room with the Director of Case Management on July 10, 2012, at 10:45 a.m., confirmed the patient was readmitted to the facility prior to the follow-up appointment with the surgeon who performed the Amputation. Continued interview confirmed there was no documentation the sutures were removed from the patient right foot prior to being discharged for the admission of May 17, 2012. Continued interview confirmed there was no documentation of a follow up appointment or documentation of the patient needing to contact the surgeon for a follow-up appointment. Continued interview confirmed the patient's discharge need for a follow-up appointment with the surgeon was not met.




Medical record review revealed Patient #4 was admitted to the hospital May 16, 2012, with diagnoses of Dislocated Right Total Hip. Further record review revealed the patient was discharged home on May 17, 2012.

Review of Patient #4's discharge summary dated May 17, 2012, revealed "...suggest using gunslinger brace, and (patient) is going to follow up for possible revision of right total hip arthroplasty." Review of the Discharge Planning Summary dated May 18, 2012 (day after discharge) and discharge instructions dated May 17, 2012, revealed no documentation of any referrals for follow up care or patient instructions related to the follow up needs. Further review revealed no referrals or patiennt instruction regarding obtaining and using a gunslinger brace.



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