HospitalInspections.org

Based on record review and interview the facility failed to provide a discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care for 3 of 5 sampled patients, #1,2, and 5.

The findings are:

Record review for sampled patient #1 revealed an admission date of 10/15/10 with an initial diagnosis of Congestive Heart Failure. The patient was discharged home with home health services on 10/18/10. The medical record does not contain a discharge summary describing the course of the hospitalization, the final diagnosis, patient outcome, disposition of care, or provisions for follow-up care.

Record review for sampled patient #2 revealed an admission date of 10/15/10 with an initial diagnosis of Leukocytosis Unspecified and Fever Unspecified. The patient was discharged home on 10/18/10. The medical record does not contain a discharge summary describing the course of the hospitalization, final diagnosis, patient outcome, disposition of care, or provisions for follow-up care.

Record review for sampled patient #5 revealed an admission date of 10/20/10 with an initial diagnosis of Fluid/Electrolyte Imbalance, Diabetes, and Anxiety. The patient was discharged home on 10/24/10. The medical record does not contain a discharge summary describing the course of the hospitalization, the final diagnosis, patient outcome, disposition of care, or provisions of follow-up care.

Interview with the Director Of Nursing on 12/2/10 at 1:50 PM confirmed there is no discharge summary available for these patients. She stated "we're still waiting on those from their doctors".

Based on record review and interview the facility failed to complete medical records and failed to document the final diagnosis within 30 days of discharge for 3 of 5 sampled patients, #1, 2, and 5.

The findings are:

Record review for sampled patient #1 revealed an admission date of 10/15/10 with an initial diagnosis of Congestive Heart Failure. The patient was discharged on 10/18/10. The medical record remains incomplete and does not contain documentation of a final diagnosis.

Record review for sampled patient #2 revealed an admission date of 10/15/10 with an initial diagnosis of Leukocytosis Unspecified and Fever Unspecified. The patient was discharged home on 10/18/10. The medical record remains incomplete and does not contain documentation of a final diagnosis.

Record review for sampled patient #5 revealed an admission date of 10/20/10 with an initial diagnosis of Fluid/Electrolyte Imbalance, Diabetes, and Anxiety. The patient was discharged home on 10/24/10. The medical record remains incomplete and does not contain documentation of a final diagnosis.

Interview with the Director Of Nursing on 12/2/10 at 1:50 PM confirmed these medical records are incomplete and do not contain documentation of the final diagnosis. She stated she is still waiting for the physicians to write their discharge summaries to complete the medical records.

Based on record review and interview the facility failed to provide discharge planning evaluations (refer to A806); failed to evaluate the likelihood of need for post-hospital services (refer to A808); failed to evaluate the likelihood of capacity for self-care (refer to A809); failed to document discussion of discharge evaluation and discharge plans with patients (refer to A811); failed to implement discharge plans (refer to A820); and failed to counsel with patients/family to prepare for discharge and post-hospital care (refer to A822). The cumulative effect of these systemic problems resulted in the condition of participation not being met.

Based on record review and interview the facility failed to provide a discharge planning evaluation for 2 of 5 sampled patients (#1 and 3) identified to be in need of post-hospital services or resources.

The findings are:

Record review for sampled patient #1 revealed she was admitted to the facility on 10/15/10 from home with a diagnosis of Congestive Heart Failure. The patient was discharged home with an order for home health services on 10/18/10. The record does not contain evidence that a discharge planning evaluation was completed for this patient.

Record review for sampled patient #3 revealed the patient was admitted as a direct admit to the care of a facility doctor on 10/13/10. The patient was transferred to this doctors care by a skilled nursing facility in Tennessee. Interview with the doctor on 12/2/10 at 12:50 PM revealed the patient arrived via private vehicle and badly needed a bath and personal care. The patient was morbidly obese (close to 500 lbs), and had been incontinent of bowel and bladder during the trip from Tennessee as the friend transporting him had been unable to get him out of the vehicle to toilet during the trip. The patient was admitted for a planned 3 day stay to qualify for Medicare admission to a local skilled nursing facility (SNF). The SNF declined admission due to the patient's obesity and being unable to accommodate him because of his size. The doctor stated he requested assistance from the facility's Discharge Planner, who contacted several area SNF's to secure placement for this patient. He stated all of them refused to accept the patient. The record contains no documentation of these efforts by the Discharge Planner.

The record documents that the patient was non-ambulatory and required extensive to total assistance with activities of daily living (ADL's) such as bathing, toileting, dressing, and personal hygiene. The medical record does not contain evidence of a discharge evaluation which addresses the likelihood that this patient would need continued assistance for ADL's post hospital, or who would provide this assistance. The record indicates the patient has little ability to provide self-care and has a continued need for placement in an environment similar to that which he lived in prior to hospitalization. The only reference to any attempts to secure post hospital care is mention in a few of the physician orders of plans to discharge to certain facilities. None of these plans materialized and the final physician order, dated 10/19/10, is "Discharge. Follow up with regular physician". There is no documentation as to where the patient was discharged to, nor who would assist with self-care deficits related to transfers, ambulation, or ADL's. The record contains no discharge planning evaluation form nor any notes by the Discharge Planner.

Interview on 12/2/10 at 1:05 PM with the facility Discharge Planner confirmed she failed to complete a discharge planning evaluation form for these patients. She stated she is assigned multiple duties at the facility and has gotten behind on her paperwork. She confirmed the procedure is for her to visit all inpatients as soon as possible after their admission and discuss anticipated post-hospital needs with the patient and/or their family and to document these on a Discharge Planning form.

Review of the facility policies and procedures related to discharge planning state that continuity of care goals are to identify as early as possible the high-risk patients who may require case management and/or complex discharge planning; to evaluate discharge needs and assist in developing discharge plans to meet the patient's needs; to assist the high-risk patient in implementing a timely and effective discharge plan. The policies describe procedures for carrying out these goals as: the Utilization Review (UR) Coordinator will screen the inpatients to identify the potential need for the high-risk patient's discharge planning; the UR Coordinator will notify the Discharge Planner (DP) daily of any newly identified patient in need of assistance; the DP will respond to a request for an evaluation from the physician, nursing staff, or patient as needed; the DP will document the patient's interview/evaluation on the "Discharge Planning" form in the medical record (this form will be on colored paper and will remain a permanent part of the medical record; the form will be used as a communication tool to the physician); the DP will coordinate discharge planning activities with the attending physician, the patient, and or patient's representative to formulate a plan to meet the patient's needs; the DP will communicate to the attending physician, the patient, and the nursing staff regarding the findings and recommendations of the discharge planning interview and evaluation process.

Based on record review and interview the facility failed to provide evidence of a discharge evaluation which addressed the likelihood of needing post-hospital services and availability of the services for 1 of 5 sampled patients, #3.

The findings are:

Record review for sampled patient #3 revealed the patient was admitted as a direct admit to the care of a facility doctor on 10/13/10. The patient was transferred to this doctors care by a skilled nursing facility in Tennessee. Interview with the doctor on 12/2/10 at 12:50 PM revealed the patient arrived via private vehicle and badly needed a bath and personal care. The patient was morbidly obese (close to 500 lbs), and had been incontinent of bowel and bladder during the trip from Tennessee as the friend transporting him had been unable to get him out of the vehicle to toilet during the trip. The patient was admitted for a planned 3 day stay to qualify for Medicare admission to a local skilled nursing facility (SNF). The SNF declined admission due to the patient's obesity and being unable to accommodate him because of his size. The record documents that the patient was non-ambulatory and required extensive to total assistance with activities of daily living (ADL's) such as bathing, toileting, dressing, and personal hygiene. The medical record does not contain evidence of a discharge evaluation which addresses the likelihood that this patient would need continued assistance for ADL's post hospital, or who would provide this assistance. The only reference to any attempts to secure post hospital care is mention in a few of the physician orders of plans to discharge to certain facilities. None of these plans materialized and the final physician order, dated 10/19/10, is "Discharge. Follow up with regular physician". There is no documentation as to where the patient was discharged to, nor who would assist with transfers, ambulation, or ADL's.

Interview on 12/2/10 at 1:05 PM with the facility Discharge Planner revealed she was aware of this patient's special needs for post hospital care. She described numerous attempts to place the patient at SNF's "within a 100 mile radius", she stated every facility she contacted declined admission due to the patient's size and need for special accommodations. She stated the patient was kept at the facility beyond the time considered medically necessary in order to continue to try to place the patient appropriately. She stated she was finally instructed by the administration that the patient had to be discharged. He was discharged by the physician and staff assisted with placing the patient in a taxi and sending him to the bus station with the intention for him to return to Tennessee to his former SNF. She confirmed she did not document her evaluation of efforts at placement in the medical record. She stated she has multiple duties at the facility and had gotten behind with her paperwork.

Based on record review and interview the facility failed to provide evidence of a discharge evaluation to address the capacity for self-care or the possibility of the patient being cared for in the environment from which he/she entered the hospital for 2 of 5 sampled patients, #1 and 3.

The findings are:

Record review for sampled patient #1 revealed she was admitted to the facility on 10/15/10 from home with a diagnosis of Congestive Heart Failure. The patient was discharged home with an order for home health services on 10/18/10. The record does not contain any documentation of the patient's capacity for self-care or services to be provided by the home health agency.

Record review for sampled patient #3 revealed the patient was admitted as a direct admit to the care of a facility doctor on 10/13/10. The patient was transferred to this doctors care by a skilled nursing facility in Tennessee. Interview with the doctor on 12/2/10 at 12:50 PM revealed the patient arrived via private vehicle and badly needed a bath and personal care. The patient was morbidly obese (close to 500 lbs), and had been incontinent of bowel and bladder during the trip from Tennessee as the friend transporting him had been unable to get him out of the vehicle to toilet during the trip. The patient was admitted for a planned 3 day stay to qualify for Medicare admission to a local skilled nursing facility (SNF). The SNF declined admission due to the patient's obesity and being unable to accommodate him because of his size. The record documents that the patient was non-ambulatory and required extensive to total assistance with activities of daily living (ADL's) such as bathing, toileting, dressing, and personal hygiene. The medical record does not contain evidence of a discharge evaluation which addresses the likelihood that this patient would need continued assistance for ADL's post hospital, or who would provide this assistance. The record indicates the patient has little ability to provide self-care and has a continued need for placement in an environment similar to that which he lived in prior to hospitalization. The only reference to any attempts to secure post hospital care is mention in a few of the physician orders of plans to discharge to certain facilities. None of these plans materialized and the final physician order, dated 10/19/10, is "Discharge. Follow up with regular physician". There is no documentation as to where the patient was discharged to, nor who would assist self-care deficits related to transfers, ambulation, or ADL's.

Interview on 12/2/10 at 1:05 PM with the facility Discharge Planner confirmed she failed to document capacity for self -care for both patients #1 and 3. She also acknowledged patient #3 was discharged from the facility with continued self-care needs which she had not been able to resolve despite diligent attempts to place the patient in a SNF.

Based on record review and interview the facility failed to include the discharge planning evaluation in the patient's medical record and failed to discuss the results of the evaluation with the patient/patient's representative for 2 of 5 sampled patients, #1 and 3.

The findings are:

Record review for sampled patient #1 revealed she was admitted to the facility on 10/15/10 from home with a diagnosis of Congestive Heart Failure. The patient was discharged home with an order for home health services on 10/18/10. The medical record does not contain a discharge planning evaluation and there is no documentation that results of the evaluation were discussed with the patient or their representative.

Record review for sampled patient #3 revealed the patient was admitted as a direct admit to the care of a facility doctor on 10/13/10. The patient was transferred to this doctors care by a skilled nursing facility in Tennessee. Interview with the doctor on 12/2/10 at 12:50 PM revealed the patient arrived via private vehicle and badly needed a bath and personal care. The patient was morbidly obese (close to 500 lbs), and had been incontinent of bowel and bladder during the trip from Tennessee as the friend transporting him had been unable to get him out of the vehicle to toilet during the trip. The patient was admitted for a planned 3 day stay to qualify for Medicare admission to a local skilled nursing facility (SNF). The SNF declined admission due to the patient's obesity and being unable to accommodate him because of his size. The record documents that the patient was non-ambulatory and required extensive to total assistance with activities of daily living (ADL's) such as bathing, toileting, dressing, and personal hygiene. The medical record does not contain evidence of a discharge evaluation which addresses post hospital needs. The final physician order, dated 10/19/10, is "Discharge. Follow up with regular physician". There is no documentation as to where the patient was discharged to, nor who would assist with self-care deficits related to transfers, ambulation, or ADL's. The record contains no documentation of discussion with the patient of results of the evaluation, nor of participation in the discharge plans.

Interview on 12/2/10 at 1:05 PM with the facility Discharge Planner confirmed she failed to complete written discharge evaluations for these patients and failed to document discussions with the patients regarding discharge plans.

Based on record review and interview the facility failed to implement the discharge plan for 1 of 5 sampled patients, #3.

The findings are:

Record review for sampled patient #3 revealed the patient was admitted as a direct admit to the care of a facility doctor on 10/13/10. The patient was transferred to this doctors care by a skilled nursing facility in Tennessee. Interview with the doctor on 12/2/10 at 12:50 PM revealed the patient arrived via private vehicle and badly needed a bath and personal care. The patient was morbidly obese (close to 500 lbs), and had been incontinent of bowel and bladder during the trip from Tennessee as the friend transporting him had been unable to get him out of the vehicle to toilet during the trip. The patient was admitted for a planned 3 day stay to qualify for Medicare admission to a local skilled nursing facility (SNF). The SNF declined admission due to the patient's obesity and being unable to accommodate him because of his size. The doctor stated he requested assistance from the facility's Discharge Planner, who contacted several area SNF's to secure placement for this patient. He stated all of them refused to accept the patient.

The record documents that the patient was non-ambulatory and required extensive to total assistance with activities of daily living (ADL's) such as bathing, toileting, dressing, and personal hygiene. The medical record does not contain documentation of a discharge evaluation which addresses the likelihood that this patient would need continued assistance for ADL's post hospital, or who would provide this assistance. The record indicates the patient has little ability to provide self-care and has a continued need for placement in an environment similar to that which he lived in prior to hospitalization. The only reference to any attempts to secure post hospital care is mention in a few of the physician orders of plans to discharge to certain facilities. None of these plans materialized and the final physician order, dated 10/19/10, is "Discharge. Follow up with regular physician". There is no documentation as to where the patient was discharged to, nor who would assist with self-care deficits related to transfers, ambulation, or ADL's.

Interview on 12/2/10 at 1:05 PM with the facility Discharge Planner confirmed she was aware of this patient's special needs and had contacted several SNF's "within a 100 mile radius", but had been unable to secure placement. She confirmed the patient had finally been discharged because there was no further medical need for hospitalization and she was instructed by the administration that he had to be discharged. She stated staff assisted the patient into a taxi and he left for the bus station. She acknowledged it was unlikely the patient would be able to board a bus due to his size, and she did not know how he would even be able to get out of the taxi. She confirmed she had been unable to implement appropriate discharge plans for this patient.

Based on record review and interview the facility failed to provide evidence of patient counseling to prepare for discharge and post-hospital care for 1 of 5 sampled patients, #3.

The findings are:

Record review for sampled patient #3 revealed the patient was admitted as a direct admit to the care of a facility doctor on 10/13/10. The patient was transferred to this doctors care by a skilled nursing facility in Tennessee. Interview with the doctor on 12/2/10 at 12:50 PM revealed the patient arrived via private vehicle and badly needed a bath and personal care. The patient was morbidly obese (close to 500 lbs), and had been incontinent of bowel and bladder during the trip from Tennessee as the friend transporting him had been unable to get him out of the vehicle to toilet during the trip. The patient was admitted for a planned 3 day stay to qualify for Medicare admission to a local skilled nursing facility (SNF). The SNF declined admission due to the patient's obesity and being unable to accommodate him because of his size. The record documents that the patient was non-ambulatory and required extensive to total assistance with activities of daily living (ADL's) such as bathing, toileting, dressing, and personal hygiene. The record indicates the patient has little ability to provide self-care and has a continued need for placement in an environment similar to that which he lived in prior to hospitalization. The only reference to any attempts to secure post hospital care is mention in a few of the physician orders of plans to discharge to certain facilities. None of these plans materialized and the final physician order, dated 10/19/10, is "Discharge. Follow up with regular physician". There is no documentation as to where the patient was discharged to, nor who would assist with self-care deficits related to transfers, ambulation, or ADL's. The medical record does not contain evidence of patient counseling or preparation for discharge or post-hospital care.

Interview on 12/2/10 at 1:05 PM with the facility Discharge Planner confirmed patient #3 was discharged from the facility with continued self-care needs which she had not been able to resolve despite diligent attempts to place the patient in a SNF. She stated the patient was assisted into a taxi by staff and left for the bus station. She acknowledged it was unlikely the patient would be able to board a bus due to his size, or that he would even be able to transfer out of the taxi. She stated she believed the patient intended to take a bus back to Tennessee. She confirmed she could not provide any documentation of patient counseling or preparation for discharge, especially as original discharge plans were not carried out.