HospitalInspections.org

During an open medical record review it was determined that three out of six patients had not received initial psychosocial/case management assessments. None of the three patients had any ongoing progress note documentation from case management in their medical records. Case management staff, both registered nurses and social workers, are responsible for identifying patients who may be in need of discharge planning to facilitate a safe discharge and aftercare plan.

In an interview with case management staff on May 3, 2011, at 12:30 PM, it was determined that per hospital policy, all patients are to have a psychosocial evaluation within 48 hours of admission. The process is to interview the patient and/or family and document the interview and perceived needs at discharge in the case management health information management system. After entering the information a hard copy is printed for the medical record. This had not been performed on Patients # 4, #5, and # 6. An interview with the director of case management confirmed the hospital policy. She further stated the facility was short-staffed and case managers on this unit have been called to cover other areas to handle assessment and insurance reviews.

A pre-discharge assessment and evaluation is necessary in planning a successful and safe discharge for any patient.