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Based on record review, staff interview, family interview the facility failed for 1 of 5 patients, (#2) to ensure that the family member, responsible for making health care decisions, participated in the discharge planning and was counseled about the discharge planning. Failure to involve the patient/family in discharge planning places the patient at risk of not receiving care and services in a safe and effective manner.

Findings:

Review of the medical record for patient #2 revealed that the patient was admitted to facility on 07/02/2010 with the diagnosis of deep vein thrombophlebitis and alzheimer's disease. The medical record further revealed that the patient is a elderly individual that lives in a private residence with his/her elderly spouse.

Review of the medical revealed that it contained a Durable Power of Attorney that May 23, 2008 designated patient's adult child as the patient Health Care Surrogate.

Review of the medical record revealed that the patient's adult child signed the Patient Information and Choice Letter on 07/06/2010 indicating the home health company to provide patient home care following discharge planned for the same day.

Interview with the patient's adult child on 07/12/2010 at 6:00 PM revealed that he/she had attempted starting on 07/03/2010 to arrange a meeting with the discharge planner so arrangements could be made to have his/her parent discharged to a skilled nursing facility, (SNF). Interview with the adult child revealed that he/she had concerns about his/her parent returning home while receiving a blood thinner, (Coumadin) and requiring insulin without a past history of diabetes. According to the patient's adult child, he/she had arranged a meeting with the discharge planner on 07/06/2010 at 3:30 PM. During the interview, the adult child stated he/she arrived at the hospital for the meeting and found the Social Worker, (SW), attempting to have the patient sign discharge papers that indicated which home health agency that the patient wanted when discharged later that day. According to the adult child, when he/she asked about being transferred to a nursing home the SW told him/her to speak to the Case Manager. The adult child further stated that he/she was told that if his/her parent was not discharged today that he/she would be responsible for the bill. The adult child stated that when he/she asked about the patient having high blood glucose levels requiring insulin injections he/she was told he/she would have to take it up with the patient's (pt's) primary care physician.

Review of a SW note dated 07/06/2010 at 4:02 PM revealed "SW met with pt's [adult child]who Agreed on getting [home health] in the home, signed HIPPA. Info faced to [named individual] at [named agency]. SW provided a list of agencies to the family and contacted via telephone. Spoke to [named individual]". Review of the medical record revealed a physician's order dated 07/06/2010 at 3:00 PM, "Discharge Home with home health care with [named agency, same as listed in above SW entry] for [physical therapy and occupational therapy] PT/OT Coumadin teaching". Review of the medical record revealed a Home Medication(Pre-Hospital) Summary Admission Physician Order Sheet that indicated a copy be given to the patient upon discharge. Review of the form revealed that the form was started on 07/02/2010 and the section titled Outpatient Discharge medication Instructions was left blank.

Review of the medical record did not reveal that POA or any family member were provided any instruction on why the patient's blood glucose levels were elevated to the point the patient required insulin injections to correct the elevated levels. The medical record did not reveal that the POA, any family members or the home health company had received any documented instructions related to the patient's elevated blood glucose levels or instructions for any follow-up actions to be taken.

Interview with the Social Worker, (SW) on 07/13/2010 revealed that she was asked to review the discharge documents with the patient. The SW stated that half way through reviewing the form with the patient, the patient's adult child entered the room and asked her what she was doing, he/she stated that the patient has dementia and he/she was the POA. The SW stated that she then took the patient to meet with the Case Manager and that the Case Manager told the adult child that the patient did not meet admission criteria for skilled nursing facilities and that the doctor did not write an order for transfer to a skilled nursing facility. When asked about reviewing the elevated blood glucose levels and the need for insulin injections the SW stated that was not discharge planning's responsibility, that it would be the responsibility of nursing.

Review of the Case Management Department policy and procedure titled Discharge Planning revealed under PURPOSE, "To ensure patients and their families participate in the discharge planning process". Review of the PROCEDURE section revealed, "The Case Manager/Social Worker in collaboration with the patient, family, physician and the interdisciplinary team will determine an appropriate discharge plan. After the discharge plan has been formulated, it will be implemented by the nurse only when the patient, proxy and physician are in agreement".