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Based on medical record review, review of policy and procedure and interviews, the hospital failed to initiate discharge planning within 24 hours of admission as required by hospital policy and procedure.

This affected Patient Identifier (PI) # (Numbers): PI # 2, PI # 3, and PI # 4, three of eleven medical records reviewed.

Findings include:

1. PI # 2 was admitted on 11/7/16 with diagnoses to include Urinary Tract Infection, Diabetes Type 1... The first case management note (Initial Discharge Planning Evaluation) was documented 48 hours after admission on 11/9/16.

2. PI # 3 was admitted on 11/8/16 with diagnoses to include Chest Pain, Rule out Myocardial Infarction with enzymes and EKG (electrocardiogram) and Chronic Diastolic Congestive Heart Failure... The first case management note (Initial Discharge Planning Evaluation) was documented on 11/10/16, 48 hours after PI # 3 was admitted.

3. PI # 4 was admitted on 11/6/16 with diagnoses to include pneumonia and Paroxysmal Atrial Fibrillation / AF (at least two separate episodes of AF that terminate spontaneously, usually within 24 hours, and are not related to a reversible cause, www.medpagetoday.com). The first case management note (Initial Discharge Planning Evaluation) was documented on 11/9/16, 72 hours after PI # 4's admission to the hospital.


Policy Review:

Discharge Planning Documentation;

Revised Date: 5/2009...
Procedure:

1. Initial Assessment will include discharge planning needs assessment. This is documented on the initial discharge planning needs form in the E-form section of CPSI (hospital's computer system).

a. Pre-hospitalization place of residence.

1. Home, alone.
2. Home with spouse
3. Home with relatives.
4. Other.
5. No known place of residence.

b. Is return at time of discharge realistic?

2. Community resources being utilized at time of admission...

a. Anticipated needs at time of discharge.

1. Equipment- list.
2. Medical supplies...

3. Frequency of documentation for other than brief, uncomplicated discharge plans of care;

a. Assessment /documentation at admission to include at least:

1. Extended care at time of admission.

2. Level of care required...

b. Every two to three working days.

1. Facilities contacted.
2. Changes in needs.

c. Indication of referral for community service and actions taken in securing those services reflects update every three working days or more frequently as indicated by the plan of care.

1. Home Health Services...
3. Hospice...

d. Medical records include a copy of the discharge record and all contacts made.


Interviews:

During an in interview on 11/10/16 at 10:00 AM, the Director of Nursing (DON) / Employee Identifier (EI) # 1, stated admission as defined in the discharge policy means within 24 hours of admission. Case Management is expected to document an initial note regarding the patient's discharge plan within 24 hours of admission. Updates are expected every two to three working days.

During an in interview on 11/10/16 at 10:30 AM, EI # 1 verified discharge planning was not initiated within 24 hours per hospital policy for PI # 2, PI # 3 and PI # 4.