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Based on a review of the facility's policy and procedures and interview with staff members, the facility failed to identify at an early stage of hospitalization which patients are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.

Findings include:
Interview with the temporarily assigned Director of Case Management (DCM) and Social Services Case Manager #1 was done on 1/5/15 at 10:10 A.M. Inquired how does the hospital identify patients in need of discharge planning services. The DCM reported all patients are eligible for discharge planning from the time of admission.

The facility's discharge policy and procedures was provided on 1/5/15 at 12:55 P.M. by the DCM. A review of the policy and procedure found there is no documentation to indicate the hospital adopts a policy of developing a discharge plan for every patient. Interview with the DCM on 1/7/15 at 8:55 A.M. confirmed that the hospital's policy and procedure does not identify all patients as being eligible for discharge planning. Inquired if all patients are eligible for discharge planning what is the purpose of utilizing the "Case Management Triggers" form that refers to a screening process. The DCM responded that this is confusing; however, the practice for the case managers is to provide discharge planning services for all patients.

Based on record review, interview with staff members and review of the facility's policy and procedures, the facility failed to provide a discharge planning evaluation for 4 of 8 patients in the sample.

Findings include:
Review of the facility's policy and procedures for discharge planning evaluation did not include the requirement for assessing the likelihood of a patient needing post-hospital services and the availability of services and an assessment of the patient's capacity for self-care of the possibility of the patient being cared for in the environment from which he or she entered the hospital.

Interview with the temporarily assigned Director of Case Management (DCM) was done on 1/7/15 at 8:55 A.M. The DCM confirmed the facility's policy and procedures does not address the discharge planning evaluation process. The DCM clarified the "Case Management Assessment" found in the patient's electronic medical record indicates that a discharge planning evaluation was done. The DCM further shared that the facility is exploring the use of other tools to facilitate the discharge planning evaluation.

1) Interview was done with Patient #4 on 1/5/15 at 2:10 P.M. The patient reported that she fell down and injured her right hip. Inquired if she is aware of when she will be discharged? The patient replied she will be able to go home when she is able to get up and is independent. The patient reported that she lives alone. Inquired whether the facility staff has discussed discharge planning with her. The patient responded that she will return home and there was no discussion regarding discharge planning.

Interview and concurrent record review was done on 1/5/15 at 2:10 P.M. with Case Manager #2. Review found Patient #4 was admitted to the facility on 1/2/15 (Friday) due to acute pelvic fracture. There was no documentation of a discharge planning evaluation as evidenced by completion of the Case Management Assessment. The case manager reported based on the "Case Management Triggers" (provided by the facility on 1/5/15 at 12:55 P.M.), the patient needs to be seen for case management services. The case manager noted the patient was admitted on a Friday, the facility does not have case managers on the weekend to do discharge evaluations.

2) Interview and concurrent record review was done with Case Manager #3 on 1/6/15 at 2:25 P.M. Patient #5 was a closed record review. The patient was discharged to a long term care nursing facility. The case manager did not complete the "Case Management Assessment" and was unable to provide documentation of an assessment of the patient's ability to perform activities of daily living and an assessment to determine that the patient or family/support persons are unable to meet all care needs of Patient #5.

3) Patient #6 was a closed record review. Record review with the assistance of the Assistant Director of Nursing (ADON) was done on 1/6/15. The patient was admitted to the facility's Intensive Care Unit (ICU) on 12/5/14 with diagnoses of junctional bradycardia with block, chronic pain opioid depression, chronic obstruction lung disease and depression. The patient was discharged home on 12/10/15 with discharge instructions. The patient was readmitted on 12/13/14 to the ICU for bradycardia and hypertension. Documentation in the history and physical notes the patient denies taking medication and is not compliant with her medication regimen.
Interview and concurrent record review was done on 1/7/15 at 8:55 A.M. with the DCM. The DCM confirmed there is no documentation of discharge planning evaluation and no discharge planning was done. The patient was discharged home on 12/17/14. The DCM reviewed the patient's record and found that the patient is not compliant with taking medication. The assigned Case Manager did not assess whether the resident's insurance coverage could provide necessary services post hospitalization. The DCM identified the insurance program has a a post hospitalization service to do follow up with their patients for medication compliance.

4) Patient #8 was a closed record review. Record review was done with the ADON on 1/6/15 at 3:00 P.M. Patient #8 was admitted on 12/12/14 with diagnosis of change of mental status due to alcohol, opiate and sedative use. The Case Management Assessment was not completed by the case manager. Interview and concurrent record review was done on 1/7/15 at 8:55 A.M. with the DCM. The DCM confirmed the Case Management Assessment was not completed.

The patient was discharged to his son's home. A referral was made to a home health agency; however, there is no documentation of the reason for referral or an order for services.

Based on record review, interview with staff member and a review of the facility's policy and procedures, the facility failed to ensure a discharge plan was provided to 1 (Patient #6) of 8 patients in the case sample.

Findings include:
The facility provided a copy of the policy and procedures for discharge planning was provided on 1/5/15 at 12:55 P.M. Review of the documents found the facility did not include in the discharge planning policy and procedure identification of qualified personnel for the development and supervision of the development of a discharge plan.

Cross Reference to A 806. Patient #6 was admitted to the facility's ICU unit on 12/5/14 for functional bradycardia with block and discharged home on 12/10/14. The patient was readmitted to the ICU on 12/13/14 for bradycardia and hypertension. The patient was discharged home on 12/17/14. There is no documentation of a discharge plan evaluation or a discharge plan. Interview and concurrent record review was done with the temporarily assigned Director of Case Management on 1/7/15 at 8:55 A.M. The DCM confirmed there is no documentation of a discharge plan evaluation and a discharge plan.

The DCM reviewed the patient's record and found that the patient is not compliant with taking medication. The assigned Case Manager did not assess whether the resident's insurance coverage could provide necessary services post hospitalization. The DCM identified the insurance program has a a post hospitalization service to do follow up with their patients for medication compliance.

Based on record review, interview with staff member and review of the facility's policy and procedures, the facility failed to include in the discharge plan a list of home health agencies and skilled nursing facilities that are available to the patient that are participating in the Medicare program and serve the geographic area and must document in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf for 5 (Patients #2, #3, #5, #7 and #8) of 8 patients in the sample.

Findings include:
1) Interview with Case Manager #1 and concurrent record review was done on 1/5/14 at 1:50 P.M. Patient #3 was admitted to the facility on 12/28/14 for left hemi-arthroplasty related to left femoral neck fracture. The plan was for discharge to a long term care facility for short term rehabilitation on 1/5/14. There was no documentation in the record that a list of skilled nursing facilities was presented to the patient.

Inquired whether the facility provides a list to the patients of HHAs and SNFs available. CM#1 reported a list is not provided and for this resident only one SNF is available to the patient based on her insurance.

2) Record review and interview with Case Manager #2 was done on 1/5/15 at 2:15 P.M. for Patient #4. Patient #4 was admitted to the facility on 1/2/15. Inquired whether the facility provides patients with a listing of available HHAs and SNFs based on geographic area. CM #2 responded that the facility has brochures; however, does not have a listing to provide to the patient.

3) Record review and interview with Case Manager #3 was done on 1/6/15 at 2:25 P.M. for Patient #5. Patient #5 was admitted to the facility on 11/24/14 with diagnoses of TIA, dementia, hypertension and fell at home. The plan was for discharge to a skilled nursing facility (SNF) for long term placement. Inquired whether the facility provided a listing of available SNFs based on geographic area. The CM responded that the family identified the SNF facility.

4) Record review for Patient #2 was done on the morning of 1/6/14. The patient was admitted to the facility on 3/23/13. The initial plan was to transfer the patient to a SNF for long term placement. There was no documentation that the patient was provided with a listing of SNF facilities and/or HHAs.

5) Record review done for Patient #8 done on 1/6/15 at 3:00 P.M. notes the patient was admitted to the facility on 12/12/13 and discharged home on 1/2/15 with home health services. There is no documentation of a listing of home health agencies available to this patient. The ADON reported presently there is only one home health agency on the island and the other agency is only available to their insurance consumers.

The facility provided a copy of the discharge planning policy and procedures on 1/5/14 at 12:55 P.M. A review found the procedure for providing and documenting in patients' medical record a list of HHAs and SNF facilities in the geographic area were provided was not included.

On 1/7/15 at 11:40 A.M. interview with the temporarily assigned Director of Case Management (DCM) confirmed the facility does not provide a listing of SNF facilities and HHAs to their patients. At this time, the DCM provided a copy of a document entitled "Placement Options: which lists the following options: care homes, foster families and other facilities. The DCM confirmed this is a tool utilized by the case managers to assist with discharge planning and is not provided to the patients. Patients #3, #5 and #7 were affected by this deficient practice as they were discharged to a SNF facility and Patient #2 was intended for discharge to a SNF facility. Patient #8 was discharged home with HHA services.