HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed for discharge planning, the Hospital failed to ensure all discharge planning was documented in the patient's clinical record, to include home health information.

Findings include:

1. Hospital policy entitled, "Discharge Planning and the Discharge Process," (revised 5/13) required, Policy: 2. Discharge planning is documented in the Meditech Care Coordinator Notes and Assessments..."

2. The clinical record of Pt #1 was reviewed on 12/9/14. Pt #1 was a 77 year old female admitted on 6/27/14 from (receiving Hospital) with a diagnosis of sepsis and a history of colon cancer, dementia, hypertension and diabetes mellitus. Care Coordinator notes dated 7/22/14 at 11:37 AM included, "Referral packets were sent to Home Health Agency #1 (HHA), the son's preferred home health..." Care Coordinator notes dated 7/25/14 at 6:10 PM included, "...This worker also informed him (son) that HHA #1 called and stated that they are not in network with patient's insurance and they cannot take her case. The son stated that his second choice is HHA #2."

On 12/9/14 at approximately 1:30 PM the Medical Social Worker (MSW) (E #1) working with Pt #1's family was interviewed During the interview E #1 stated, "I provided the son with a booklet of other agencies as well as skilled facilities located within the son's required area. This is where the son identified HHA #2."

The Care Coordinator Note documentation in Pt #1's clinical record lacked documentation that Pt #1's son was provided with the booklet listing home health agencies.

3. The Chief Quality Officer was interviewed on 12/10/14 at 9:00 AM. During the interview the Quality Officer stated that there should be documentation of providing the son with the list of home health agencies.