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Based on medical record review, staff interview, and policy and procedure review it was determined the hospital's case management staff failed to provide evidence the patient's discharge plan was reassessed throughout the hospital stay or prior to discharge.

Findings:

Patient #2's electronic medical record was reviewed in the morning of 7/13/11. The patient was admitted to the facility on 3/8/11 and was discharged 10 days later on 3/18/11. The medical record contained an initial discharge plan by the facility's case manager (CM) dated 3/9/11. The CM documented on the initial discharge planning evaluation that Patient #2 currently lived alone, was functioning independently, was alert and oriented. The CM noted the tentative discharge plan as, "Home ? home health." and also wrote, "spoke with patient about d/c (discharge) plans and the possibility of needing home health, patient stated he will strongly consider home health. will (sic) continue to track and monitor case." On the day of discharge, the physician's progress notes described the patient as "Awake/Confused" and noted the patient's encephalopathy was secondary to alcohol abuse/dementia. The medical record did not contain evidence a reassessment to the initial discharge plan.

The facility's CM was interviewed on 7/13/11 following review of Patient #2's electronic medical record. The CM stated he recalled Patient #2 well and described the patient's hospital course from admission to discharge. He stated that after conducting the initial discharge planning evaluation, the patient's health status and treatment rendered him unable to communicate for a few days. During this time, the CM discussed Patient #2's condition/progress with his nurses and physicians. Once Patient #2 was able to communicate, he provided the CM with a family friend's contact information. The CM stated he attempted unsuccessfully, to call the family friend multiple times before reaching her to discuss potential post-hospital plans for Patient #2. The CM stated that on the day of discharge, he met in Patient #2's room with the patient, the patient's sister, brother-in-law and family friend. He stated that he informed everyone in the exit interview that home health arrangements could be made for Patient #2 even though he was uninsured and that everyone preferred the patient to be discharged to the home of the family friend. The CM acknowledged the medical record did not contain evidence of a discharge plan reassessment following his initial evaluation on 3/9/11 and stated that if he could go back and do anything differently, he would document the exit interview on the day of discharge in Patient #2's medical record.

A review of the facility's policy titled, "Patient Care Services Ch 02: Discharge Planning" was conducted on 7/13/11 in the afternoon. The policy stated, in part, under "Collaborative Discharge Planning" that "Patients will be continually re-assessed via daily collaboration between members of the Interdisciplinary team and in the formal Interdisciplinary team meetings. If it is then determined that a patient will need assistance at discharge, a discharge plan will be formulated and documented. The Interdisciplinary Team will collaborate with the patient/family and physician to formulate a discharge plan for each patient who is determined to be in need of assistance. The discharge plan is documented in the medical record."