HospitalInspections.org

Based on record review and staff interview, the facility failed to implement a discharge plan for one (# 4) of 10 patients. Failing to complete discharge evaluations and to ensure availability of needed services may result in rehospitalizations or negative outcomes.

The findings include:

Patient #4 was admitted to the facility on 10/11/11 with multiple medical problems including abnormal heart rhythms. The patient was non compliant with lifestyle changes and opted for conservative medical management.

Record review of the medical record on 12/22/11 for Patient #4 revealed that the patient and family were presented with options for discharge planning. The patient's wife did not think that the patient was ready for hospice and the social worker documented that she would obtain home health care for the patient on 10/13/11. The patient was discharged on 10/14/11 without an order for home health care evaluation or any other services. There were no further notes to indicate that staff communicated with the physician regarding an order for home health or hospice evaluation. There was no coordination seen documented in the medical record between nursing and case management to follow up with the patient to reassess their discharge needs when the patient was discharged on the weekend.

Interview with the Social Worker at 4:30pm revealed that there were no orders for home health care; that the patient left on a Saturday. She stated that they get to people as soon as they can; that the order for routine consults for discharge planning was on every admission for every patient. The social worker stated that she attempted to see patients when they first come in and some days they were not able to see everyone in 24 hours. The social worker stated that her notes stated that she spoke to the patient about home health care but there was no order when he left on a Saturday. She stated that the patient's wife was not sure about hospice because the daughter was the one that brought up hospice to her.