HospitalInspections.org

Based on medical record review and staff interview, the facility failed to implement a discharge plan for 1 (#3) of 7 patients.
The findings include:
A review of the electronic medical record for Patient #3 was completed on 2/17/12 at 9:15am with the 10th floor Charge Nurse. Patient #3 was admitted to the facility on 2/13/12 at 8:30pm with a diagnosis of pneumonia. The physician orders dated 2/15/12 revealed an order to discharge the patient to an Assisted Living Facility (ALF) when accepted. The Charge Nurse could not find any documentation of a discharge planning assessment having been done for Patient #3. The Charge Nurse then asked the Nurse Manager/Case Management staff if an ALF had been located yet. The Nurse Manager/Case Management stated she could not find anything documented about that and she would get the Case Manager/Social Worker to find it. The Case Manager/Social Worker looked in the electronic medical record and could not find any documented discharge planning assessment or communication about locating an ALF for Patient #3. The Nurse Manager/Case Management stated " we are trying desperately to get the assessments done in a timely manner but I don ' t see one on him. "
An interview was conducted with the Director of Case Management on 2/17/12 at 11:00am. She stated we are having some staffing challenges. We are working on the problem. We have some new people in training. We did some education with the staff and we just went to a new computer system with a new assessment tool for documentation. The staff is trying to get used to it but there have been some issues with that as well. Our goal is to start discharge planning on admission. Each staff member is assigned two units to cover. They go into the computer and see the list of patients on their floor that need to be seen. Not every patient is seen by case management, only if it is identified as necessary or we receive an order. The intent is to get the patients seen in 24-48 hours of admission. I am currently in the process of building up my staff. It is difficult to find qualified social workers with discharge planning experience.