HospitalInspections.org

Based on findings from document review, medical record (MR) review and interview, in 3 of 5 MRs reviewed (Patient B, D, and E), discharge screenings (used to identify patients in need of discharge planning evaluations) were not completed.

Findings include:

-- The hospital policy and procedure (P&P) titled "High Risk Screening," last reviewed 10/2013, indicated high risk patients are identified as patients of any age and a resident of a residential care facility (skilled nursing facility, adult home), patients age 75 and above with an admitting diagnosis of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). These patients should be screened for discharge planning needs.

However, per MR review the following patient's MRs lacked discharge planning evaluation screenings:

*Patient B, a 75 year old resident of an adult home was admitted on 5/18/15 due to extreme weakness and frequent falls.

*Patient D, a 89 year old resident of a skilled nursing facility (SNF) was admitted to the hospital 6/12/15 after a fall at the SNF.

*Patient E, a 75 year old patient admitted to the hospital from his/her home on 3/30/15 with exacerbation of COPD, and CHF.

-- During interview with Staff #1 (Social Worker) and Staff #2 (IT Registered Nurse) on 6/17/15 at 11:15 am and on 6/18/15 at 10:15 am, (respectively) the above findings were acknowledged.

Based on findings from document review, medical record (MR) review and interview, in 3 of 5 MRs reviewed (Patient B, D, and E), discharge planning evaluations were not completed.

Findings include:

-- The hospital policy and procedure (P&P) titled "High Risk Screening," last reviewed 10/2013, indicated high risk patients are to be assessed by a Social Worker/Discharge Planner and intervention/plans will be noted in the patient's electronic medical record within 2 working days of admission.

However, per MR review the following patient's MRs lacked discharge planning evaluations:

*Patient B, a 75 year old resident of an adult home was admitted on 5/18/15 due to extreme weakness and frequent falls.

*Patient D, a 89 year old resident of a skilled nursing facility (SNF) was admitted to the hospital 6/12/15 after a fall at the SNF.

*Patient E, a 75 year old patient admitted to the hospital from his/her home on 3/30/15 with exacerbation of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF).

-- During interview with Staff #1 (Social Worker) and Staff #2 (IT Registered Nurse) on 6/17/15 at 11:15 am and on 6/18/15 at 10:15 am, (respectively) the above findings were acknowledged.

Based on findings from document review and interview, the hospital did not disclose their financial interest in a skilled nursing facility (SNF) on the hospital's list of adult care facilities provided to patients.

Findings include:

-- The hospital policy and procedure (P&P) titled, "Referral of Patients For Adult Care Facility" last reviewed 10/2013 stated the following: "The patient and/or designated personal representative will be provided with a list of community Adult Care Facilities and given the opportunity to choose."

The list of community Adult Care Facilities provided to patients did not disclose the hospital's financial interest in a SNF identified on the list.

-- During interview with Staff #3 (Director of Care Transitions) on 6/18/15 at 9:45 am, the above findings were acknowledged.