HospitalInspections.org

Based on medical record review, review of policy and staff interview it was determined the hospital failed to ensure the nursing staff kept a current nursing care plan and documented progress daily for two (2) of five (5) hospital records reviewed for care planning (patient #3, visits B, C). This failure creates the potential for the nursing care of all patients to be adversely impacted.

Findings include:

1. The policy 'Interdisciplinary Care Planning (ICP)', revised Nov 2011, was provided for review. The policy states in part: "Appropriate members of the health care team will evaluate the patient needs as warranted by the patient's diagnosis and condition during ICP/discharge planning activities/meetings in all settings. Needs and/or problems identified through the ICP/discharge planning process will be documented on Interdisciplinary Plan of Care (IPOC) form for in-patients...The ICP will be continuously monitored and changes will be made to the Plan as necessary to meet the patient's needs and discharges criteria. Patient progress will be documented on the Interdisciplinary Care Plan Progress Note form for in-patients...as appropriate for each discipline: In-Patient Setting, Nursing daily."

2. Review of the medical record for patient #3, visit B, revealed she was hospitalized 9/4/13 through 9/11/13. Review of the IPOC revealed it was initiated on 9/5/13. Review of the IPOC and IPOC Progress Notes revealed no review or documentation of progress was documented by the nurse on 9/9//13 and 9/10/13.

This record was reviewed and discussed with the Case Management Director at 1000 hours on 9/25/13. She agreed with this finding.

3. Review of the current medical record for patient #3, visit C, revealed she was hospitalized on 9/17/13. Review of the IPOC revealed it was initiated on 9/18/13. Review of the IPOC and IPOC Progress Notes revealed no review or documentation of progress was documented by the nurse on 9/21/13.

Phone interview with RN #1 at 1535 on 9/24/13 revealed the patient's condition had declined and discharge was postponed. She stated the patient was complaining of dizziness and her hemoglobin level had dropped. Interview with the 4 N Charge Nurse at 1100 on 9/25/13 revealed the patient received blood transfusions throughout the night.

Review of the IPOC and IPOC Progress Notes through 9/25/13 revealed the patient's change of condition was not reflected.

Interview was conducted with the 4 N Nurse Manager at 0915 on 9/26/13 and these records were reviewed and discussed. She agreed with these findings.

Based on review of medical records, review of policy and staff interview it was determined the hospital failed to ensure results of Social Work/Case Coordination Risk Assessments were discussed with patients for three (3) of three (3) records reviewed which indicated increased risk of readmission (patient #3 A, B, C visits). This failure decreases the potential for providing an effective/successful discharge plan for patients who demonstrate increased risk of readmission.

Findings include:

1. Review of the medical record for patient #3, A visit, revealed the patient was hospitalized 8/21/13 through 8/24/13. Review of the medical record revealed Social Worker #1 completed a Social Work/Case Coordination (SW/CC) Risk Assessment on 8/23/13 which noted the patient's Readmission Risk Score as 6, which indicates High Risk. Review of the medical record revealed no documentation to reflect the results of this evaluation were discussed with the patient.

2. Review of the medical record for patient #3, B visit, revealed the patient was readmitted and hospitalized 9/4/13 through 9/11/13. Review of the medical record revealed Case Coordinator #1 completed a SW/CC Risk Assessment on 9/9/13 which noted the patient's Readmission Risk Score as 8, which indicates High Risk. Review of the medical record revealed no documentation to reflect the results of this evaluation were discussed with the patient.

3. Review of the current medical record for patient #3, C visit, revealed the patient was readmitted on 9/17/13. Review of the medical record revealed Case Coordinator #1 completed a SW/CC Risk Assessment on 9/18/13 which noted the patient's Readmission Risk Score as 3, which reflects Moderate Risk. A review of the medical record and Risk Assessment revealed this Assessment was incomplete and scored incorrectly. The correct score, based on information in the medical record and Assessment criteria, should have been 8, which reflects High Risk. Review of the medical record revealed no documentation to reflect the results of this evaluation were discussed with the patient.

At 1000 on 9/25/13 these records were reviewed and discussed with the Case Management Director. She agreed with these findings.

At 1100 on 9/25/13 these records were reviewed and discussed jointly with the Case Management Director, Case Coordinator #1 and Social Worker #2. Social Worker #2 was noted to be the patient's Social Worker. She stated she does not read the SW/CC Risk Assessments and was not aware the patient had been admitted three (3) times in the past thirty (30) days. The Case Coordinator stated she was aware the patient was a recent readmission and acknowledged she had incorrectly completed/scored the SW/CC Risk Assessment. Case Coordinator #1 acknowledged the results of the assessments had not been discussed or utilized for discharge planning with the patient. The Director of Case Management indicated the SW/CC documentation failed to meet expectations.

The policy 'Assessment/Documentation/Intervention,' last reviewed 8/12, was provided for review. It states in part: "Social Workers and Case Coordinators will provide timely, thorough and accurate information on services provided to patients and families...If ongoing assessment or problem resolution is required, documentation will be completed at the time of each intervention...Documentation should include a statement indicating that the patient and/or their representative has been involved in the planning and is aware of the issues and agrees with the proposed plan of action."

Based on medical record review, review of policy and staff interview it was determined the hospital failed to ensure staff develop, or supervise the development of, a discharge plan for three (3) of three (3) records reviewed, which indicated high risk of readmission (patient #3, A, B, C visits). This failure creates the potential for the discharge needs of all high risk patients to go unmet.

Findings include:

1. The policy 'Interdisciplinary Care Planning (ICP), revised Nov 2011, was provided for review. The policy states in part: "Appropriate members of the health care team will evaluate the patient needs as warranted by the patient's diagnosis and condition during ICP/discharge planning activities/meetings ...Needs and/or problems identified through ICP/discharge planning process will be documented on Interdisciplinary Plan of Care (IPOC) form for in-patients...The ICP will be continuously monitored and changes will be made to the Plan as necessary to meet the patient's needs and discharge criteria. Patient progress will be documented on the Interdisciplinary Care Plan Progress Note form for in-patients...as appropriate for each discipline: In-patient Setting...Case Coordinator-per patient risk and need."

2. The policy 'Assessment/Documentation/Intervention,' last reviewed 8/12, was provided for review. It states in part: "Social Workers and Case Coordinators will provide timely, thorough and accurate information on services provided to patients and families...If ongoing assessment or problem resolution is required, documentation will be completed at the time of each intervention...Places to Document: Progress Notes, IPOC (plan of care when arranging a service & IPOC progress note at least every 3 days."

3. Review of the medical record for patient #3, A visit, reveals the patient was hospitalized 8/21/13 through 8/24/13. Review of the medical record revealed Social Worker #1 completed a Social Work/Case Coordination (SW/CC) Risk Assessment on 8/23/13 which noted the patient's Readmission Risk Score as 6, which indicates High Risk.

Review of the patient's Interdisciplinary Care Plan Progress Notes for the 8/21/13, 8/22/13, 8/23/13 and 8/24/13 revealed no Case Coordinator documentation.

4. Review of the medical record for patient #3, B visit, reveals the patient was readmitted and hospitalized 9/4/13 through 9/11/13. Review of the medical record revealed Case Coordinator #1 completed a SW/CC Risk Assessment on 9/9/13 which noted the patient's Readmission Risk Score as 8, which indicates High Risk.

Review of the patient's Interdisciplinary Care Plan Progress Notes, 9/5/13 through 9/11/13 revealed only one (1) Case Coordinator note on 9/9/13, which noted patient was active with Home Health prior to hospitalization and noted "continue to follow for discharge needs."

5. Review of the current medical record for patient #3, C visit, reveals the patient was readmitted on 9/17/13. Review of the medical record revealed Case Coordinator #1 completed a SW/CC Risk Assessment on 9/18/13 which noted the patient's Readmission Risk Score as 3, which reflects Moderate Risk. A review of the medical record and Risk Assessment revealed this Assessment was incomplete and scored incorrectly. The correct score, based on information in the medical record and Assessment criteria, should have been 8, which reflects High Risk.

Review of the patient's Interdisciplinary Care Plan Progress Notes, 9/18/13 through 9/25/13 revealed only one (1) Case Coordinator note on 9/23/13 which noted "for possible discharge today, already active with Mountaineer Home Health."

None of the above records contained any documentation related to incorporating the patient's multiple hospitalizations and high risk for readmission into the plan of care/discharge plan.

At 1000 on 9/25/13 these records were reviewed and discussed with the Case Management Director. She agreed with these findings.