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Based on medical record review and staff interview, the facility failed to develop and implement a discharge plan that included the provision of a list of available skilled nursing facilities (SNFs) for 1 of 3 sample patients (#2) who required SNF services after discharge from the hospital. The findings were:

Review of the medical record for patient #2 showed s/he was admitted on 5/16/12. Further review showed the patient was discharged to the hospital's extended care facility (ECF), a SNF, on 5/18/12. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated the discharge plan for all patients who require SNF services should include information about staff providing a list of available facilities. She further revealed that this part of the discharge plan was most likely omitted because patient #2 had selected the hospital's ECF during a previous admission, and staff assumed the patient wanted the same facility. At that time she verified the 5/16/12 to 5/18/12 discharge plan failed to include information about a list of available facilities. Review of the medical record revealed documentation that addressed this issue was lacking.

According to the Discharge Planning Policy and Procedure, revised July 2011, "As a standard of practice, patients will be informed of their freedom to choose among providers when planning to discharge from the hospital into another agency's/providers' care. This includes, but is not limited to, ensuring that the patient and family members are provided with information on all participating agencies that are available..."

Based on medical record review and staff interview, the facility failed to include documentation in the medical record that a list of available skilled nursing facilities (SNFs) was given to 1 of 3 sample patients (#2) who required SNF services. The findings were:

Review of medical records showed patient #2 was admitted on 5/16/12. Further review showed the patient was discharged to the hospital's extended care facility (ECF), a SNF, on 5/18/12. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated that, although her staff was aware of the requirement to provide a list of SNFs, she did not have evidence to show it was provided for patient #2. Review of the medical record revealed no documentation about giving the patient a list of available SNFs prior to discharge.

Based on staff interview and medical record review, the facility failed to ensure the discharge plans for 1 of 3 sample patients (#2) identified that the hospital had a disclosable financial interest in the skilled nursing facility (SNF) to which the patient were discharged. The findings were:

According to the medical records, patient #2 was discharged to the hospital's extended care facility (ECF, a SNF) on 5/18/12. Review of the discharge plans showed no evidence the patient was informed prior to his/her discharge that the hospital owned the facility. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated she did not know whether the staff person responsible for informing the patient that the hospital had a disclosable financial interest in the ECF had done this. At that time she verified the financial disclosure information had not been included in the documented discharge planning process for this patient.

Based on medical record review and staff interview, the facility failed to develop and implement a system for identifying preventable readmissions. The findings were:

During an interview on 8/20/12 at 1:15 PM, the discharge planner revealed all readmissions were flagged for her review. She further stated discharge planning concerns were discussed with the physicians, nursing staff and other healthcare professional; but the facility did not have a formalized systematic approach for identifying preventable readmissions. Review of the discharge planning policies and procedure also revealed the lack of a system for identifying preventable readmissions related to the discharge planning process.

Based on medical record review and staff interview, the facility failed to develop and implement a discharge plan that included the provision of a list of available skilled nursing facilities (SNFs) for 1 of 3 sample patients (#2) who required SNF services after discharge from the hospital. The findings were:

Review of the medical record for patient #2 showed s/he was admitted on 5/16/12. Further review showed the patient was discharged to the hospital's extended care facility (ECF), a SNF, on 5/18/12. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated the discharge plan for all patients who require SNF services should include information about staff providing a list of available facilities. She further revealed that this part of the discharge plan was most likely omitted because patient #2 had selected the hospital's ECF during a previous admission, and staff assumed the patient wanted the same facility. At that time she verified the 5/16/12 to 5/18/12 discharge plan failed to include information about a list of available facilities. Review of the medical record revealed documentation that addressed this issue was lacking.

According to the Discharge Planning Policy and Procedure, revised July 2011, "As a standard of practice, patients will be informed of their freedom to choose among providers when planning to discharge from the hospital into another agency's/providers' care. This includes, but is not limited to, ensuring that the patient and family members are provided with information on all participating agencies that are available..."

Based on medical record review and staff interview, the facility failed to include documentation in the medical record that a list of available skilled nursing facilities (SNFs) was given to 1 of 3 sample patients (#2) who required SNF services. The findings were:

Review of medical records showed patient #2 was admitted on 5/16/12. Further review showed the patient was discharged to the hospital's extended care facility (ECF), a SNF, on 5/18/12. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated that, although her staff was aware of the requirement to provide a list of SNFs, she did not have evidence to show it was provided for patient #2. Review of the medical record revealed no documentation about giving the patient a list of available SNFs prior to discharge.

Based on staff interview and medical record review, the facility failed to ensure the discharge plans for 1 of 3 sample patients (#2) identified that the hospital had a disclosable financial interest in the skilled nursing facility (SNF) to which the patient were discharged. The findings were:

According to the medical records, patient #2 was discharged to the hospital's extended care facility (ECF, a SNF) on 5/18/12. Review of the discharge plans showed no evidence the patient was informed prior to his/her discharge that the hospital owned the facility. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated she did not know whether the staff person responsible for informing the patient that the hospital had a disclosable financial interest in the ECF had done this. At that time she verified the financial disclosure information had not been included in the documented discharge planning process for this patient.