HospitalInspections.org

Based on record review and interview, the facility failed to document compliance with patient and family preferences when they are expressed related to discharge planning for 1 of 3 sampled records (#2).

Findings:

Review of patient #2's records reflected the patient was admitted on 10/18/2010 and discharged on 10/31/2010. The daily note by the case manager on 10/29/2010 confirmed that patient #2's wife requested home care and identified the provider she preferred. The clinical resume, physician's orders, nursing notes, and discharge documentation failed to reflect the physician was informed of the request and documented the patient was discharged home with no documentation of home care arrangements.

Interview on 12/10/2010 at 12 p.m. with the case manger confirmed that patient #2's wife had requested home care and the accuracy of her note on 10/29/2010. She could not confirm that the physician was notified and indicated she thought the nurse would notify the physician.

Interview with the Risk Manager and Case Manager on 12/10/2010 at 12:15 p.m. confirmed the records were accurate and that the facility could not provide evidence or documentation the physician was notified of the patient's wife's request for home care.