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Based on record review and interview the facility failed to ensure each patient had the right to participate in their plan of care including discharge planning for 1 (Patient #5) of 10 patient records reviewed for documentation of discharge planning.

The findings include:

On 11/14/11 review of the medical record for Patient #5 reveals he was admitted to the facility on 7/22/11, from an Assisted Living Facility (ALF). He was discharged to the same ALF on 7/26/11.

Discharge planning was initiated by nursing upon admission and the AHCA Form 1823 was placed in the medical record for completion by the physician.

There are no discharge planning notes in the medical record regarding return to the ALF, discussion with the patient regarding his discharge preference. There is also no documentation of communication with the ALF regarding return to the facility and if they were willing to accept him upon discharge.

From the lack of documentation related to discharge planning, it is not able to be determined if the discharge of Patient #5 to the ALF was appropriate or if it was his wishes of where he wanted to go after being discharged from the hospital.

After review of the medical record of Patient #5 the director of Social Services and the Risk Manager both confirmed there were no discharge planning notes in the medical record for Patient #5. They confirmed it was the responsibility of the Social Worker to document any communication with the patient and receiving facility regarding the placement of the patient after discharge.

Review of the nurses notes on the day of discharge reveals the discharging nurse contacted the social worker by phone and she confirmed the discharge to the ALF. There is no documentation from the Social Worker regarding this conversation with nursing.

Based on record review and interview the facility failed to ensure the medical record contained a discharge summary promptly after discharge for 1 (Patient #4) of 10 patient medical records reviewed for hospital discharges.

The findings include:

On 11/14/11 review of the medical record for Patient #4 reveals he was admitted to the facility on 7/23/11 with a discharge date of 7/25/11. Further review reveals there is no discharge summary from the physician.

Review of the facility policy regarding discharge summaries reveals a dictated discharge summary is not necessary if the patient has been in the hospital for less than 48 hours.

During an interview with the medical records director on 11/14/11 at 3:30 p.m., she stated even though the policy does not require a dictated discharge summary a written progress note from the physician would suffice if all the components needed for a discharge summary were noted in the progress note.

After review of the medical record the medical records director confirmed there was no discharge summary in the medical record of Patient #5. She stated the progress notes and physician's orders do not meet the requirements for a discharge summary.