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Based on interview and record review facility discharge planners failed to ensure a list of home health agencies (HHAs) was included in the discharge plan for two of two patients (Patient #1 and #11) who required services of a home health agency after discharge. The facility census was 38 patients.

Findings included:

1. Record review of current Patient #11's internal medicine admission history and physical showed staff admitted the patient on 07/10/11 with sepsis (whole body infection) possibly caused by inflammation in the left lower leg and urinary tract infection.

Record review of the patient's Interdisciplinary Care Plan showed a plan to discharge to home with home health, dated and authenticated by the case manager on 07/11/11.

Record review on 07/13/11 showed staff failed to include a list of available home health agencies in the discharge plan.

2. Record review of discharged Patient #1's psychiatry evaluation showed staff admitted the patient to the psychiatry unit on 06/06/11 with depression and suicide attempt.

Record review of the Social Worker's progress notes dated 06/16/11 showed the Social Worker and the patient discussed after discharge care by a HHA, the patient named one however no evidence of a list of available HHAs, presented to the patient for selection, was in the discharge plan documentation.

Record review of the Social Worker's progress notes dated 06/17/11 showed the one HHA named by the patient declined to take the patient and the Social Worker then faxed information to two other HHAs however no evidence of a list of available HHAs that was presented to the patient for selection, was in the discharge plan documentation.

3. During an interview on 07/13/11 at 2:00 PM Staff B, Director of Case Management (organizationally responsible for discharge planning on non-psychiatry units) stated if a HHA was required to care for a patient after discharge a list was provided for the patient to select from however staff do not include the list on the discharge plan.

During an interview on 07/13/11 at 2:42 PM Staff D, Social Worker for the psychiatry unit stated he/she did not have time to record every verbal exchange with patients and staff in the patient's medical record.

Based on interview and record review facility discharge planners failed to ensure a list of skilled nursing facilities (SNFs) was included in the discharge plan for four of four patients (Patient #1, #6, #8 and #9 ) who required services of a skilled nursing facility upon discharge. The facility census was 38 patients.

Findings included:

1. Record review of current Patient #8's psychiatry evaluation showed staff admitted the patient to the psychiatry unit on 06/29/11 with dementia with depression and delusions.

During an interview on 07/13/11 at 11:35 AM Staff E, Nurse Manager for psychiatry unit stated the patient was discharged to a skilled nursing facility.

2. Record review of current Patient #9's psychiatry evaluation showed staff admitted the patient on 06/29/11 with recurrent depression with psychotic features.

Record review of the patient's Senior Mental Health Admission Assessment dated 06/29/11 showed staff planned for placement in a skilled nursing facility on discharge,

During an interview on 07/13/11 at 11:35 AM Staff E, Nurse Manager for psychiatry unit stated the patient was discharged to a skilled nursing facility.

3. Record review of discharged Patient #1's psychiatry evaluation showed staff admitted the patient to the psychiatry unit on 06/06/11 with depression and suicide attempt.

Record review of the Social Worker's progress notes dated 06/10/11 showed the Social Worker and the patient discussed discharge to a skilled nursing facility (SNF) however no evidence of a list of available SNFs that was presented to the patient for selection, was in the discharge plan documentation.

Record review of the Social Worker's progress notes dated 06/13/11 showed the Social Worker called one SNF that did not have an available bed then, discussed SNF placement at other SNFs in the patient's home area however no evidence of a list of available SNFs that was presented to the patient for selection, was in the discharge plan documentation.

4. Record review of discharged Patient #6's admission history and physical showed staff admitted the patient to the psychiatry unit for depression on 01/31/11 and discharged the patient to a SNF on 02/21/11.

Further review of the patient's discharge documents showed staff failed to include a list of available SNFs that was presented to the patient for selection.

5. During an interview on 07/13/11 at 2:00 PM Staff B, Director of Case Management (organizationally responsible for discharge planning on non-psychiatry units) stated if a SNF was required to care for a patient after discharge a list was provided for the patient to select from however staff do not include the list on the discharge plan.

During an interview on 07/13/11 at 2:42 PM Staff D, Social Worker for the psychiatry unit stated he/she did not have time to record every verbal exchange with patients and staff in the patient's medical record.

Based on review of the facility quality assessment report and interview, facility staff failed to develop and maintain an on-going discharge planning process evaluation. This deficient practice had the potential to affect all patients in the current census of 38.
Finding included:
1. Record review of the discharge planning process quality assessment/ performance improvement report, titled 2011 Quality Scorecard, the Case Management department (organizationally responsible for patient discharge planning on non-psychiatry units) showed staff called forty patients and/or facilities to find if the patient reported satisfaction with the discharge. The response to the telephone call was the only factor analyzed and there was no assessment or reassessment of the discharge planning process itself.
Record review of the same 2011 scorecard showed Social Services (organizationally responsible for patient discharge planning on the psychiatry unit) showed that department had no quality assessment projects, studies or assessment and reassessment of the discharge planning process.
2. During an interview on 07/13/11 at 11:40 AM, Staff C, the Director of the Gero-psychiatry Unit stated the following:
-He/she maintained lots of data on where patients were admitted from and where they were discharged to however he/she did not maintain any formalized quality assessment projects on the discharge planning process.
-He/she performed telephone satisfaction surveys with facilitates that received discharged patients however did not record these in a formalized analysis of the discharge planning process.
-He/she did not maintain other quality assessment studies or projects to evaluate the discharge planning process.
During an interview on 07/13/11 at 2:00 PM, Staff B, the Director of Case Management stated discharge planners do not perform quality assessment on discharges that do not go smoothly or other studies of the discharge planning process.