HospitalInspections.org

Based on record review and interview, it was determined that the facility failed to implement all of the elements required in the facility policy regarding interdisciplinary discharge planning specific to counseling for post-hospital care.

Findings were:

Facility policy, Interdisciplinary Discharge Planning and Continuing Stay Criteria (policy # PC-115, last reviewed date 6/23/14), stated the following in part "3. Responsibilities: ...c. Social Worker Responsibilities ...xi. Provide patient and support system with education on suicide risk factors and symptoms of relapse. Documentation in the medical record must contain evidence of educational material provided."

10 of 10 medical records reviewed, for patients who were identified as being at risk for suicide during their admission, revealed that there was no documentation to indicate that patients and their support system were given education on suicide risk factors and symptoms of relapse, as required in the facility policy # PC-115.

During an interview with the Director of Risk Management/Performance Improvement on 5/15/15, it was confirmed that the facility was not documenting the required information as specified in policy # PC-115. The Director of Risk Management/Performance Improvement said that the facility had already identified this issue and had created a plan to correct it, however the plan had not been implemented at the time of this investigation.