HospitalInspections.org

Based on findings from document review, medical record (MR) review, and interview, in 2 of 5 MRs reviewed discharge planning evaluations did not include all required components.

Findings include:

-- Per review of the facility policy and procedure (P&P) titled "Discharge Planning," last reviewed 11/2014, it described the following: Discharge staff will screen patients/family on admission and complete an assessment which identifies a patient's post-acute needs. Discharge staff document the patients continuing needs in the medical record on the Interdisciplinary Progress Notes.

-- Per MR review, Patient C was a 59 year old admitted to the hospital on 6/11/15 with chronic obstructive pulmonary disease (COPD) exacerbation. Patient C was discharged to his/her home on 6/16/15. The discharge planning evaluation completed for Patient C lacked assessment of the patient's ability to perform activities of daily living (ADL) and self care and/or the assessment of the patient's family's ability to provide this care.

-- Per MR review, Patient B was an 82 year old admitted to the hospital on 5/26/15 from a skilled nursing facility (SNF) with confusion and abdominal pain. He/she was diagnosed with hepatic encephalopathy. Patient B was discharged to the same SNF on 5/28/15. The discharge planning evaluation completed lacked assessment as to whether the SNF had the capability to provide required post hospital care to the patient.

-- During interview with Staff #1 (Care Manager) on 7/22/15 at 10:30 am, he/she acknowledged the above findings.

Based on findings from document review, medical record (MR) review, and interview, in 1 of 5 MRs reviewed, the MR lacked documentation that the hospital provided a patient (Patient E) with a list of Medicare participating home health agencies (HHA) available to meet the patients needs after discharge. Additionally, the list of community Adult Care Facilities provided to patients that need post hospital care services, did not disclose the hospital's financial interest in a HHA or a skilled nursing facility (SNF).

Findings included:

-- Per review of facility's policy and procedure (P&P) titled "Discharge Planning," last reviewed 11/2014, it indicated the discharge planners will provide patients and families a written list of available community services and providers which can meet their post acute care needs. This will be documented in the medical record.

-- Per MR review, Patient E was admitted to the hospital on 6/11/15 with shortness of breath and chronic obstructive pulmonary disease (COPD) exacerbation. Patient E was treated and discharged with home care services. The MR lacked documented evidence that Patient E received a list of Medicare participating HHA during the discharge process.

-- During interview with Staff #1 on 7/22/15 at 10:30 am, he/she acknowledged the above findings.

-- Review of the hospital's lists of Community Adult Care Facilities, provided to patients during the discharge process, identified the lack of disclosure of the hospital's financial interest in a HHA and a SNF on the list.

-- During interview with Staff #2 (Vice President of Quality Management) the above findings were acknowledged.