HospitalInspections.org

Based on review of policies and staff interview, it was determined the hospital failed to ensure a procedure had been developed to identify patients who were likely to suffer adverse health consequences upon discharge if adequate discharge planning was not provided. Specifically, the hospital had not developed a procedure to ensure patients who had not been identified as initially needing a discharge plan would be provided with a discharge plan if their needs changed. This had the potential to allow patients to be discharged with unmet discharge planning needs. Findings include:

The policy "Discharge Planning Policy," revised 12/10/11, did not address changes in patient condition that would call for the development of a discharge plan for patients not previously identified as in need of one.

The Director of Clinical Resources Management, the department responsible for discharge planning, reviewed the policy on 7/10/12 at 11:00 AM. She confirmed the policy did not direct staff to re-evaluate discharge planning needs for patients whose condition had changed after their initial discharge planning assessment had been completed.

A system to reevaluate discharge planning needs had not been developed.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure discharge planning needs for 1 of 4 patients (Patient #1) whose records were reviewed, were re-evaluated on a timely basis as needs changed. This prevented the hospital from identifying discharge planning needs in a timely manner. Findings include:

Patient #1's medical record documented a 50 year old female who was admitted to the hospital on 6/25/12 and was discharged home on 7/09/12. Diagnoses included exacerbation of wounds on her right foot and leg and Crohn's Disease. The History and Physical, dated 6/25/12, stated the foot wound was a long term wound which had required skin grafting in January 2012. Patient #1's wounds were treated with intravenous antibiotics and treatment by a wound care nurse.

A "CASE MANAGEMENT ASSESSMENT" note, dated 6/25/12 at 1:28 PM, stated Patient #1 lived at home with family, was independent with activities of daily living, and would return home upon discharge. No discharge planning needs were identified. The next case management notes were dated 7/09/12 at 11:14 AM, the date Patient #1 was discharged. The note stated Patient #1 was moving to a nearby town for financial reasons. It said she needed wound care 3 times a week and would need to return to the hospital for the wound care nurse to dress the wound. The note stated Patient #1 did not have transportation to the hospital from the town she was moving to. The final case management note was dated 7/09/12 at 5:09 PM. It stated the Case Manager had not been able to contact the transportation company representative to arrange for transportation. The note stated the Case Manager had arranged for home health services for wound care 2 times a week.

The Case Manager for Patient #1 was interviewed on 7/09/12 beginning at 2:00 PM. The Case Manager stated Patient #1 was seen on admission and did not appear to have discharge planning needs at that time. The Case Manager stated by the time of discharge the patient had complex discharge planning needs. She stated Patient #1 needed wound care 3 times a week. The Case Manager stated Patient #1 did not have financial resources so it was difficult to find a home heath agency who would treat her on a pro bono basis. The Case Manager stated Patient #1 needed to return to the hospital once a week for wound care but did not have transportation. The Case Manager stated Patient #1 was moving to another town for financial reasons and no public transportation was available between the 2 towns. The Case Manager stated she had attempted to contact a transportation agency but had not been able to reach them. The Case Manager stated she did not know if transportation could be arranged. The Case Manager stated a discharge planning evaluation was not documented. The Case Manager stated Patient #1 was to be discharged that day.

A discharge planning evaluation had not been completed after it became apparent Patient #1 would need assistance with post hospital services.