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Based on policy and procedure review, closed medical record review, and staff interviews, the facility failed to ensure guardian notification of discharge and counsel family members to prepare for a patient's post hospital care in 1 of 4 medical records reviewed. (#2).

The findings include:

Review of hospital policy dated November 23, 2015, titled "Discharge/Transition to Alternative Level of Care," revealed "...Procedure: Upon referral (Unit-Based) interview the patient/family to determine the anticipated post hospital needs, and identify issues and any barriers....Meet with the patient and/or family to confirm the discharge/transition plan. Communicate this plan with the multidisciplinary team, including at the Care Progression Meetings, on an ongoing basis...."

Closed medical record review revealed a 68 year old female with court appointed guardian due to "incompetent person" admitted on 09/14/2016 from dialysis center after witnessed seizure like activity. Patient was discharged on 09/17/2016 to skilled nursing facility. Further review of CSW (clinical social worker) note dated 09/17/2016 at 1513 with late entry date of 09/21/2016 revealed "CSW was notified by RN AC (administrator in charge) that Patient's family came to hospital last night to sit with patient and were not aware of d/c. CSW got #'s (numbers) from AC for Pt's daughter (name of daughter) to follow up and offer support or answer questions regarding d/c (discharge) to (name of facility)..."

Interview with LCSW #1 on 11/9/2016 at 1115 revealed guardian did not know of mother's discharge until family visited on the evening after discharge. Further interview revealed attempts to reach daughter prior to discharge were unsuccessful. Further interview revealed discharge should have been delayed until guardian was reached.

Based on policy and procedure review, closed medical record review, and staff interviews, the facility failed to provide guardian choice of post hospital care facility for 1 of 1 medical records reviewed. (#2).

The findings include:

Review of hospital policy titled "Discharge/Transition to Alternative Level of Care," dated November 23, 2015, revealed "...Procedure: Upon referral (Unit-Based) interview the patient/family to determine the anticipated post hospital needs, and identify issues and any barriers....Meet with the patient and/or family to confirm the discharge/transition plan. Communicate this plan with the multidisciplinary team, including at the Care Progression Meetings, on an ongoing basis...."

Review of hospital policy titled "Agency Referrals" dated November 17, 2015 revealed "...The patient, family or patient representative must agree to the post- discharge/transition plan prior to any referrals. 2. Patients are provided with a list of agencies and providers and informed of (name of referring facility) ownership interest in any of those agencies/providers and that they are under no obligation to use those agencies/providers. The patient and/or family is asked to select an agency/provider...4. The patient's and/or family's choice of agencies/providers documented in the medical record and in the Care Management Department's electronic documentation system as well as that the referral has been made and for what services. 5. The patient and/or family is informed that the agency/provider referral has been completed and provided with the name, contact telephone number, and anticipated day and time of the initial visit or equipment delivery or transfer...."

Closed medical record review revealed a 68 year old female with court appointed guardian due to "incompetent person" admitted on 09/14/2016 from dialysis center after witnessed seizure like activity. Patient was discharged on 09/17/2016 to skilled nursing facility. Further review revealed patient's daughter was guardian. Further review of medical record revealed "Social Worker assessment/plan:...CSW met with patient alone at bedside. Patient appeared to be confused....Patient did give CSW permission to fax out referral. CSW explained that patient will have to go to a SNF (skilled nursing facility)...(Name of nursing facility) made a bed offer. CSW asked if patient wanted to go to (name of nursing facility) and she shook her head yes."

Interview with AS #2 (administrative staff) on 11/10/2016 at 0905 after review of assigned LCSW's notes revealed LCSW did not follow policy to provide choice to patient's guardian.

NC00121088