HospitalInspections.org

Based on, record review and staff interviews the facility failed to ensure a complete discharge plan for one (#4) of seven sampled patients. This does not ensure appropriate post-hospital care plan needs are met.

Findings include:

Medical record review was conduced for patient #4 on 5/10/11. His operative report read as follows: Admit date 3/31/11 at 15:32, discharged 4/6/11 at 18:30. Date of the procedure was 4/1/2011. The patient had a pre-operative diagnosis of a right subtrochanteric femur fracture with no complications. A review of the discharge summary (addendum) revealed that it was dictated on 4/7/11 at 12:43 with the following information: I have discussed with surgeon who has agreed with the discharge plan to home, and out-patient therapy. The patient will come as an outpatient for physical therapy and rehab.

The patient's last physician's progress note was dated 4/6/11 at 8:50 a.m. - Because of insurance patient not covered for inpatient rehab or home health. Needs outpatient physical therapy and Rx written with instructions. Rx: walker, BSC (bed side commode), wheelchair, hospital bed. Follow up with (name of surgeon) in two weeks, evaluate and remove staples. A physicians' order dated 4/6/11 with a time of 11:00 read: outpatient physical therapy. A nursing note dated 4/6/11 at 1452 read: Discharge instructions given, patient verbalized understanding, and daughter at bedside, upset about discharge. Social services notified as daughter needs hospital bed to be home when patient gets there. Social Service is in with patient and daughter.

A case managements collaborative care worksheet was reviewed along with the Case Manager for this patient on 5/10/11 at approximately 3:00 p.m. Under the heading discharge assessment/social services, with a date of 4/6/2011 at 13:28, it indicated that the items that were arranged for delivery were a bedside commode and a walker for the patient. There was no documented evidence that case management addressed the needs of the patient for outpatient rehab or a hospital bed. The Case Manager stated that the patient did not have benefit coverage. When asked If a determination is made that medically necessary and appropriate services are not covered benefits, case management should make every attempt to access other community, State and Federal resources for all patients no matter what their benefit coverage or in many cases patients with "no coverage", he stated that she attempted to find placement for the patient for services. She did not have any documented evidence to support her statement.