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Based on interview, clinical record review and review of facility's policies, "Patient's Rights and Responsibilities," policy number A10-0601-03, effective date 05/17/2012, and "Discharge Planning Plan," policy number A10-0609-14, effective date 05/25/2000, it was determined the facility failed to ensure the patient's right to participate in the development of his/her discharge plan was met as evidenced by no discharge planning evaluation or documentation of discussion(s) of the evaluation with the patient or family in the clinical record for three (3) of ten (10) patients that required post-hospital placement with other facilities (Patient #8, #9, and #10).

The findings include:

Review of the facility policy, "Patient's Rights and Responsibilities," policy number A10-0601-03, effective date 05/17/2012, revealed patients have the right to participate in the development and implementation of the plan of care. Review of the facility policy, "Discharge Planning Plan," policy number A10-0609-14, effective date 05/25/2000, revealed Social Services would provide services to those patients identified at high risk for discharge planning needs by recommending referrals to agencies and by making entries in the medical record which would communicate the resulting plan and daily progress to other concerned staff members. It also stated Social Services would interview the high-risk patient and/or family member(s) to determine needs and to make recommendations for the discharge plan. The policy further revealed patients at high risk for discharge planning needs included those with preexisting diagnoses interfering with home functioning; those with a debilitating or chronic illness; those with a diagnosis of catastrophic illness; and those that lived alone.

1. Review of the clinical record of Patient #8 revealed he/she was admitted on 04/02/12 with diagnoses which included Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Metastatic Lung Cancer. Record review revealed a Computed Tomography (CT) of the chest on admission showed worsening of the Metastatic Lung Disease and new liver lesions. A hospice consult was obtained on 04/10/12, and he/she was admitted to hospice on the same date, using a bed in the same facility. Patient #8 expired on 04/11/12. Record review revealed no documented evidence of a discharge planning note or documentation of discussion(s) with patient and/or family about discharge planning needs by Social Services.

2. Review of the clinical record of Patient #9 revealed he/she was admitted on 05/30/12 with diagnoses which included Lumbar Compression Fracture/Severe Low Back Pain and Coronary Artery Disease. Patient #9 had previously been admitted on 05/20/12 and discharged on 05/22/12 with diagnoses of Upper and Lower Back Pain, probable cardiac origin. Review of the record revealed a Lumbar spine x-ray on 05/20/12 which showed mild degenerative changes with no acute fractures. Magnetic Resonance Imaging (MRI) of the lumbar spine, on 05/30/12, showed acute versus subacute compression fracture of the twelfth thoracic vertebrae, first lumbar vertebrae. On 05/30/12 there was a Physical Therapy consult and Discharge Planning consult, ordered by the Physician, for possible rehabilitation. Continued review of the record revealed Patient #9 was discharged to a Skilled Nursing Facility (SNF) on 06/01/12. There was no discharge planning note or documentation of discussion(s) with patient and/or family about discharge planning needs in the clinical record by Social Services.

3. Review of the clinical record of Patient #10 revealed he/she was admitted on 04/10/12 with diagnoses which included Bilateral Pneumonia, Hypertension and Coronary Artery Disease. Record review revealed Patient #10 lived alone and was discharged to the Transitional Care Unit (TCU) on 04/17/12 for skilled care due to deconditioning. He/she remained there until 04/28/12 and was then discharged to home. Record review revealed there was documented evidence of a discharge planning note or documentation of discussion(s) with patient and/or family about discharge planning needs in the clinical record by Social Services.

Interview with Social Worker #1, on 06/11/12 at 4:45 PM, revealed neither she nor any other Social Worker had evaluated or interviewed Patient #8 or #10 and typically, this would have and should have occurred, since both met the criteria for high risk for discharge planning needs. She could offer no explanation as to the lack of documentation for discharge planning needs.

Interview with Social Worker #2, on 06/11/12 at 4:35 PM, revealed she arranged the SNF placement for Patient #9. She also revealed Patient #9 did not have the required three (3) day qualifying inpatient stay that would have allowed him/her to be eligible for Medicare skilled care benefits, so Patient #9 was admitted to the SNF under his/her Medicaid benefits. Social Worker #2 could offer no explanation for the lack of documentation concerning discharge planning needs since Patient #9 met the high risk criteria for discharge planning needs. She further stated she should have documented these needs and the SNF placement in the clinical record.

Based on interview, clinical record review and review of facility policy, "Discharge Planning Plan," policy number A10-0609-14, effective date 05/25/2000, the facility failed to ensure there was appropriate discharge planning as evidenced by no discharge planning evaluation or documentation of discussion of the evaluation with the patient or family in the clinical record for three (3) of ten (10) patients that required post-hospital placement with other facilities (Patient #8, #9, and #10).

The findings include:

Review of the facility policy, "Discharge Planning Plan," policy number A10-0609-14, effective date 05/25/2000, revealed Social Services would provide services to those patients identified at high risk for discharge planning needs by recommending referrals to agencies and by making entries in the medical record which would communicate the resulting plan and daily progress to other concerned staff members. It also stated Social Services would interview the high-risk patient and/or family member(s) to determine needs and to make recommendations for the discharge plan. The policy further revealed patients at high risk for discharge planning needs included those with preexisting diagnoses interfering with home functioning; those with a debilitating or chronic illness; those with a diagnosis of catastrophic illness; and those that lived alone.

Review of the clinical record of Patient #8 revealed he/she was admitted on 04/02/12 with Diagnoses which included Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Metastatic Lung Cancer. Computed Tomography (CT) of the chest on admission showed worsening of the Metastatic Lung Disease and new liver lesions. A hospice consult was obtained on 04/10/12, and he/she was admitted to hospice on the same date, using a bed in the same facility. Patient #8 expired on 04/11/12. There was no discharge planning note or documentation of discussion(s) with patient and/or family about discharge planning needs in the clinical record by Social Services.

Review of the clinical record of Patient #9 revealed he/she was admitted on 05/30/12 with Diagnoses which included Lumbar Compression Fracture/Severe Low Back Pain and Coronary Artery Disease. Patient #9 had previously been admitted on 05/20/12 and discharged on 05/22/12 with Diagnoses of Upper and Lower Back Pain, probable cardiac origin. Lumbar spine x-ray on 05/20/12 showed mild degenerative changes with no acute fractures. Magnetic Resonance Imaging (MRI) of the lumbar spine, on 05/30/12, showed acute versus subacute compression fracture of the twelfth thoracic vertebrae, first lumbar vertebrae. On 05/30/12 there was a Physical Therapy consult and Discharge Planning consult, ordered by the Physician, for possible rehabilitation. Patient #9 was discharged to a skilled nursing facility (SNF) on 06/01/12. There was no discharge planning note or documentation of discussion(s) with patient and/or family about discharge planning needs in the clinical record by Social Services.

Review of the clinical record of Patient #10 revealed he/she was admitted on 04/10/12 with Diagnoses which included Bilateral Pneumonia, Hypertension and Coronary Artery Disease. Patient #10 lived alone and was discharged to the Transitional Care Unit (TCU) on 04/17/12 for skilled care due to deconditioning. He/she remained there until 04/28/12 and was then discharged to home. There was no discharge planning note or documentation of discussion(s) with patient and/or family about discharge planning needs in the clinical record by Social Services.

Interview with Social Worker #1, on 06/11/12 at 4:45 PM, revealed neither she nor any other Social Worker had evaluated or interviewed Patient #8 or #10 and typically, this would have and should have occurred, since both met the criteria for high risk for discharge planning needs. She could offer no explanation as to the lack of documentation for discharge planning needs.

Interview with Social Worker #2, on 06/11/12 at 4:35 PM, revealed she arranged the SNF placement for Patient #9. She also revealed Patient #9 did not have the required three (3) day qualifying inpatient stay that would have allowed him/her to be eligible for Medicare skilled care benefits, so Patient #9 was admitted to the SNF under his/her Medicaid benefits. Social Worker #2 could offer no explanation for the lack of documentation concerning discharge planning needs since Patient #9 met the high risk criteria for discharge planning needs. She further stated she should have documented these needs and the SNF placement in the clinical record.