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Based on policy and procedure review, medical record review, and staff interview, hospital staff failed to complete the discharge screen timely or accurately for 1 of 1 readmission patients reviewed (Pt # 2).

The findings include:

Review of policy titled "Discharge Planning", reviewed 06/04/2014, revealed"...POLICY....1. Discharge planning is an interdisciplinary process in which the discharge and continuing care needs....of patients are identified, evaluated and addressed by nurses and other health care providers....2. Discharge planning is done thoroughly and timely allowing patients to be discharged safely from the hospital when physicians deem they are medically ready....PROCEDURE....A. Discharge Planning....2. An assessment of discharge planning needs is conducted by nurses, therapist, physicians and/or case managers/social workers prior to or upon entry into the acute care setting....5. The nurse.... obtains relevant information from the patient, support person(s), medical record or others having relevant information. ..."

Review of policy titled "Assessment/Reassessment Dimensions", effective 07/15/2016, revealed "...PROCEDURE....D....1. Admission Documentation....to be completed within 24 hours of admission. 2. The following screenings will be completed....discharge planning. Identified positive screens will be communicated to applicable areas/services. ..."

1. Closed medical record review, on 08/01/2017, revealed Patient #2, a 79 year old, presented to the Emergency Department on 07/23/2017. Review of History and Physical, date of service 07/23/2017 at 2050, revealed diagnoses that included Atrial Fibrillation (rapid irregular pumping of the heart) with RVR (rapid ventricular rate), acute on chronic heart failure, worsening chronic kidney disease, and diabetes. Review revealed the nursing discharge screen was completed 07/26/2017 at 1630 (approximately 67 hours after admission). Record review revealed Patient #2 was discharged 07/27/2017 around 1656.

Interview, on 8/02/2017 at 0925, with RN #3 revealed she cared for Patient #2 07/26/2017 and completed the Discharge Screening portion of the RN Admission Assessment. Interview revealed the Admission Assessment Discharge Screen should be completed within 24 hours if possible, and revealed when portions of the initial assessment screens are not completed after 24 hours, an incomplete assessment notice is visible and remains until the incomplete portions are done. RN #3 stated the Discharge Screen was not completed prior to 07/26/2017 so RN #3 completed it at 1630. Interview revealed the screen should have been completed earlier.

2. Medical record review, on 08/02/2017, revealed Patient #2 was readmitted to the hospital on 07/30/2017 (3 days after discharge). Review of the Nursing Assessment/ Discharge Screen revealed it was completed 07/31/2017 at 0240 (on time), but revealed the nurse responded "No" to the screening question of whether Patient #2 was a readmission within 30 days. Review revealed the nurse answered the screening question incorrectly. Review did not reveal a discharge planning consult based on the nursing assessment.

Interview with RN #1, on 08/02/2017 at 1200, revealed RN #1 completed the Admission Assessment Discharge Screen for Patient #2 on 07/31/2017. Interview revealed RN #1 asked the patient "Have you been here before and he said no." Interview revealed Patient #2 "must have meant he had not been on that floor (specific unit)." Further interview revealed the RN was aware the patient had recently been in a hospital, but did not know if it was this hospital.

Interview with the Manager of Case Management, on 08/02/2017, revealed Patient #2 should have received a Discharge Planning evaluation during the 07/30/2017 admission. Interview revealed if the discharge screen had been accurate, Case Management would have been alerted to complete a discharge planning evaluation.

Based on policy and procedure review, medical record review, and staff interviews facility staff failed to ensure a hospital bed to meet the needs of a patient was available for 1 of 5 discharge records reviewed (Patient #3).

The findings include:

Review on 08/01/2017 of a policy titled "Discharge Planning" last revised 06/04/2017 revealed "Discharge planning is an interdisciplinary process in which the discharge and continuing care needs (i.e. physical, emotional, social) of patients are identified, evaluated and addressed ... Arrangements for continuing care services may include, but are not limited to, home health...durable medical equipment...and transportation..."

Review of a closed medical record on 08/01/2017 revealed Patient #3 was an 84 year old male admitted on 06/07/2017 with a diagnosis of pneumonia. Review of the initial assessment consult by case management (CM) written on 06/07/2017 at 1448 indicated "Current functional status: Requires physical assistance on a 24 hour basis... Per (family member #1) ...plan is home with (name of home health company) HH (home health)...and (family member #1) to provide 24/7 assistance ... (family member #1) anticipates needing a hospital bed..." Review revealed family member #1 had been the caregiver prior to admission and would be the caregiver upon discharge. Review of the initial physical therapy (PT) note on 06/07/2017 at 1000 stated "PT Recommendations: SNF (skilled nursing facility) Rehab consult; 24 hour supervision/assist. Based on patient's functional status with therapy as of today, recommend SNF...Therapy will update recommendations as needed w/ (with) changes in pt (patient) status." Review of additional PT treatment notes throughout Patient #3's hospital admission continued to recommend SNF, and did not indicate an assessment for a hospital bed had been done, or that Patient #3 would be going home with home health. Review of case management notes written on 06/12/2017 at 1104 revealed "Per provider patient is medically stable and may discharge-request for CM to speak with family to confirm their discharge plans...Provider updated on family choice for home with HH--anticipate d/c (discharge) later today or tomorrow." Record review failed to reveal communication between PT and case management about Patient #3 going home with home health had occurred, or what Patient #3's physical care needs at home would be. Review revealed Patient #3 was discharged to home in family member #1's care on 06/14/2017 at 0743. Review failed to identify any follow up with family member #1, by the interdisciplinary team about the need for a hospital bed or other home care needs.

Interview on 08/02/2017 at 1420 with CM #1 revealed she did not speak to Patient #3's caregiver about follow up for the anticipated need for a hospital bed.

Interview on 08/03/2017 at 0925 with the Manager of Case Management revealed the expectation was that there would be communication between case management and a patient's caregiver related to continuing care and the need for a hospital bed so patients and caregivers would be successful after discharge. Interview revealed there had been no discussion with the caregiver about the need for a hospital bed.

Interview on 08/03/2017 at 1230 with physical therapy aide (PTA #1) revealed she saw Patient #3 twice for physical therapy. Interview revealed if Patient #3's family refused the PT recommendations for SNF, then a comment about the refusal should be documented as well as what the family would need for Patient #3's care at home. Further interview of PTA #1 revealed Patient #3 would need "everything" at home, including a hospital bed. Interview revealed there was no update in the medical record about the family refusal of SNF/Hospice and the PT note did not state the discharge plan was to go home with home health services. PTA #1 stated if there was a change in the discharge plan, or if family refused PT recommendations, it should also be discussed during care conference and documented. Interview revealed there was no documentation to indicate a discussion about a hospital bed occurred.

NC00129052