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Based on interviews and review of clinical records, policy and procedures, the facility failed to provide for a safe and effective discharge from the acute care setting for high-risk patients for 3 of 14 patients (#3, #11, #13) and ensure the staff was trained for their role in the discharge plan.

1. Facility failure to to ensure a discharge planning process that identifies high-risk patients for post hospital services was implemented. (Refer to A0800)

2. The facility failed to develop and implement a patient's needs assessments involving families and establish capacity for self care for: 1) A psychiatric patient who was not able to provide self care and the family was not abler to provide assistance. The patient was discharged home and re-Baler Acted the next day. 2) An infant was admitted on 3/7/2012 with a diagnosis of Failure to Thrive and had a gastric feeding tube. The infant failed to gain weight a home. The patient was to be discharged on 3/12/12. There was no discharge plan in the medical record. 3) A patient was admitted to the behavioral health unit on 3/11/12 and was to be discharged on 3/13/12. There was no documented discharge planning in the record. (Refer to A0800 and A0809).

3, The facility failed to train hospital staff involved in the discharge process. Refer to (A0818).

Due to the lack of assessment and planing for patients' discharge needs and lack of education for staff members involved in the discharge of high-risk patients, the Condition of Participation for Discharge Planning was found to be out of compliance.










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Based on interviews and review of discharge policy, procedure and clinical records it was determined that the facility failed to have an established system to screen patients for high-risk for post hospital services for two (#3, #11) of fourteen sampled records. This practice does not ensure a safe and effective discharge and may lead to a re-admission to an acute care setting.

Findings Include:

Review of Policy and Procedure "Discharge Planning" #200.255, Original Date 3/96, Last Revision Date 12/11 stated all inpatients are screened by nursing for discharge planning needs. If discharge needs are identified, nursing will initiate a Clinical Resource Management consult.

Interviews of clinical nursing staff responsible for discharge planning for the pediatric and behavioral health units were conducted on 3/13/2012. The staff members were unable to state the discharge plans of current patients #3 and #11.

Review of the clinical record for patients #3 and #11 revealed the patients did not have a care plan to include discharge planning. Neither patient was assessed to be high-risk for possible services post hospitalization.

1. Patient #11, a premature infant with cardiac anomalies, was admitted on 3/7/2012 with a diagnosis of Failure to Thrive. The infant did not gain weight at home after the placement of the gastric feeding tube and was admitted to the hospital. Review of the record revealed 3/12/2012 was the anticipated discharge date as documented by the Anticipated Date of Discharge (ADOD) form.

An interview was conducted on 3/12/2012 at 1:15 p.m. with the nurse assigned to the care of the patient. She confirmed 3/12/2012 was the planned discharge date, however, the discharge was canceled that morning. Review of both the paper and the electronic medical record revealed no documentation of a discharge plan for the patient. The finding was confirmed by the charge nurse present on 3/12/2012 at 1:15 p.m.

Interview of the charge nurse and the staff nurse regarding the discharge planning process revealed that discharge planning was initiated by the nurse caring for the patient. Interview of the staff nurse assigned to the patient regarding discharge planning for the infant revealed that she considered the discharge plan for the infant to be to discharge home to family with outpatient follow up. The staff nurse and the charge nurse both confirmed this discharge plan was not documented in the patient's record. The staff nurse was asked if, since the infant was admitted with a diagnosis of Failure to Thrive, would it trigger Social Services or a Discharge Planner to assist in discharge planning for the infant. The staff nurse answered, "We only contact them if the patient needs equipment. Since this patient was already getting tube feedings at home before they came in, they have everything they need". When asked who the primary caregiver for the infant was, the staff nurse responded, "The mother, I think. That is who is listed in the chart". She stated she had not seen or spoken to the infant's mother during this admission.

On 3/14/2012 at 2:00 p.m. the Manager of Quality and Safety presented documentation from the Social Worker of an attempt to contact the mother of the infant. The documentation was dated 3/13/2012, one day following the anticipated discharge date, and six days after the date of admission. There was no other documentation of discharge planning activities by the facility on behalf of the infant.

These findings were confirmed by the Manager of Quality and Safety on 3/14/2012 at 2:00 p.m.

2. Interview of the clinical nurse on the behavioral unit responsible for discharge planning of patient #3, with a diagnosis of major depression and suicidal ideation, was conducted on 3/12/12. The patient was being discharged home that day. The patient had not been assessed for discharge planning and did not have a care plan for discharge. The nurse stated that the Behavioral Discharge Planner "usually would see the patient prior to her leaving". There was no discharge planning documentation evident or available on request.

Based on interviews and clinical record reviews it was determined the facility failed to provide a discharge plan based on the lack of capacity of the patient to provide self-care for 1 (#13) of 14 patients. The practice may place a patient at risk for re-hospitalization.

Findings Include:

Patient #13 was admitted to the facility under the Baker Act after she was found disoriented in an optometrist office. The patient was admitted for medical clearance and further examination due to the marked and sudden disorientation to time and place. Prior to the episode the patient had lived at home alone and drove her car. On 12/20/2011 the patient was transferred to the inpatient psychiatric unit for further evaluation and treatment. The Psychiatrist documents the following:
12/31/11, "She has no insight into her cognitive deficit. She would require supervision to survive outside of hospital."
1/3/12, "I spoke to the patient's sisters, they don't know how much help they can provide for her at home. She refuses placement at this point."
1/5/12, The court hearing was continued.
1/7/12, "Her memory is not good and that forebodes problems if she lives alone." She is not aware of her deficiency and refuses Assisted Living Facility and Psychiatric follow-up.
1/8/12, Difficult to support under these circumstances it will be difficult to discharge we will proceed with the court hearing and will contact an adult protective agency for placement.
1/9/12, "I am afraid to send her home without supervision. Will need proxy."
1/11/12, "I spoke to the Discharge Planner, patient's sister will be checking in on her at home and if she is neglecting or endangering herself she will call 911, or the number for adult neglect."
1/12/12, the patient was discharged with the sister, without further plan.

Review of another facility/agency documentation revealed on 1/13/12 the patient was found in her apartment alone, confused and unable to answer questions. She was placed under the Baker Act for patient protection from neglect.

On 3/14/2012 at 11:00 a.m. additional information was requested to the Quality and Safety Manager for patient #13's discharge planning. No additional information was available.

Based on staff interviews and review of clinical records it was determined that the a qualified registered nurse and/or social worker developed or supervised the development of a discharge plan for three (#3, #11, #13) of fourteen records reviewed. This practice does not ensure a safe and effective discharge.

Findings Include:


1. Patient #11, a premature infant, was admitted on 3/7/2012 with a diagnosis of Failure to Thrive. The infant did not gain weight after the placement of the gastric feeding tube and was admitted to the hospital.

In an interview conducted on 3/12/2012 at 1:15 p.m. with the nurse assigned to the care of the patient. She confirmed 3/12/2012 was the planned discharge date. Review of both the paper and the electronic medical record revealed no documentation of a discharge plan for the patient.

Interview of the charge nurse and the staff nurse regarding the discharge planning process revealed that discharge planning was initiated by the nurse caring for the patient. Interview of the staff nurse assigned to the patient regarding discharge planning for the infant revealed that she considered the discharge plan for the infant to be to discharge home to family. The staff nurse was asked if, since the infant was admitted with a diagnosis of Failure to Thrive, would it trigger Social Services or a Discharge Planner to assist in discharge planning for the infant. The staff nurse answered, "We only contact them if the patient needs equipment. Since this patient was already getting tube feedings at home before they came in, they have everything they need". When asked who the primary caregiver for the infant was, the staff nurse responded, "The mother, I think. That is who is listed in the chart". She stated she had not seen or spoken to the infant's mother during this admission.

Interview of the pediatric clinical nurse on 3/13/2012 revealed that there may have been training approximately 3 years ago in discharge needs.

2. Interview of the clinical nurse on the behavioral unit responsible for discharge planning of patient #3, with a diagnosis of major depression and suicidal ideation, was conducted on 3/12/12. The patient was being discharged home that day. The patient had not been assessed for discharge planning and did not have a care plan for discharge. The nurse stated that the Behavioral Discharge Planner "usually would see the patient prior to her leaving". There was no discharge planning documentation evident or available on request.

Review of the staff nurse personnel file revealed no documentation of training or education in discharge planning.

3. Patient #13 was admitted to the facility under the Baker Act. Prior to admission the patient had lived at home alone and drove her car. On 12/20/2011 the patient was transferred to the inpatient psychiatric unit for further evaluation and treatment. The Psychiatrist documents the following:
12/31/11, "She has no insight into her cognitive deficit. She would require supervision to survive outside of hospital."
1/3/12, "I spoke to the patient's sisters, they don't know how much help they can provide for her at home. She refuses placement at this point."
1/5/12, The court hearing was continued.
1/7/12, "Her memory is not good and that forebodes problems if she lives alone." She is not aware of her deficiency and refuses Assisted Living Facility and Psychiatric follow-up.
1/8/12, Difficult to support under these circumstances it will be difficult to discharge we will proceed with the court hearing and will contact an adult protective agency for placement.
1/9/12, "I am afraid to send her home without supervision. Will need proxy."
1/11/12, "I spoke to the Discharge Planner, patient's sister will be checking in on her at home and if she is neglecting or endangering herself she will call 911, or the number for adult neglect."
1/12/12, the patient was discharged with the sister, without further plan.

Review of another facility/agency documentation revealed on 1/13/12 the patient was found in her apartment alone, confused and unable to answer questions. She was placed under the Baker Act for patient protection from neglect.

On 3/14/2012 at 11:00 a.m. additional information was requested to the Quality and Safety Manager for patient #13's discharge planning. No additional information was available.

Review of the staff nurse personnel file revealed no documentation of training or education in discharge planning.

Interview of the Charge Nurse and the Unit-Based Educator on 3/14/2012 at 2:10 p.m. revealed no specific training or education in discharge planning was offered to staff in the facility. The Unit-Based Educator thought she recalled it might have been included in a Psycho-Social Day inservice offered about 3 years ago, but she was not sure.


4. A review of 9 staff members', including Registered Nurses and Social Services staff, personnel and training records did not reveal evidence of specific training to include discharge planning.