HospitalInspections.org

Based on document review and staff interview, it was determined for 2 of 8 (Pts #6 and #8) clinical records reviewed for discharge planning, the hospital failed to ensure discharge planning evaluations were completed within the timeframe specified by hospital policy.

Findings include:

1. The hospital's policy entitled "CM Plan for Discharge Planning" (revised 03/2014) was reviewed on 7/21/15 at approximmately 10:00 am and required, "...The Case Manager will screen all in-patients, within one working day of admission, for potential discharge planning needs, utilizing a High-Risk Screening tool. This screen will take place during the initial clinical review..."

2. The clinical record for Pt #2 was reviewed on 7/21/15 at approximately 11:45 am and included Pt #2 was an 84 year old male admitted to the hospital's ICU (intensive care unit) on 7/15/15 with a diagnosis of hypoxemia. Pt #2 was transferred to the hospital's Progressive Care Unit (PCU) on 5/20/15. Pt #2's clinical record lacked documentation of screening by the Case Manager.

3. The clinical record for Pt #6 was reviewed on 7/21/15 at approximately 12:00 pm and included Pt #6 was a 77 year old male admitted to the hospital on 7/4/15 with diagnoses of foot pain and osteomylitis. Pt #6's clinical record lacked documentation of screening by the Case Manager, and the first note documented by a Case Manager was dated 7/14/15 (10 days after admission).

4. During an interview with the Director of Case Management (E #6) on 7/21/15 at approximately 2:00 pm, E #6 stated that the screening should have been completed by the Case Manager within one day of admission.