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Based on records reviewed and interviews for 2 of 10 sample patients (Pt #2 and #3) the Hospital failed to screen for risk of adverse health consequences if the patients lacked discharge planning.


The Hospital policy titled Nursing/Discharge Planning/Nursing Discharge Note, dated 6/5/13, indicated that the discharge screening will be completed by a Case Manager within 24 hours of admission.

The Director of Case Management was interviewed at 8:40 A.M. on 7/26/16. The Director of Case Management said discharge planning begins on admission for all inpatients and case managers were assigned to patient care units. The Director of Case Management said the case managers were provided with a computer generated list of patients.

Case Manager #2 was interviewed at 9:00 A.M. on 7/27/16. Case Manager #2 said he would work from his work list on the discharge needs of those patients closer to discharge and not necessarily screening new patients for discharge needs.

The Clinical Update Report (case management tool) for Pt #2, a 72 year old, dated 7/18/16, indicated Pt #2 was admitted to the Hospital on 7/18/16 with cellulitis of his/her left foot. The Case Management Report, dated 7/18 and 7/19/16, did not indicate identified discharge needs, only that the Case Management Nurse would follow Pt #2's care needs. The Case Management Report, dated 7/20/16, indicated the plan for Patient #2 was uncertain.

The medical progress note, dated 7/26/16, for Patient #3, a 78 year old patient, admitted to the Hospital on 7/25/16 for gynecological surgery indicated there was no discharge screening performed by case management.

Based on records reviewed for 4 of 10 sampled patients, (Pt #1, Pt #2, Pt #3, Pt #4), the Hospital failed to have an admission assessment completed by case management as required by hospital policies and procedures.

Findings included:

The Hospital policy titled Nursing/Discharge Planning/Nursing Discharge Note, dated 6/25/13, indicated that the discharge screening process will be completed by a case manager within 24 hours of admission. The policy and procedure did not indicate the required assessment/evaluation of a patient's capacity for self-care or the possibility of the patient being cared for in the environment from which he or she entered the hospital nor did the policy require that the assessment/evaluation be documented in the medical record.

The form titled Patient Admission Assessment (documentation tool used by case management) was not completed for Pt #1, Pt #2, Pt #3 and Pt #4.

A form titled, Clinical Update Report, for Pt #1, a 79 year old, dated 7/25/16, indicated Pt #1 was admitted on 7/23/16 with a fractured ankle. There was no Patient Admission Assessment Form completed by Case Management.

A form titled, Clinical Update Report for Patient #2, a 72 year old, dated 7/19/16, admitted on 7/18/16 indicated there was no Patient Admission Assessment completed by Case Management for Pt #2. The Clinical Update Report indicated no details of Pt #2's discharge care needs.

A medical progress note, dated 7/26/16, for Pt #3, a 78 year old patient, indicated Pt #3 was admitted to the Hospital on 7/25/16 for gynecological surgery. There was no Patient Admission Assessment completed by Case Management for Pt #3. A Nursing Note, dated 7/27/16, indicated Patient #3 was discharged home without services.

A form titled, Clinical Update Report for Pt #4, a 67 year old, dated 7/26/16, admitted 7/25/16 indicated there was no Patient Admission Assessment completed by Case Management for Pt #4. The report indicated the discharge plan for Pt #4 was for Pt #4 to be transferred back to the facility from where he/she came; however, there were no details of Pt #4's post-hospital discharge needs.

Based on records reviewed and interview for 6 of 10 sample patients (Pt #1, #2, #4, #5, #9 and #10), the hospital failed to consistently include in the patients discharge plan a list of home health agencies or skilled nursing facilities available to the patient.


Social Worker #1 was interviewed at 10:00 A.M. on 7/26/16. Social Worker #1 said the Hospital's independent physician organization preferred to use a certain home health agency (HHA). Social Worker #1 she would direct a patient toward the preferred HHA if a patient did not have a preference because by choosing a preferred facility the patient could be followed by a hospital physician or provider which could improve your post hospital care.

Pt #1's #2, #4, #5, #9 and #10's medical records indicated that an available list of HHAs and skilled nursing facilities (SNFs) was not documented in the patients discharge plan, despite documentation to indicate choices were discussed with either the patient or family members.

The Director of Case Management was interviewed at 8:40 A.M. on 7/26/16. The Director of Case Management said the Case Management Department was in the process of drafting a list of HHA and SNF to be used by case managers that would be available to patients and their families.

Case Manager #2 was interviewed at 9:00 A.M. on 7/27/16. Case Manager #2 said he drafted his own list of HHA and SNF to be given to patients as part of the discharge plan.

The Chief Operating Officer was interviewed at 12:00 P.M. on 7/27/16. The Chief Operating Officer said the HHA referred to patients was a department of the Hospital. The Chief Operating Officer said as of 8/1/16, the HHA was under a new organization and a new partnership and there was a plan to distribute material to all patients with the new name and a disclose that this new organization was wholly owned as a subsidiary of the Hospital.

Based on records reviewed and interviews the Hospital failed to reassess its discharge planning processes for 10 of 10 patients reviewed to ensure the Hospital had well defined documented policies and procedures which outlined the requirements of the discharge planning process.

The Hospital's Quality and Metrics Dashboard, dated 2011-2016, indicated measurements for re-admission rates; however Case Management Policies and Procedures were not identified as being current, accepted and signed as a Hospital policy and procedure. The Hospital's quality data for case management did not identify the inconsistent documentation practices nor did it identify the failure of the required documentation for discharge planning processes by case management in 10 of 10 patient records reviewed.

The Hospital policy titled Nursing/Discharge Planning/Nursing Discharge Note, dated 6/5/13, indicated that the discharge screening will be completed by a case Manager within 24 hours of admission.

The Hospital's Case Management Department Policy and Procedure, not dated and not signed as an approved Hospital policy and procedure, failed to include the following elements as required by hospital regulations:

1) the process used by the case mangers for the discharge screening to identify those inpatients at risk of adverse health consequences post-discharge if they lack discharge planning

2) the evaluation of the post-discharge needs of those inpatients identified at risk and containing factors such as functional status and cognitive ability of the patient, the type of post-hospital care the patient requires and whether such care requires the services of health care professional or facilities; the availability of the required post-hospital care services to the patient; and the availability and capability of family and/or friends to provide follow-up care in the home.

3) the development of a discharge plan if indicated by the evaluation or at the request of the patient's physician and ensure that the discharge plan contains a documented list of home health agencies or skilled nursing facilities provided and available to patients.

4) the implementation of the discharge plan prior to the discharge of an inpatient.