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Based on medical record and policy review and staff interviews the facility failed to provide a complete assessment of post hospital needs in 1 of 4 (#2) patients admitted from home.

Finding by surveyor # 29963 and # 22198 include:

Per medical record and policy review on 5/21/12 from 2:30 PM to 4:30 PM, Patient #2's four (4) admissions/re-admissions were reviewed.

The most current policy entitled "Discharge Management" 3 pages, effective date: 04/01/2009 (no policy number) was received and reviewed on 05/21/12 at 11:40 AM. with DQI A and DCM B.

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"Definition: Discharge Planning is a process that facilitates the transition of the patient from a hospital to the most independent level of care, whether that is home or another agency. The overall goals of discharge planning is to provide the most appropriate level and quality of care throughout all stages of a patient's illness. Every hospitalized patient requires discharge planning."

Policy: "It is the policy of Wheaton Franciscan Healthcare-Southeast Wisconsin, Inc. and its sponsored hospitals to identify a patient's continuing health care needs on admission to assist in the coordination of services needed at the time of discharge. The multidisciplinary team will work closely with the patient, the patients's family/significant other and appropriate community agencies to ensure the care continuum is maintained for a safe discharge."

Patient #2 was admitted on 02/09/12 through 02/14/12 with a primary discharge diagnosis was Sepsis.

Physical Therapy (PT) consult dated 02/10/12 at 2:17 PM, indicated PT was waiting on the completion of a vascular consult and would evaluate Patient #2 after the Vascular Consult was completed.

The PT consult was never completed during this admission. PT failed to documented rationale for not completing the ordered PT evaluation or if the issue was resolved. No evaluation or care planning was completed for post discharge PT evaluation or potential home limitations.

Vascular consult dated 02/11/12 at 10:21 AM, indicated Patient #1 showed evidence of enlarged (from 3.8 centimeters (cm) to 4.5 cm) abdominal aortic aneurysm (AAA) that would require repair, the Ultra Sound identified Gallstones but no cholecystitis.

Patient #2's discharge evaluation indicated no discharge planning was necessary. The discharge documentation provided to Patient #2 consisted of an incomplete 2 page check list. No discharge evaluation or planning was completed to determine Patient #2's potential needs related to gallstones or limitations or precautions related to enlarged AAA pending surgery.

Patient #2 was admitted on 02/22/12 through 03/03/12 with a primary discharge diagnosis of repair Abdominal Aortic Aneurysm (AAA).

Discharge evaluation dated 02/23/12 at 3:36 PM stated: discharge needs undetermined. Discharge evaluation dated 02/27/12 at 12:31 PM stated: no need for a discharge plan, continue follow-up.

There was no comprehensive discharge evaluation or planning, to identify potential needs post AAA repair surgery, that might include signs and symptoms of infection, physical limitation, or post-operative complication to a vascular surgery, or the healing process.

Patient #2 was admitted on 03/06/12 through 03/08/12, primary discharge diagnosis of complicated peptic ulcer, nausea and vomiting. No discharge needs were identified for this admission/discharge.

Patient #2 was admitted on 03/20/12 through 03/28/12 with a primary discharge diagnosis was laparoscopic cholecystectomy.

Patient #2's medical record revealed during the hospitalization a new order was written for amiodarone and oxygen.

Patient #2 was identified at moderate risk nutritionally at the time of discharge and had a cardioversion (procedure using electricity or drugs in an attempt to convert the heart to a normal rhythm) for a new diagnosis of atrial fibrillation (A-Fib).

Therapy documented Patient #2 was fatigued with activities.

The discharge evaluation and plan for this admission was limited to obtaining home oxygen for Patient #2, failing to address the new A-Fib diagnosis, or nutritional limitations related to gallbladder removal and other potential nutritional complications/needs related to Acute Renal Failure and post surgical wound healing.

No discharge evaluation of Patient #2 or Patient #2's spouse to determine risk and safety when having oxygen in the home setting. Pt was sent home from the hospital with an oxygen tank and the phone number to contact the supplier to set up a time for delivery of rest of supplies.

This was confirmed in interview with DQI A and DCM B on 5/21/12 at 4:30 PM and this information was validated as accurate by DQI A and DCM B on 05/22/12 at 8:20 AM.

Based on interviews and medical record review the facility failed to include 1 of 4 families (Family of Patient #2) in the discharge evaluation results.

Findings by Surveyor #22198 and #29963 include:

Per medical record review on 5/21/12 from 2:30 PM. to 4:30 PM, four (4) admissions/re-admissions were reviewed for Patient #2.

Patient #2 had multiple co-morbidities that included exacerbation of chronic obstructive pulmonary disease (COPD) , hypertension, and acute renal failure, in addition to the reasons for each of the 4 hospital admissions.

Patient #2 was his own person. Patient #2's spouse was listed as Patient #2's primary contact/support system. The discharge evaluation confirmed Patient #2 lived with his spouse in a 2 story home.

Admission #1 for Patient #2 from 02/09/12 through 02/14/12, had a primary discharge diagnosis of sepsis/pneumonia.

Admission #2 for Patient #2 from 02/22/12 through 03/03/12, had a primary discharge diagnosis for a repair of an abdominal aortic aneurysm (AAA).

Admission #3 for Patient #2 from 03/06/12 through 03/08/12, had a primary discharge diagnosis of a complicated peptic ulcer, nausea and vomiting.

Admission #4 for Patient #2 from 03/20/12 through 03/28/12 had a primary discharge diagnosis of laparoscopic cholecystectomy.

For admissions #1 (02/09/12 through 02/14/12) and #4 (03/20/12 through 03/28/12) there was documentation in the medical record of mobility concerns that included pain and fatigue with activities. The medical record showed no evidence of Patient #2's spouse's input or involvement in the discharge evaluation or plan.

For admissions #2 (02/22/12 through 03/03/12) and #4 (03/20/12 through 03/28/12) the documentation in the medical record confirmed Patient #2 during admission #2 has an abdominal surgery repairing an aortic aneurysm and during admission #4, 17 days after the AAA repair Patient #2 had a second surgery to remove his gallbladder laparoscopically. The medical record showed no evidence of Patient #2's spouse's input or involvement in the discharge evaluation or plan.

For admission #4 (03/20/12 through 03/28/12) there was documentation in the medical record that the Registered Dietician had Patient #2 at a high (3/23/12 at 12:45 PM) and moderate (3/21/12 9:54 AM) risk for nutritional concerns. The medical record showed no evidence of Patient #2's spouse's input or involvement in the discharge evaluation or plan that might include caloric needs for wound healing and prohibited fat content related to the gallbladder removal.

For admission #4 (03/20/12 through 03/28/12) there was documentation in the medical record Patient #2 had atrial fibrillation (A-Fib) and needed cardioversion during this visit and was subsequently started on a new medication (Amiodarone). The medical record showed no evidence of Patient #2's spouses input or involvement in the discharge evaluation or plan.

For admission #4 (03/20/12 through 03/28/12) there was documentation in the medical record Patient #2 would need home oxygen and was sent home with oxygen from the hospital. The medical record showed no evidence of Patient #2's spouse's input or involvement in the discharge evaluation or plan for home oxygen that would include safety precautions.

4 of 4 discharge evaluations and plans contained no evidence of Patient #2's spouse being involved in the discharge evaluation or planning regarding any concerns as the primary support for Patient #2.

This was confirmed in interview with DQI A and DCM B on 5/21/12 at 4:30 PM and this information was validated as accurate by DQI A and DCM B on 05/22/12 at 8:20 a.m.

Based on medical record and policy review and staff interview the hospital failed to ensure 2 of 4 (#1 and #2) patient discharge plans were complete and met the individual patients' needs.

Finding by surveyor # 29963 and # 22198 include:

A policy review was conducted on 05/21/12 at 11:40 AM, of the most current policy entitled "Discharge Management" 3 pages, effective date: 04/01/2009 (no policy number) and discussed with DQI A and DCM B.

Page 1
"Definition: Discharge Planning is a process that facilitates the transition of the patient from a hospital to the most independent level of care, whether that is home or another agency. The overall goals of discharge planning is to provide the most appropriate level and quality of care throughout all stages of a patient's illness. Every hospitalized patient requires discharge planning."

Policy: "It is the policy of Wheaton Franciscan Healthcare-Southeast Wisconsin, Inc. and its sponsored hospitals to identify a patient's continuing health care needs on admission to assist in the coordination of services needed at the time of discharge. The multidisciplinary team will work closely with the patient, the patients's family/significant other and appropriate community agencies to ensure the care continuum is maintained for a safe discharge."

Per interview with DQI A and DCM B on 5/21/12 from 1:20 p.m. to 2:30 p.m. in conjunction with the medical record review of Patient #1 confirmed the hospital failed to complete the discharge evaluation and plan for Patient #1.

Patient #1 was a primary care giver to a spouse. Patient #1's current admission 12/24/11 to 01/05/12 was related to a cerebral vascular accident (CVA) (brain hemorrhage) and during this admission had a tracheotomy surgery and was currently on mechanical ventilation and was chemically sedated. Patient #1's discharge plan included a discharge to a long term acute care hospital (LTACH).

DCM B confirmed it is the current practice of this hospital, to have the LTACH case managers come into this hospital to complete the patient evaluation and construct the discharge plan, not hospital staff.

DCM B confirmed there are no guidelines for this process, but this hospital staff would collaborate with the LTACH case manager.

DCM B confirmed there was no evidence of this hospital's staff collaboration with the LTACH's Case Manager for Patient #1

DQM B confirmed there was no evidence of a completed discharge evaluation and discharge plan for Patient #1.

This was confirmed in interview with DQI A and DCM B on 5/21/12 at 2:30 PM and this information was validated as accurate by DQI A and DCM B on 05/22/12 at 8:20 a.m.

Per interview with DQI A and DCM B on 5/21/12 from 2:30 p.m. to 4:30 p.m. in conjunction with the medical record review of Patient #2 confirmed the hospital failed to individualize the discharge evaluation and plan for Patient #2 and failed to include Patient #2's spouse in the discharge evaluation and plan.

Four (4) admissions/re-admissions were reviewed during this review.

Baseline medical records information confirmed Patient #2 had multiple co-morbidities that include (but not all inclusive) exacerbation of chronic obstructive pulmonary disease (COPD), hypertension, and acute renal failure.

Patient #2 was his own person. Patient #2's spouse was listed as Patient #2's primary contact/support system. The discharge evaluation confirmed Patient #2 lived with his spouse in a 2 story home.

Admission #1 from 02/09/12 through 02/14/12, primary discharge diagnosis was Sepsis/Pneumonia.

Admission #2 from 02/22/12 through 03/03/12, primary discharge diagnosis was repair of abdominal aortic aneurysm (AAA).

Admission #3 from 03/06/12 through 03/08/12, primary discharge diagnosis was complicated peptic ulcer, nausea and vomiting.

Admission #4 from 03/20/12 through 03/28/12, primary discharge diagnosis was laparoscopic cholecystectomy.

4 of 4 admissions failed to include the spouse in the evaluation or discharge planning for any concerns as the primary support for Patient #2.

Admissions #2 and #4 failed to show evidence of Patient #2's spouse's input or involvement in the discharge evaluation or plan when the documentation in the medical record identified mobility concerns that included pain and fatigue with activities, and Patient #2 lived in a 2 story home.

Admissions #2 and #4 failed to include Patient #2's spouse's input or involvement in the discharge evaluation or plan after an abdominal surgery repairing an aortic aneurysm (#2) or for admission #4, (17 days after the AAA repair) when Patient #2 had a second surgery to remove his gallbladder laparoscopically.

Admission #4 failed to include Patient #2's spouses input or involvement in the discharge evaluation or plan for new nutritional concern. The Registered Dietitian documented Patient #2 at a high nutritional risk (3/23/12 at 12:45 PM) and moderate nutritional risk (3/21/12 9:54 AM). The medical record showed no evidence of Patient #2 or Patient #2's spouses regarding Patient #2's co-morbidities (COPD, acute renal failure) caloric needs for wound healing and prohibited fat content related to the gallbladder removal.

Admission #4 failed to include Patient #2's spouse's input or involvement in the discharge evaluation or plan for new diagnosis of atrial fibrillation (A-Fib) and needed cardioversion during this visit and was subsequently started on a new medication (Amiodarone).

Admission #4 failed to include Patient #2's spouse's input or involvement in the discharge evaluation or plan for new diagnosis order that required home oxygen, that might include safety precautions.

4 of 4 discharge evaluations and plans contained no evidence of Patient #2's spouse as primary support being involved in the discharge evaluation or planning regarding any concerns for Patient #2 being discharged home.

This was confirmed in interview with DQI A and DCM B on 5/21/12 at 4:30 PM and this information was validated as accurate by DQI A and DCM B on 05/22/12 at 8:20 AM

Based on medical record review, facility policy review and staff interviews, the hospital failed to educate 1 of 1 patients (#2) discharged home and their home support person to identify significant changes in health status, and failed to evaluate potential need for follow ups and referrals to outside agencies for Physical Therapy (PT), evaluation or nutritional consult and education.

Finding by surveyor # 29963 and # 22198 include:

The most current policy entitled "Discharge Management" 3 pages, effective date: 04/01/2009 (no policy number) was received and reviewed on 05/21/12 at 11:40 AM. with DQI A and DCM B.

Page 1
"Definition: Discharge Planning is a process that facilitates the transition of he patient from a hospital to the most independent level of care, whether that is home or another agency. The overall goals of discharge planning is to provide the most appropriate level and quality of care throughout all stages of a patient's illness. Every hospitalized patient requires discharge planning."

Policy: "It is the policy of Wheaton Franciscan Healthcare-Southeast Wisconsin, Inc. and its sponsored hospitals to identify a patient's continuing health care needs on admission to assist in the coordination of services needed at the time of discharge. The multidisciplinary team will work closely with the patient, the patients's family/significant other and appropriate community agencies to ensure the care continuum is maintained for a safe discharge."
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4. "Patients and their families/significant others will make decisions about their discharge planning options. Patient values, preferences, and expressed needs must be respected and considered by the healthcare team."
5. "This discharge plan will address short and long term patient needs. it includes plans and opportunities required to deal with specific disabilities and limitations which will in turn maximize the patient's functional independence and dignity. The plan will also include an evaluation of the patient's needing post hospital services and the availability of these services"
6. "This discharge plan is reassess by the physician and the healthcare team to determine whether discharge needs have changed. patient's preferences are also likely to change over time requiring constant reassessment and evaluation."
Per review of patient (Pt) #2's medical record on 5/21/12 from 2:30 PM. to 4:30 PM, Pt #2 was admitted to the hospital 4 times from 2/9/12-3/28/12.

Baseline medical records information confirmed Patient #2 had multiple co-morbidities that include (but not all inclusive) exacerbation of chronic obstructive pulmonary disease (COPD), hypertension, and acute renal failure.

Admission #1
Patient #2 was admitted on 02/09/12 through 02/14/12 with a primary discharge diagnosis of sepsis/pneumonia.

02/10/12 at 2:17 PM a Physical Therapy (PT) consult note indicated PT was waiting on the completion of the vascular consult and would evaluate Patient #2 after the vascular consult was completed. On 02/11/12 at 10:21 AM the vascular consult was completed (3 days before discharge). No evidence of a PT evaluation or re-assessment could be found in Patient #2's medical record.

02/11/12 at 10:21 AM, a Vascular consult indicated Patient #1 showed evidence of an enlarged abdominal aortic aneurysm (AAA) (from 3.8 centimeters (cm) to 4.5 cm) that would require surgery, and an Ultra Sound which identified gallstones at this time there was no cholecystitis.

Patient #2's initial discharge evaluation (02/09/12) indicated no discharge planning was necessary.

The discharge documentation provided to Patient #2 consisted of an incomplete 2 page check list. No discharge evaluation or planning was completed to determine Patient #2's potential needs related to gallstones or precautions related to pending surgery (AAA).

Patient #2's discharge planning failed to include potential home needs or a home referral for a PT evaluation to determine mobility limitations.

Admission #2
Patient #2 was admitted on 02/22/12 through 03/03/12 with a primary discharge diagnosis: repair of abdominal aortic aneurysm (AAA).

Discharge evaluation dated 02/23/12 at 3:36 PM indicates: discharge needs undetermined. Discharge evaluation dated 02/27/12 at 12:31 PM. indicates: no need for a discharge plan, continue follow-up.

No comprehensive discharge instructions or planning to identify potential needs post AAA repair surgery that might include signs and symptoms of infection, physical limitation, post-operative complication to a vascular surgery, or the healing process were documented.

No documentation of Patient #2's spouse or primary support received any training or education regarding Patient #2's potential post surgical complications.

Admission #3
Patient #2 was admitted on 03/06/12 through 03/08/12 with a primary discharge diagnosis of a complicated peptic ulcer, nausea and vomiting. No discharge needs were identified for this admission/discharge.

No documentation of Patient #2's spouse or primary support was involved in the discharge plan or evaluations including dietary alterations or restrictions.

Admission #4
Patient #2 was admitted on 03/20/12 through 03/28/12 with a discharge diagnosis of laparoscopic cholecystectomy.

Patient #2's medical record revealed during the hospitalization, a new diagnosis/treatments included:

1. Atrial fibrillation (A-fib) that needed cardioversion to correct
2. Amiodarone (cardiac medication)
3. Oxygen
4. Moderate risk nutritionally, prior to discharge by the dietitian.

03/20/12 at 11:38 PM, Patient #2's medical record noted limited walking and fatigued with activities.

The discharge evaluation and plan for this admission was limited to obtaining home oxygen for Patient #2 failed to address the new diagnosis, the treatment and any potential complications or needs.

No discharge evaluation of Patient #2 or Patient #2's spouse to determine risk and safety with having oxygen in the home setting. Pt. was sent home from the hospital with an oxygen tank and provided a number to call for delivery of the rest of the supplies.

4 of 4 admissions/discharges failed to have evidence or documentation of education, training or evaluation of Patient #2 and Patient #2's spouse to determine any potential or additional home needs.

Surveyors were informed during this record review by DQI A and DCM B that discharge information consists of printed document out of Micro-Medix program.

No documentation or evidence was found in the medical record to confirm what information is included in the Micro-Medix program material (i.e.: the new diagnoses and treatment; home oxygen and oxygen safety and new cardiac medication, post surgical restrictions and any potential complications or potential exacerbation of acute renal failure or COPD).

No evidence in Patient #2's medical record was found to support the hospital had educated and trained Patient #2 and Patient #2's spouse, or that the printed materials from the Micro-Medix program was received and understood by Patient # 2.

There was no evidence in the medical record that the primary support for Patient #2 had been involved in the discharge decision-making to identify any additional or potential needs post discharge or what Patient #2's spouse's options were.

This was confirmed in interview with DQI A and DCM B on 5/21/12 at 4:30 PM and this information was validated as accurate by DQI A and DCM B on 05/22/12 at 8:20 AM.

On 05/22/12 at 11:13 AM,. Registered Nurse (RN) F during an interview confirmed to Surveyor #22198, " it is up to the RN's to determine what is printed off in Micro-Medix but it is not documented in the medical record. RN's just check the box indicating Micro-Medix documentation was provided". Also present during this interview was DQI A and DCM B.

On 05/22/12 at 11:30 AM, DQI A and DCM B confirmed currently the hospital does not have a standardized system for documenting what written educational materials are provided out of the Micro-Medix system or if the patient (including, significant others, spouse, family or guardian) understands them.

Based on staff interview, 2 of 4 medical records ( # 1 and # 2) reviewed and facility policy review, the hospital failed to assure discharge planning was reassessed and documented.

Findings include:

Policy reviewed by surveyor # 22198 and # 29963 and DQI A and DCM B, on 5/21/12 at 11:40 PM titled "Discharge Management", effective date: 04/01/2009.
"Definition: Discharge Planning is a process that facilitates the transition of he patient from a hospital to the most independent level of care, whether that is home or another agency. The overall goals of discharge planning is to provide the most appropriate level and quality of care throughout all stages of a patient's illness. Every hospitalized patient requires discharge planning."
Policy: "It is the policy of Wheaton Franciscan Healthcare-Southeast Wisconsin, Inc. and its sponsored hospitals to identify a patient's continuing health care needs on admission to assist in the coordination of services needed at the time of discharge. The multidisciplinary team will work closely with the patient, the patients's family/significant other and appropriate community agencies to ensure the care continuum is maintained for a safe discharge."
5. "This discharge plan will address short and long term patient needs. it includes plans and opportunities required to deal with specific disabilities and limitations which will in turn maximize the patient's functional independence and dignity. The plan will also include an evaluation of the patient's needing post hospital services and the availability of these services"
6. "This discharge plan is reassess by the physician and the healthcare team to determine whether discharge needs have changed. patient's preferences are also likely to change over time requiring constant reassessment and evaluation."
Patient # 1's medical record reviewed on 5/21/12 at 1:25 PM by Surveyor # 22198 and # 29963 revealed an admission date of 12/24/11 and a discharge date of 01/05/12. Admission diagnosis includes cerebral vascular accident (CVA) (brain hemorrhage) with placement of tracheotomy with mechanical ventilation. Patient #1's discharge plan included a discharge to a long term acute care hospital (LTACH).

DCM B confirmed it is the current practice of this hospital, to have the LTACH case managers come into this hospital to complete the patient evaluation and construct the discharge plan, not hospital staff.

DCM B confirmed there was no evidence of documentation of this hospitals staff collaboration with the LTACH's case manager for Patient #1 regarding the current and potential needs for discharge care.

DCM B and DQI A confirmed there was no evidence of a completed discharge evaluation and discharge plan for Patient # 1 during an interview on 5/21/12 at 2:30 PM. On 05/22/12 at 8:20 AM DQI A and DCM B validated these findings as accurate.

Patient #2's medical record reviewed on 5/21/12 at 2:20 PM to 4:30 PM by Surveyor #22198 and #29963 from hospitalization dates including 2/9/12 through 2/14/12.

Medical record revealed documentation on 2/9/12 at 11:14 PM that Patient #2 had complaints of back pain and a decline in ambulation which initiated a referral for Physical Therapy (PT) to evaluate patient.

MR revealed documentation on 2/10/12 at 2:57 PM from PT evaluation indicating "patient was not seen for initial screening, waiting on vascular consult". Vascular consult documented on 2/11/12 indicating probability was low for pulmonary embolism (a blood clot in the lungs).

No further entry from PT that a screen was completed or patients discharge needs were assessed during that hospitalization. Patient was discharged to home on 2/14/12 without discharge planning addressing new diagnosis of gall stones and expansion of abdominal aortic aneurysm (AAA).

This is confirmed in interview with DQI A and DCM B on 5/21/12 at 2:40 PM.

Per review of medical record of Pt. # 2 on 5/21/12 starting at 2:40 PM, by Surveyor #22198 and #29963, revealed diagnosis of chronic obstructive pulmonary disease (COPD), hypertension, and acute renal failure. Pt. # 2 entered hospital on 3/20/12 due to nausea and vomiting which resulted in surgery to remove gall bladder.

Per nutritional assessment, completed by dietitian on 3/21/12 at 9:54 AM, indicating pt. is at high risk due to NPO (nothing by mouth) status in addition to above diagnosis. The next nutritional assessment completed on 3/23/12 at 12:45 PM indicated moderate risk.

Pt. # 2 was discharged to home on 3/28/12 at 4:29 PM without any further nutritional assessments or teaching regarding dietary limitations. Discharge summary indicates "no special diet."

Per interview with RD C on 5/22/12 at 10:30 AM with Surveyor #22198 and #29963, indicated "dietitians are not informed of discharges and would not see patients for discharge teaching unless an order for dietary consult is ordered by doctor prior to discharge."

RD C stated " a high risk score would indicate a nutrition assessment would be completed every 1-2 days and a moderate risk score would indicate a nutritional assessment would be completed every 5-7 days."

RD C stated "Pt. # 2 would have benefited from teaching regarding a low fat diet." RD C also stated that nursing is also responsible to provide education regarding diet changes.

The above findings are confirmed with RD C on 5/22/12 at 10:37 AM.

Based on record review and 1 of 1 staff interview (B) , the hospital failed to complete evaluations of their readmissions to determine if readmissions were potentially preventable.

Findings include:

Per interview on 5/21/12 at 11:15 AM with DCM B by surveyor #22198 and #29963 revealed that all tracking of readmission is completed by a data warehouse(SG2), who aggregates the information.

The information is then reviewed by DCM B and reviews discharge planning but does not evaluate the data to determine whether readmissions to the hospital were potentially preventable.

Also present at interview and confirmed findings was DQI A.