HospitalInspections.org

Based on interview, record review and a review of hospital documentation, the hospital failed to ensure that it documented in the medical record that a list of available home health services was presented to the patient or to an individual acting on the patient's behalf for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted through the Emergency Department on 2/05/18.

A physician note of 2/10/18 at 12:35 PM read, "He is alert and appropriate.... I have spoken to the patient about going to a rehab center, but he seems to be adamantly reluctant to it...He will need home health care. The patient's care plan discussed with him today." A physician order of 2/10/18 at 1:53 PM read, "Discharge to: Home with Home Health. Nursing assessment. Therapy per HH (home health) nurse...."

A Case Management note of 2/10/18 at 2:04 PM by registered nurse (RN) B read, "[Home health agency name] will be providing nursing to teach....and physical therapy....I have sent to [home health agency name] the referral order and [RN A] has been informed of the status."

On 5/10/18 at 2:10 PM, RN B stated she had not documented any discussion of home health agency choices on the Patient Choice Form, as required in hospital policy. A nurse's note of 2/10/18 at 5:20 PM by RN A read, "Dr.... order for pt to be d/c (discharged) home. Home health to follow." A Case Management note of 2/10/18 at 6:28 PM read, "SOC (start of care) with [home health agency name] 2/11/18."

The hospital policy "Discharge Planning" read, "When the patient needs home health services....the Case Manager provides the patient or persons acting on his/her behalf with a list of Medicare certified providers who service the geographic area in which the patient resides. The patient's choice is documented on the Patient Choice Form and placed in the Medical Record...."

Since there was no evidence of a Patient Choice Form in the record, the facility was in violation of this policy.

On 5/10/18 at approximately 4:30 PM, the interim Director of Quality Management confirmed the finding.