HospitalInspections.org

Based on record review and interview, the facility failed to ensure patients at risk for poor outcomes upon discharge received adequate discharge planning, Citing 1 of 10 patient records reviewed. (patient #1).

Review of patient #1 medical record on 5/21/2013 revealed the following:
1. Patient admitted with diagnosis of Pneumonia, Status post tracheotomy, Multiple decubitus, and Chronic vegetative state, secondary head trauma in motor vehicle accident.
2. Was transferred to hospital from nursing home for care in an acute care setting.
3. Patient had been transferred to current nursing home recently due to development of multiple decubitus.
4. The patient's mother didn't live close to hospital and called frequently to inquire about patient status. When the mother did come to visit she had multiple questions concerning his care and delivery of pain medication.

Review of Case Management Department Policy
Title: Role of Case Manager
Date Adopted: 7/1/2005 Date Revised: 1/09
Supersedes: 09/00 Date Reviewed: 2/2012
Affected Departments: Case Management
Purpose: To describe what patient's, families, and other health care team members can expect from Case Management in receiving holistic care during their hospital experience.
Policy: It is the policy of Case Management to provide a multidisciplinary approach for continuity of care for all patients and their family with emphasis on clinical, psychosocial and spiritual outcomes of care.
Procedure:
? Case Manager Services are available at no cost to any patient and family/significant other regardless of age, race, creed, religious affiliation or financial status.
? A case manager/social worker is available Monday through Friday, from 0800 to 1630, and on an on-call basis on the week-ends, after hours or holidays.
? Case manager will review for medical necessity based on criteria of Milliman and/or Interqual as guided by contracted providers.
? Case Manager in conjunction with the Social Worker will develop discharge plan within 48 business hours of admission to meet the patient ' s continuum of care.
? Documentation of the Discharge plan will be noted on the progress notes of the medical record and/or in the Meditech case management notes.
? Continuum of care notes will be documented in the Meditech case management notes every 3 days of inpatient hospitalization.
? Case manager will screen patients in accordance with the Social Worker on referrals and or high risk need which can include but are not limited to:
1. Readmission within 30 days
2. Self-Pay
3. Chronic Disease
4. Alternate level of care transition such as Nursing Home transfers
5. Age 65 years and older
? Case Managers will communicate with the patient, physician, hospital staff and transitional care staff as indicated.
? Case Managers will provide a Choice letter to patients for any home health, LTAC, Hospice, or DME provider. The patient will sign the letter of choice once a provider is determined. This letter will be placed in the medical record.
? Case manager will document pertinent notes regarding the discharge planning in the patient medical record and/or Meditech case management notes as indicated.
? Case manager will document the plan of care, patient and/or significant other ' s response to the plan and any reassessment needed for the plan as indicated.
? Case manager will communicate clinical, financial, and psychosocial outcome data for trending and process improvement activity as indicated.

Review of Case Management Department Policy
Title: Discharge Planning
Date adopted: 07/01/05 Date revised: 01/09
Supersedes: 09/00 Date reviewed: 02/2012
Affected Departments: Case Management, All Patient Care Areas and Spiritual Care.
Purpose: To describe the scope of Case Management in discharge planning and to formalize the role of the Case Manager and/or Social Worker in the Interdisciplinary Team meeting.
Policy: It is the policy to provide for the continuing care based upon the patient's assessed needs at the time of discharge through the Case Management Department (RN Case Managers and/or Licensed Social Worker).
Scope:
1. Discharge planning involves the patient, the family, the physician, nursing, social services and case managers as well as other health care team professionals.
2. It is a multi-disciplinary approach to identify patients' continuing physical, emotional, symptom management, housekeeping, transportation, social, and other needs, and arranges for services to meet them.
3. Discharge services may include for example:
? Home health services
? Adult foster care
? Hospice
? Rehabilitation services
? Community mental health
? Ambulatory care
? Support groups
? Case management
4. Third party payors play a significant role in the process by representing reimbursement opportunities for required services.
Procedures:
1. Case Managers begin the discharge plan, as do the clinicians in direct patient care, upon initial assessment.
2. Case Managers, through concurrent review and Social Workers, through Psycho-Social Evaluations assess the patient's needs continually.
3. When the health care tam determines services that will meet the patient's needs at the time of discharge, the Case Managers and/or Social worker ensure the services are available.
4. The following action are taken by Case Management Department to ensure there are post discharge services:
? Communicate with payors to secure services and payment of those services
? Refer patients and families to community resources to meet service needs
? Present the patient with clear discharge plans and provide choice of provider information to patient and/or family as indicated. Once the patient has chosen a provider, this information will be entered into the medical record.
? Provide supplemental patient and/or family education to dispel confusion, answer questions and concerns and to increase compliance with the discharge plan.
? Document in Meditech PCS the name, number and if possible, the authorization number for discharge services.
? Ensure that the physician has written orders for the provision of services that require orders MD orders.
? Cooperate with nursing services to ensure service providers receive both physician orders and clinical information to ensure continuity of care.

Review of medical record for patient #1 on 5/21/2013 and 5/22/2013 revealed no documentation of assessment and/or evaluation per discharge planning and/or social worker during patient stay at the facility. The Admission Data sheet completed by the Registered Nurse on admission to the intensive care unit on 4/19/2013 provided documentation of no referral to discharge planning and/or Social Worker for discharge planning.

Interview with staff #8 on 5/22/2013 at 10:15 am revealed the following:
"I spoke with Case Manager and ask if the patient was returning to the nursing home on discharge, would they always see an assessment as part of discharge planning. Case Manager advised " not always." "I can't find any documentation in the patient record to confirm the mother was provided information concerning discharge back to nursing home or included in the decisions made concerning patient's follow-up care."

Interview with staff #8 on 5/22/2013 at 10:20 am confirmed the patient was not assessed per social worker and/or member of the Discharge Planning department and patient did fall into a high risk category. The facility uses a team approach to patient care and this includes assessment of each patient for discharge criteria concerning need for discharge planning.