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Based on medical record review the Hospital failed to ensure that patients were evaluated for discharge risk in 9 of 9 medical records.

Findings included:

Review of the Hospital's Policy/procedure titled Policy on Continuum of Care, effective 10/30/09, indicated that case management was responsible for screening for potential discharge needs including high risk criteria.

Review of 9 randomly selected medical records, conducted on 5/21/10 between 12:30 P.M. and 1:45 P.M.,determined that screening for discharge risk was not performed and/or documented in 9 of 9 medical records.

Based on interviews and medical record reviews the Hospital failed to ensure that the listing/booklet of facilities used by the Hospital as referral sources was provided 3 of 4 patients.

Findings included:

Review of the admission packets provided by the Hospital, conducted on 5/21/10, indicated that the packet contained a listing of facilities located in the geographic area of the Hospital. Additionally a booklet (New Lifestyles; winter/spring 2010 edition) was available that provided listings of services/facilities throughout the state.

During the tour of the Medical/Surgical Units conducted on 5/21/10 at 12:30 P.M. a case manager (Case manager #1) was interviewed. Case Manager #1 said patients were asked if they had previously used a service/facility and if not, Case Manager #1 would verbally review all available services/facilities based on insurance allowances. Case Manager #1 said limitations, such as lack of family transportation, were taken into consideration when considering services/placement..

Interviews with 4 patients (Patient #1, Patient #2, Patient #3, and Patient #4) were conducted during tours of the Medical/Surgical Units on 5/21/10 at 12:30 P.M.. Interviews were as follows: Patient #1 said Patient #1 was being discharged that day to a skilled nursing facility and although Patient #1 was happy with the designated facility Patient #1 was not provided with a list or choices regarding placement; Patient #2 reported although not provided with a list, Patient #2 could go wherever he/she wanted; Patient #3, who was being discharged to a skilled nursing facility, was unsure if a list had been provided, and Patient #4, who was scheduled for discharge to a rehabilitation facility, said Patient #4 was not provided with a listing of facility choices.

Review of the medical records for Patient #1, Patient #2, Patient #3, and Patient #4 indicated that there was no documented evidence they were provided with the list/booklet.

Based on medical record review the Hospital failed to ensure that a list of Home Health Agencies/facilities were provided to 9/9 patients.

Findings included:

Please refer to A-0824.

Review of 9 randomly selected medical records and case management documentation, conducted on 5/21/10, indicated that there was no documented evidence that the lists/booklet with referral sources available through the Hospital and/or in admission packets was provided to 9/9 patients.