HospitalInspections.org

Based on findings from medical record (MR) review and interview, in 5 of 5 MR's reviewed, discharge planning evaluations did not include an assessment of the patient's ability to perform activities of daily living or the capability of the skilled nursing facility to provide the required post hospital care.

Findings include:

-- Per MR review, Patient A was admitted from home on 7/30/15 with complaints of abdominal pain secondary to biliary stent placement. Patient A was discharged to home on 8/5/15. Patient A's MR lacked a discharge evaluation that included an assessment of the patient's ability to perform activities of daily living (ADL's) (e.g., personal hygiene and grooming, dressing and undressing, feeding, voluntary control of bowel and bladder etc.).

-- Per MR review, Patient B was admitted from a skilled nursing facility (SNF) on 7/27/15 with malignant lymphoma. Patient B was discharged to a SNF on 8/10/15. The discharge planning evaluation completed lacked assessment as to whether the SNF had the capability to provide required post hospital care to the patient.

The same problems with discharge evaluation lacking an assessment of the patients ability to perform ADL's and self-care and/or the skilled nursing facilities capability to provide care were also found in the MR's of Patients C, D, and E for the review period of 8/17/15 - 8/18/15.

-- During interview with Staff #1 on 8/17/15 at 2:30 pm, the above findings were acknowledged.

Based on findings from medical record (MR) review and interview, in 1 of 4 MRs reviewed, there was no documentation indicating that Care Coordination staff performed a discharge planning evaluation.

Findings include:

-- Per MR review, Patient E was admitted to the hospital on 8/12/15 for infection and pain. There is no documentation that Care Coordination staff performed a discharge planning evaluation that included assessment of the patient's enviromental and functional status, ability for self care and/or the support persons ability to provide care after the patient's admission to the hospital.

--During interview with Staff #1 on 8/17/15 at 12:00 pm, the above finding was acknowledged.

Based on findings from medical record (MR) review and interview, in 2 of 4 MRs reviewed, discharge instructions were not provided to patients (Patients C and F) upon discharge to a skilled nursing facility.

Findings include:

-- Per MR review, Patient C, an 89 year-old female, was transferred to a SNF on 8/10/15 for rehabilitation after a hip fracture. An unidentified hospital staff member documented "d/c to facility" in the signature area of the Discharge Instructions form that indicated the patient or guardian had received the discharge instructions. There is no documentation indicating the patient acknowledged receipt of the discharge instructions or was provided a copy at discharge.

-- Per MR review, Patient F, a 76 year-old male, was discharged to a SNF on 8/10/15 for rehabilitation after a hip fracture. An unidentified hospital staff member documented "d/c to facility" in the signature area of the Discharge Instructions form that indicated the patient or guardian had received the discharge instructions. There is no documention indicating the patient acknowledged receipt of the discharge instructions or was provided a copy at discharge.

-- During interview with Staff #1 on 8/17/15 at 2:30 pm, the above findings were acknowledged.