HospitalInspections.org

35461




Based on interviews and document review, the facility failed to ensure a complete discharge evaluation was performed in 4 of 10 medical records reviewed (Patients #1, 2, 8 and 10).

The failure created the potential that patients who required post-hospital assistance would not receive the appropriate level of assistance necessary for transition to the next level of care.

FINDINGS

POLICY

According to the policy Discharge Planning, the Case Manager (CM) will assess the discharge needs of each patient beginning upon admission. The development, implementation, and evaluation of the discharge plan will be on-going until discharge.

The CM will identify discharge planning needs through assessment of factors including financial status and insurance benefits.

According the procedure Discharge Planning, within 2 business days of admission, the Case Manager will identify discharge planning needs.

1. The facility failed to perform a complete Case Management/Social Services Assessment of discharge needs of Patients #1, 2, 8, and 10.

a) On 11/24/15 a review of Case Management/Social Services Assessment forms was completed. The review revealed the Financial Information section of the form was not completed in 4 of 10 patient records.

Review of the Case Management/Social Services assessment for Patient #1, completed on 11/9/15, revealed a blank Financial Information section.

Patient #2 was admitted on 09/10/15 and had an initial assessment completed on 09/28/15, which was 12 business days after admission. Review of the assessment form revealed the Financial Information section was left blank.

On 6/8/15, Patient #8 had an assessment form which lacked documentation of Financial Information.

Patient #10 was admitted on 11/06/15 and had an initial assessment completed on 11/17/15, which was 7 business days after admission. Review of the assessment form revealed the Financial Information section was left blank.

b) In an interview with Case Manager (CM) #1 on 11/24/15 at 2:47 p.m., s/he stated all patients admitted to the facility received a discharge plan after an initial assessment was completed to determine their status prior to admission to the facility. CM #1 stated the post-hospitalization choices provided to the patient were based on the patients' financial resources for payment. CM #1 further stated the assessment was documented in the Case Manager section of the electronic medical record.

c) On 11/25/15 at 10:36 a.m., an interview was conducted with the Interim Director of Case Management (CM #3). According to CM #3, initial assessments should have been completed within 2 business days of the patient's admission to the facility. CM #3 stated the case managers "should be documenting all their efforts" in the discharge planning process in the patient electronic medical record according to policy. CM #3 further stated that if information was not "documented it didn't happen."

The post discharge care needs of any patient discharged from the facility was dependent upon his/her financial resources for payment. Without a complete assessment to determine the resources, there was a potential the patient would not receive appropriate post discharge care.











36554

35461




Based on interviews and document review, the facility failed to provide a list of options for post-hospitalization services in 8 out of 10 medical records reviewed (Patients #1, 2, 3, 4, 5, 6, 9, and 10).

The failure created the potential of patients not being informed of all choices available to them when selecting post-discharge service providers.

FINDINGS

POLICY

According to the policy, Post Discharge Referrals-Offering Choice, patients will be informed of their discharge options and be offered choices in selecting their post-acute provider/service. Post-acute services include skilled nursing facilities, nursing facilities, home health care, sub-acute rehabilitation, acute rehabilitation, and durable medical equipment. Documentation of choice is accomplished utilizing the Patient Choice Form or documented in the medical record.

1. The facility failed to ensure all patients who needed post-hospitalization care services were provided a list of choices.

a) On 11/24/15 a focused review of 10 patients' discharge plans was completed. The review revealed that 8 of 10 patients had not been provided a list of choices for post discharge care options. The medical records of Patients #1, #2, #3, #4, #5, #6, #9, and #10 revealed no Patient Choice Form was presented to the patient and no documentation within the record showed the patients had received a list of choices for selecting service providers.

i) Patient #1 was hospitalized in the facility from 11/06/15 thru 11/19/15. Review of the discharge needs for Patient #1 revealed a Skilled Nursing Facility (SNF) was needed for post discharge care. The discharge plan for Patient #1 revealed the Case Manager (CM) did not document a list of SNF options was provided to the patient and there was no record that a Patient Choice Form had been completed and provided to the patient or family.

ii) Patient #2 was hospitalized from 09/10/15 to 10/15/15 and required post discharge care to a Skilled Nursing Facility (SNF) for further management of care for chemotherapy and rehabilitation therapies. There was no documentation in the medical record of Patient #2 to show a list of SNF choices was provided. Furthermore, there was no documentation in the medical record to show a Patient Choice Form was completed and provided to the patient or family.

iii) Patient #3 was hospitalized from 08/03/15 to 09/10/15 and required a post discharge referral to a SNF for physical rehabilitation therapy. No documentation in the medical record showed the patient had received a list of SNF choices or that a Patient Choice Form had been completed and provided to the patient or family.

iv) Patient #4 was hospitalized from 08/20/15 to 09/23/15. Patient #4 required multiple post discharge services including a Home Health Agency (HHA) for wound and tracheotomy care and special equipment and supplies. There was no documentation to show the patient or family was provided a list of choices for HHAs or equipment and supply providers. Additionally, there was no documentation a Patient Choice Form had been completed and provided to the patient or family.

v) Patient #5 was hospitalized from 08/14/15 to 09/02/15 and required HHA services post discharge for wound care. There was no documentation to show the patient or family had been provided a list of choices of HHA's or that a Patient Choice Form had been provided as required by facility policy.

vi) Patient #6 was hospitalized from 08/31/15 to 09/24/15. Upon discharge the patient required Skilled Nursing Facility (SNF) care for rehabilitation and continued chemotherapy. There was no documentation within the medical record the show the patient or family had been provided a list of SNF choices or that a Patient Choice Form had been completed and provided to the patient or family.

vii) Patient #9 was hospitalized from 08/31/15 to 09/18/15 and required SNF care after discharge for continued physical rehabilitation therapy. There was no documentation to show the patient or family had been provided with a list of SNF choices or that a Patient Choice Form had been provided prior to discharge.

viii) Patient #10 was hospitalized from 11/06/15 to 11/19/15. Review of the patient's medical record revealed no documentation to show the patient had been given a list of Home Health Agencies for selection of a provider for needed services after discharge. There was no documentation that a Patient Choice Form had been completed and provided to the patient or family.

b) On 11/24/15 at 2:47 p.m., an interview was conducted with Case Manager #1 (CM #1). CM #1 stated that when a patient was identified in the Case Management Assessment to need post discharge care services, a list was provided to the patient and/or family. The list provided contact information of the facilities covered by the patient's insurance carrier. CM #1 further stated that all documentation related to each patient's discharge plan was done in the case management section of the medical record.

c) An interview was conducted with CM #2 on 11/25/15 at 8:52 a.m. CM #2 stated s/he did not provide a list of choices of post hospitalization services to each patient who required these services. CM #2 stated s/he discussed options with the patient and/or family verbally and only provided the contact information of the facilities covered by the patient's insurance. CM #2 further stated that if the patient or family specified a SNF/HHA, there was still no list of other choices provided to the patient as required by the facilities policy.

d) An interview was conducted with the Interim Director of Case Management (CM #3) on 11/25/15 at 10:36 a.m. CM #3 stated s/he expected CM staff to follow facility policies. CM #3 further stated CM staff are expected to provide the patient with choices and document those choices in the each patient's medical record within the case management section.


















36554

35461




Based on interviews and document review, the facility failed to ensure necessary medical information was provided to a receiving facility during the discharge process in 1 of 10 medical records reviewed (Patient #4).

This failure created the potential for patient harm related to inadequate post hospitalization care for patients discharged from the facility.

FINDINGS

POLICY

According to the policy Discharge Planning:

Case Managers will collaborate with patients, families, physicians, healthcare team members, and community resources when determining the appropriate post-hospital discharge destination for the patient to ensure that patients have a smooth and safe transition from the Long Term Acute Care/Transitional Care Facility to his/her next level of care.

Case Managers make any referrals necessary for assistance from community agencies or available financial assistance.

According to the policy Case Management Responsibilities:

Clinical and utilization review activities include: performs admission and concurrent reviews, including managed care patient coordination/communication; performs ongoing discharge planning, arranges for discharge needs, including alternate level of care transfers.

Social Services related activities include: Collaborates with community agencies for patient post acute needs.

Assures Case Management responsibilities are documented in the medical record or Case Management Software as indicated.

1. The facility did not ensure the receiving Home Health Agency (HHA) Patient #4 was discharged to would be able to care for the needs of Patient #4.

a) Patient #4 was hospitalized in the facility from 08/20/15 to 09/23/15. The medical record of Patient #4 revealed that upon discharge s/he would require 24 hour care for suctioning of a tracheostomy airway, wound care, and tube feedings.

On 11/23/15 the medical record of Patient #4 was reviewed. Documentation revealed there was no referral made to the receiving Home Health Agency (HHA). Further review revealed there was no documentation the accepting HHA received medical records which identified the post discharge care needs of Patient #4. Additionally, there was no documentation within the medical record to show staff from the accepting HHA had performed an assessment of the patient or reviewed Patient #4's medical record to ensure the accepting HHA could provide the required care for Patient #4.

b) In an interview conducted on 11/25/15 at 11:16 a.m. with the assigned Case Manager (CM #1), s/he stated the case managers' responsibilities included ensuring patients were safe upon discharge and had the necessary services in place to provide required care. CM #1 further stated "I don't have documentation that I spoke with [the HHA] about this patient." CM #1 stated "I remember the [HHA] lady came in to see the patient but if it wasn't documented, it doesn't count."

c) On 11/25/15 at 8:52 a.m. an interview was conducted with CM #2. CM #2 stated that when a Home Health Agency (HHA) referral was made, a packet should have been faxed to the HHA to review the clinical care needs of the patient. CM #2 further stated that s/he was unfamiliar with the HHA that accepted care for Patient #4 or if the agency was capable of providing the care needed by Patient #4.

CM #2 stated the documentation in the medical record of Patient #4 revealed a referral was faxed to the accepting Home Health Agency (HHA) on 9/23/15, the day of discharge. CM #4 further stated there was no documentation to show the HHA representative had received a referral or performed an assessment of the post discharge care needs of Patient #4.

d) An interview was conducted with the Interim Director of Case Management (CM) #3 on 11/25/15 at 10:36 a.m. CM #3 stated s/he expected CM staff to follow facility policies. CM #3 further stated if there was no documentation to show there was communication with the Home Health Agency (HHA) it could not be assumed there had been communication. Additionally, CM #3 stated that if a referral packet had been sent to the HHA, it should have been documented by the case manager in the medical record.












36554