HospitalInspections.org

Based on interview and document review, staff members are not consistently following the facility's policies and procedures for discharge planning. This was noted in two of four medical records.

Findings:

Patient #1

The facility's policy titled 'Social Work Referral and Assessment' (Manual Code: G-1)' states that patients who are identifed as having post discharge planning needs such as a skilled nursing facillity or skilled/custodial home care are screened as a moderate risk and referred to Social Work.
Review of Patient #1's medical record identified that the 79 year old patient was admitted for a non-healing ulcer. Information in the record indicated that the patient would need post-discharge services; the patient's past medical history indicated a recent discharge from a SNF for treatment of his foot wound. There was no documentation indicating that nursing had identified this patient as a moderate risk during the initail assessment. As a result, a referral had not been made to Social Work.
This finding was confirmed with nursing and Social Work staff on February 22, 2012.

Patient #4
The facility's policy titled 'Social Work Referral and Assessment' (Manual Code: G-1)' states that patients meeting moderate risk are assesed within 72 hours of admission to the unit. In one of four records, documentation of an assessment by social work within this timeframe was not found.

The patient's medical record was reviewed on February 22, 2012. The patient's 'Admission Assessment Record ' dated February 16, 2012 indicates the patient was a moderate risk, as she lives alone and has no supports. A referral to social work was done on that day. However, the medical record lacked documentation of a social work assessment or any other documentation by the social worker.

This finding was confirmed with nursing and Social Work staff on February 22, 2012.

Based on document review and interview, the facility failed to conduct a discharge planning evalution in one of four medical records reviewed.

Findings:

Please see findings for Patient # 1 under A 800. A discharge planning evaluation was not completed for this patient.