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Based on staff interview, clinical record review, and policy review, the hospital did not identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning for one (Patient #3) of 4 patients in the sample.

Findings include:

Concurrent clinical record review was done with hospital staff on 6/21/12 for Patient #3. The patient was admitted to the facility on 6/12/12 with diagnoses of chronic obstructive pulmonary disease, shortness of breath, and upper gastrointestinal bleeding. Initial plans were to have the patient transferred to a long term care facility for short term rehabilitation therapy today, 6/21/12. However, the patient needed some medical follow-up and therefore would be discharged on 6/22/12. Further review of the record could not find documentation that a screening was done to identify whether the patient needed a discharge planning evaluation. Interview with the Case Manager (CM) revealed that he completed a discharge planning assessment on the patient's previous admission date of 5/24/12. The patient's status was unchanged and he was planning to copy that evaluation and place it in the current admission record, however, it was not done. The CM acknowledged that all patients admitted to the hospital should have an initial discharge planning assessment completed as soon as possible. Review of the facility's policy "Initial Case Management Discharge Planning Assessment" with effective date of 10/2009 noted "An initial case management discharge planning assessment will be performed on patients admitted to the facility within three working days of admission".

Based on clinical record review and interview with staff members, the facility failed to include in the discharge plan a list of skilled nursing facilities that are participating in the Medicare program, and that serve the geographic area in which the patient resides for 2 of 2 patients (Patient #2 and #3) in the sample that were transferred to a skilled nursing facility.

Findings include:

1) Clinical record review done on the morning of 6/21/12 noted Patient #2 was admitted to the facility on 5/19/12 due to bowel obstruction. The patient is a Medicare beneficiary and was determined to be at minimal risk for discharge. Patient #2 was discharged on 6/6/12 to a skilled nursing facility for short term rehabilitation. During the review queried whether the patient was provided with a listing of Medicare participating facilities based on geographic area. The Director of Case Management (DCM) reported that the case managers are provided with a list and generally the list is not provided to patients; however, the patient is given a choice. The patient selected a facility; however, was transferred to another facility.

The DCM was agreeable to follow up to confirm whether the patients are provided a listing of applicable skilled nursing facilities. On 6/21/12 at 2:00 P.M., the DCM reported that the facility does not provide a formal list to the patient or representative of skilled nursing facilities participating in the Medicare program.


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2) Concurrent clinical record review was done with hospital staff on 6/21/12 for Patient #3. The patient was admitted to the facility on 6/12/12 with diagnoses of chronic obstructive pulmonary disease, shortness of breath, and upper gastrointestinal bleeding. Initial plans were to have the patient transferred to a long term care facility for short term rehabilitation therapy today, 6/21/12. However, the patient needed some medical follow-up and therefore would be discharged on 6/22/12. There was no documentation in the record to indicate a listing of Medicare participating facilities based on geographic area was provided to the patient.