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Based on a review of medical records, hospital policies and procedures, and staff interviews, the hospital failed to ensure that discharge orders were implemented as arrangements were not made for a patient to receive post-hospitalization care as ordered.

Findings included:

Review of the medical record for Patient #1 revealed the following:
? A discharge order was entered on 1/3/15 at 10:31 am to discharge "Home with Home Health."
? The "Amb Referral to Home Health-Face to Face" order by Staff #5 (physician) on 1/3/15 at 10:33 am stated "Disposition: Home with Home Health." The order included details for physical therapy, occupational therapy, and skilled nursing in the areas of pulmonary and diabetic. Physician comments in the order included the statement that "home health services are medically necessary to provide the care and treatments as identified." The order was acknowledged by Staff #6, (RN) on 1/3/15 at 11:47 am.
? The Discharge Summary by Staff #5 (physician) on 1/3/15 at 10:36 am stated, "His wife was called and she will obtain help from family and home health is arranged ...he is to follow up with primary this week."
? The "After Visit Summary and Discharge Instructions" revealed that Patient #1 was discharged at 12:45 pm on 1/3/15. The instructions included the statement that "home health services are medically necessary to provide the care and treatments as identified" and stated the disposition as "Home with Home Health." The instructions were signed by the patient representative and by Staff #6 (RN) on 1/3/15 at 12:35 pm.

In an interview with Staff #3, Case Manager the afternoon of 3/16/2015 in the hospital conference room, she stated that "Unless a doctor orders a referral for Case Management, even if home health is ordered, there will be no implementation of the order." After reviewing the medical record for Patient #1, Staff #3 stated that there was not a referral or order for Case Management. When the surveyor asked Staff #3 about the "Amb Referral to Home Health-Face to Face", she stated that the physician is required to complete this for every patient in the hospital if they are going to order home health and they are a Medicare patient. Staff #3 stated that Staff #5 (physician) did the assessment to order home health. However, Staff #3 stated that "the Case Management referral is missing. There was no order for Case Management, so home health was not arranged for this patient." Staff #3 also confirmed that there was no communication between Case Management and nursing regarding the order for home health services. Staff #3 stated she was on call the weekend that Patient #1 was discharged and she did not recall this patient or any referral.

In an interview with Staff #4, Utilization Review Nurse the afternoon of 3/16/2015 in the hospital conference room, after reviewing the medical record for Patient #1, she stated that there was no Case Management order/referral for Patient #1 in the medical record, so "we [Case Management] would have no way of knowing that [home health referral] was the physician's desire." Staff #4 stated that there must be a referral to Case Management to set up home health either post- or pre-discharge.

In an interview with Staff #2, Quality Director the afternoon of 3/16/2015 in the hospital conference room, she was asked by the surveyor, "How do the doctors know that they have to put in an order for Case Management for home health orders to be implemented or activated?" Staff #2 stated that, "It would have been part of the training, would have been discussed during staff meetings, discharge rounds, Case Managers will ask the physicians when they see them in the hallway to put in an order for Case Management."

In an interview with Staff #6, Charge RN the afternoon of 3/16/2015 in the hospital conference room, she reviewed the medical record for Patient #1, including the "After Visit Summary and Discharge Instructions" she had signed and the "Amb Referral to Home Health-Face to Face" order that she acknowledged on 1/3/15 at 11:47 am. When asked by the surveyor what she does when she acknowledges the order and what she reviews with the patient at discharge, she stated that "I review everything that's on here, what it says." When asked specifically about making home health arrangements, Staff #6 stated, "I haven't been doing anything with that, it's for Case Management to set up with the patient. I don't notify anyone. If it is on the weekend, Case Management will see this on Monday." When asked by the surveyor how Case Management was notified of the home health order or how the home health agency was notified of the referral, Staff #6 stated, "I don't know. I assume they have a queue. I'm not sure ...My understanding is that they [Case Management] got this somehow."

In an interview with Staff #5, physician, the afternoon of 3/16/2015 in the hospital conference room, when asked about ordering home health for Patient #1 at discharge, he stated that "the order should be enough; if the Case Manager is not there, then they should get the order and carry it out." Staff #6 stated that when ordering home health, "I don't always order a Case Manager consult." Staff #1, Chief Nursing Officer, and Staff #2 Director of Quality were present for the interview with Staff #5. Staff #1 and Staff #2 confirmed that Staff #5, physician did not know that the physician has to put in an order for Case Management in order for a home health or other post hospital care order to be arranged per hospital policy and practice.

Review of the Discharge Planning policy, no policy number, last revised 5/27/13,Scott & White Hospital - Round Rock provided to the surveyor the afternoon of 3/16/15, stated, in part, "A multidisciplinary team approach should be utilized in developing the discharge plan ...Ultimately, the discharge plan is physician driven in order to ensure continuation of medically necessary services post discharge from the hospital ...1) Discharge planning for the Case Management department should be initiated within one (1) business day following receipt of the physician order requesting consult to Case Management ...d) Patients should be referred for discharge planning evaluation and transition of care development directly by physician order as identified/requested by the physician, multidisciplinary team, patient/family request, or by any other means ...Discharge Plan Information and Instructions ...2) When indicated and before discharge, the hospital arranges for or helps the patient, family and/or caregivers arrange for services needed to meet the patient's needs after discharge. The Case Manager, Social Worker, and/or designee confirms the plan and initiates and/or coordinates any necessary referrals/services including but not limited to: a) Home Health including but not limited to, skilled nursing, physical therapy, social work ..."

The above findings were confirmed the afternoon of 3/16/15 with Staff #1, Chief Nursing Officer and Staff #2, Director of Quality in the hospital conference room.