HospitalInspections.org

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the discharge planning evaluation included the possibility of the patient being cared for in the environment from which the patient entered the hospital and/or the environment where the patient was discharged for five of five medical records reviewed (MR1, MR16, MR17, MR18, and MR19).

Findings include:

Review of facility policy "Discharge Planning" dated May 2014, revealed, "Discharge planning includes any and all provisions for, or referrals to, services that may be required to improve or maintain the patient's health status. Consideration shall be given to the patient's medical, social, emotional, economic, psychological and safety needs."

Review of facility policy "Assessment & Documentation of Discharge Planning" dated May 2014, revealed, "4. Reassessment will be done as needed, according to identified medical or psychosocial patient/family needs and responses to care and treatment."

Review of facility policy "Patient Discharge Plan" dated April 2012, revealed, "2. Discharge planning is an ongoing process and is updated as new information becomes available. Documentation concerning discharge planning will be done daily, by the nurse and all disciplines involved with the patient. This may be found in the Case Management Interdisciplinary manual records. ... The initial discharge planning note must define whether an involvement of a significant other is necessary and, if so, the identification of the significant other. If possible, the initial discharge note should include the evaluation of the receptiveness and ability of the significant other."

1. Review of MR1 on January 26, 2015, revealed a 70 year old patient living alone that was admitted to the facility on December 9, 2014, and discharged on December 18, 2014 to daughter's home. Review of the discharge evaluation revealed no documentation of an assessment of the patient's and/or support person's ability to provided self-care/care or if the patient required specialized medical equipment or home and/or physical environment modifications.

2. Review of MR16 on January 26, 2015, revealed a 93 year old patient living with daughter that was admitted on November 10, 2014, and discharged on November 14, 2014. Review of the discharge evaluation revealed no documentation of an assessment of the patient's and/or support person's ability to provide self-care/care or if the patient required specialized medical equipment or home and/or physical environment modifications.

3. Review of MR17 on January 27, 2015, revealed a 67 year old patient living with spouse admitted on September 29, 2014, and discharged on October 4, 2014. Review of the discharge evaluation revealed no documentation of an assessment of the patient's and/or support person's ability to provide self-care/care or if the patient required specialized medical equipment or home and/or physical environment modifications.

4. Review of MR18 on January 27, 2015, revealed a 101 year old patient admitted from an adult community living in an apartment admitted on September 9, 2014, and discharged September 12, 2014. Review of the discharge evaluation revealed no documentation of an assessment of the patient's and/or support person's ability to provide self-care/care or if the patient required specialized medical equipment or home and/or physical environment modifications.

5 Review of MR19 on January 28, 2015, revealed a 72 year old patient that refused to return to a skilled nursing facility and daughter agreed to have the patient live with her. Review of the discharge evaluation revealed no documentation of an assessment of the patient's and/or support person's ability to provide self-care/care or if the patient required specialized medical equipment or home and/or physical environment modifications.

6. Interview with EMP8 on January 28, 2015, at approximately 10:00 AM confirmed the above findings and revealed, "I agree it's [complete discharge evaluation] not there."