HospitalInspections.org

Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to complete referrals to multidisciplinary departments based on patients' identified needs at the time of admission, in one of two open medical records reviewed (Medical Record #1) and one of three closed Medical Records reviewed (Medical Record #4).

Findings include:

Reference #1: Facility Nursing Department policy and procedure titled 'Assessment/ Reassessment of Patients', Policy #: A-23, states "POLICY Each patient admitted to --- will have an Admission Assessment completed by a nurse ... . ... Automatic triggers are identified in "RED" through the form. ... SECTION IV. Automatic Referral List Triggers generated throughout completion of assessment form are recorded and called to appropriate departments for intervention. The date and time the department is called must be recorded. A physician's order must be obtained for a Rehabilitation referral."

Reference #2: Facility Case Management Department policy and procedure titled 'Discharge Planning' states "I. POLICY It is the policy of --- that patient/ family/ significant other will be assisted in developing, planning and implementing an appropriate discharge plan. ... III. PROCEDURE ... Referrals for discharge planning shall also be accepted from physicians, all Medical Center personnel, ... ."

1. On 11/28/11 at 10:45 AM, Medical Record #1 was reviewed on Unit 3 East in the presence of Staff #2 and Staff #15. The Electronic Nursing Admission Assessment indicated the patient was admitted 10/31/11, status post fall, from her Assisted Living facility. The patient uses a walker, and has difficulty swallowing. There was no evidence in the computerized nursing Admission Assessment that a physical therapy or speech/swallow evaluation was triggered for referral.

a. Staff #15 reviewed the computerized referral list for the Rehabilitation Department and explained that nursing referrals would appear as general referrals, where as physician ordered referrals would appear as a physician order. Staff #15 reviewed the computerized referral list for the Rehabilitation Department and reported that there was no referral to the Rehabilitation Department for speech/swallow or physical therapy evaluations from Nursing, for Patient #1, stemming from the Nursing Admission Assessment, but there was a physician driven order dated 11/17/11 for physical therapy evaluation, which was completed earlier this day.

i. Note: In interview with Staff #14, it was communicated in her nursing shift report that the patient does not have difficulty swallowing in general, is able to eat and drink without difficulty, but has some difficulty with some of her larger pills. The patient eats animal crackers to assist with swallowing her larger pills, which were observed at her bedside.

b. In interview, Staff #2 stated that the triggers from the computerized Nursing Admission Assessment to other disciplines are not being communicated/is not working in the computerized system, which the facility has implemented in October of this year, and that it is being addressed.

2. On 11/28/11 at 12:15 PM, review of Medical Record #4's paper Nursing Admission Assessment indicated that the patient was admitted on 9/27/11 from a nursing home for a pulse of 30. The following 'Red' automatic triggers to other disciplines for referral were identified on the Nursing Admission, but there was no evidence that the referrals were completed because there was no evidence of a 'Signature of Staff Member Entering Triggers' on the form, and there were no checkmarks in the boxes next to the disciplines that would indicate a referral was made:

a. Social Services: Because the patient did not have an Advance Directive, has altered mental status, needed assistance with self care prior to hospitalization, and was to be discharged to a LTC facility.

b. Case Management: For requiring an interpreter [primary language is Spanish],is hard of hearing, and has impaired vision.

c. Wound Care for a Total Braden Score of less than 18 [was 17].

3. Without Nursing completing the interdisciplinary referrals triggered on admission, other disciplines and the case management department may be unable to identify discharge planning needs at the earliest time possible, to avoid adverse health consequences post discharge.

Based on medical record review, it was determined that the facility failed to provide counseling for medications at discharge in one of three closed medical records reviewed (Medical Record #4).

Findings include:

Reference: Facility policy and procedure Document Number: MHC-ADMIN-02-1280, titled 'Medication Reconciliation - Inpatient' states "... Procedure: ... Discharge: ... 2. At the time of discharge, the discharging/primary care physician/LIP will compare the current Medication Administration Record (MAR) with the admission home medication list to determine which medications should be continued, stopped, changed and/or prescribed for discharge. 3. ... Physician Discharge Responsibilities: a. If the electronic Discharge Medication list is available and used, the physician/LIP will generate the list, which incorporates an electronic signature. A copy of the electronic discharge medication list must be attached to the Medication Reconciliation form if used. b. If the medication reconciliation form is used, the physician/LIP will document the patient's discharge medications and sign the form."

1. On 11/28/11 at 12:15 PM, review of Medical Record #4's paper Nursing Admission Assessment indicated that the patient was admitted on 9/27/11, from a nursing home, and discharged back to the nursing home on 10/3/11. There was no evidence of a Medication Reconciliation Form in the Medical Record. This was confirmed by Staff #8 on 11/28/11 at 2:00 PM.

Based on review of facility policy and procedure and review of the facility's general admission consent for patients, it was determined that the facility failed to ensure that all patient rights to confidentiality are ensured before the release of patient information to other facilities or agencies.

Findings include:

1. On 11/28/11, Staff # 7 stated that the patients' consent for the facility to share confidential patient information with outside agencies or facilities, is part of the general admission consent provided to patients at the time of admission and registration.

2. Review of facility policy and procedure SUBJECT: 'Consents signed During Registration', and the attached "Consent For Medical Treatment," lacked evidence of explanation for patients to consent to release of patient information to outside facilities for the purposes of continuity of patient care.

Based on review of the the QAPI data and staff interview, it was determined that the facility failed to review all QAPI activities of the Case Management/Social Work Department at the hospital wide QA meetings, and failed to review patient readmissions to identify needs in the discharge planning process and determine corrective actions for those needs as part of their QA process.

Findings include:

1. On 11/28/11 at 2:00 PM, the facility's QAPI for Discharge Planning was reviewed in the presence of Staff #5, Staff #7 and Staff #8. The QAPI minutes lacked evidence of readmission reviews for patients that were readmitted to the hospital less than 30 days from a prior discharge. The QAPI minutes focus on evaluation of Length of stay (LOS).

2. Staff # 8 provided a Performance Improvement Dashboard for the Case Management/ Social Work Department that includes data on the discharge planning process while the patients are in the hospital; i.e. timeliness of identifying patients requiring a discharge plan, provision of community resources to patients/families. This information was not evident in the facility QAPI meeting minutes.

3. Per Staff #5 and Staff #7, the facility has began to collect data on readmissions since they have instituted an electronic medical record (EMR) in October of this year, but have only reviewed this data on a corporate level for evaluation and implementation of best practices and that submitted from the Hospital Compare report. A formalized review of this facility's readmissions, to identify needs in the discharge planning process and determine corrective actions as part of their QA process, has not been initiated at the facility to date.