HospitalInspections.org

Based on review of facility policies, review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to implement and follow the established discharge plan for one of five medical records reviewed (MR1).

Findings include:

Review on July 16, 2014, of facility policy "Discharge Planning," effective June 2012, revealed "Purpose: To delineate the process by which transition (discharge) planning is developed and implemented for each patient. Policy: Social Workers, on a daily basis, collaborate with case managers and the multidisciplinary care team to identify needs, develop an effective discharge plan. These plans are revised as needed depending on the changing condition/needs of the patient. ... C. The Social Worker communicates the preliminary plan with the case manager, physician and the patient's nurse. Refinements are made based on additional information obtained from the interdisciplinary team. D. The Social Worker provides on-going support and monitors the patient's hospital course to ensure that all elements of the discharge plan are ready to be implemented (including proper pre-authorizations) at the time of discharge. ..."

Review on July 16, 2014, of facility policy "Description of Scope of Service for Case Management," effective May 2012, revealed " Scope: ... In collaboration with the case manager, the Social Worker, implements the transition plan, assists the patient and family through the hospital course and transition and ensures that appropriate placement and transportation and timely."

Review on July 16, 2014, of facility policy "Offering of Choice for Post Acute Care Level," effective June 2014, revealed "Purpose: To delineate the process for delivering the offer the availability of post-acute care service including Skilled Nursing Facilities, assisted Living, Home care and Hospice Services. ... Procedure: ... c. ii. documentation of patient's choice will be documented in the medical record."

Review of MR1 revealed "Proxy Directive- Durable Power of Attorney for Health Care" signed and notarized by the patient and the patient's "Designated Healthcare Representative."

Review of MR1 physical therapy notes, dated May 9, 2014, timed 11:42 AM, revealed " ... Recommend STR (short term rehabilitation) verses return to ALF(assisted living facility) with 24 hour supervision and assist as needed. "

Review on July 16, 2014, of MR1 "Occupational Therapy Initial Evaluation," dated May 9, 2014, timed 11:52 AM, revealed " ... Recommend STR prior to return home to ALF Discussed with nursing, physical therapy, case manager. Posey alarm on, patient in chair, niece in room."

Review on July 16, 2014, of MR1 care coordinator notes, dated May 9, 2014, timed 2:30 PM, revealed "... they live in [name of town] and expressed an interest in facilities more in that direction. They are going to [skilled nursing facility] in Ambler tomorrow [May 10, 2014] and the admission department did call and said they have no bed but would like the info on the patient ... they expect a bed open Monday or Tuesday [May 12 or May 13, 2014]... Addendum- May 9, 2014, 3:03 PM- Twenty five page chart faxed to Admissions at [skilled nursing facility]."

Review on July 16, 2014, of MR1 physician orders, dated May 11, 2014, timed 8:15 AM revealed "discharge home." Further review of MR1 revealed no documented evidence that the patient's "Designated Healthcare Representative" was made aware of the change in the patient's discharge plan.

Review on July 16, 2014, of MR1 nursing Documenation, dated May 11, 2014, timed 10:50 AM revealed "transferred back to [assisted living facility] via ambulance. IV discontinued, monitor off, report called." Further review of MR1 revealed that the facility failed to discharge the patient in accordance with the patient's planned discharge plan.

Interview on July 16, 2014, at 11:40 AM with EMP8 confirmed that the patient was not discharged in accordance with the patient's discharge plan. EMP8 confirmed that the patient was discharged to an assisted living community, where the patient previously resided, instead of the planned skilled rehabilitation facility. EMP8 revealed that the patient was found in the patient's apartment by a family member and was returned back to the hospital later that day.