HospitalInspections.org

Based on document review and interview, it was determined for 1 of 2 (Pt. #6) patients being transferred to a nursing home, the Hospital failed to discuss the discharge plan with the patient or family.

Findings include:

1. The Hospital policy titled, "Case Management:Discharge Planning Process (revised 6/6/11)" was reviewed on 8/4/16. The policy included,"Discharge planning is a coordinated multidisciplinary process in which patient and families ... and other disciplines collaborate and coordinate care to ensure that the patients care needs are met".

2. The clinical record of Pt. #6 was reviewed on 8/3/16. Pt. #6 was an 87 year old female admitted on 5/31/16 from a nursing home with the diagnosis of altered mental status. Pt. #6 was discharged back to the nursing home on 6/3/16. The clinical record lacked documentation of any discussion with the patient or family about potential discharge plans.

3. During an interview on 8/3/16 at approximately 2:30 PM, the Regional Director of Case Management and Social Workers (E#2) stated, "There should always be communication with the patient or family, but I don't find any documentation of that in this record".

Based on document review and interview, it was determined for 2 of 3 (Pt's #3 and 4) patients discharged home with home care services, the Hospital failed to ensure patients were provided a list of available home care agencies.

Findings include:

1. The Hospital policy titled, "Patient Choice of Post Acute Services (revised 6/10/13)" was reviewed on 8/4/16. The policy required, "The Case Manager/Social Worker will document in the patient's medical record that a list of appropriate and available providers had been provided ...".

2. The clinical record of Pt. #3 was reviewed on 8/3/16. Pt. #3 was a 68 year old male admitted on 7/4/16 with the diagnosis of pulmonary embolism (blood clot in lung). Pt. #3 was discharged on 7/12/16 with home care services. The clinical record lacked documentation of a list of home care agencies being provided to the patient.

3. The clinical record of Pt. #4 was reviewed on 8/3/16. Pt. #4 was a 79 year old female admitted on 6/16/16 with the diagnosis of ovarian cancer. Pt. #4 was discharged on 6/24/16 with home care services. The clinical record lacked documentation of a list of home care agencies being provided to the patient.

4. During an interview on 8/3/16 at approximately 2:30 PM, the Regional Director of Case Management and Social Workers (E#2) stated, "There is no documentation of a list of home care agencies provided to the patient in any of these records".