HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 5 (Pt #6 and 9) clinical records reviewed for discharge planning to home care, hospice, and/or skill nursing facilities, the Hospital failed to ensure all discharge planning was documented in the patient's clinical record, to include home health/hospice information.

Findings include:

1. The Hospital policy entitled, "Post-Acute Placement Protocol/Guidelines," (revised April 2015) required, "II. Purpose: The purpose of this policy is to define a process for offering all patients a choice in the selection of post-acute care providers...Choices will be offered to patients based on those providers as appropriate, available and able to provide services in the geographical area in which the patient resides..."

2. The clinical record of Pt #6 was reviewed on 3/2/18 at approximately 10:00 AM. Pt #6 was a 79 year old female admitted on 2/28/18 with a diagnosis of dehydration. Pt #6's clinical record contained a physician's order dated 3/1/18 that required an, "Inpatient consult to Skilled Nursing." Pt #6's CFMC (Community First Medical Center) Skilled Nursing Pre-Admission Screening report dated 3/1/18 included, Pt #6 to be admitted to the Hospital's Skilled Nursing Unit on 3/3/18. Pt #6's clinical record lacked documentation that a list of available skilled nursing facilities was provided to the patient and/or family.

3. The clinical record of Pt #9 was reviewed on 3/2/18 at approximately 12:30 PM. Pt #9 was a 91 year old male admitted on 11/26/17 with a diagnosis of sepsis. Pt #9's clinical record contained a Social Work note dated 12/2/17 that included, "Received order for (Hospice Facility)..." Pt #9's clinical record lacked documentation the Pt #9 and/or family was provided with a list of available Hospice organizations.

4. The Director of Case Management (E #6) stated during an interview on 3/2/18 at approximately 1:00 PM, that the records did not include documentation that lists were provided to the patients.