HospitalInspections.org

Based on record review and interview it was determined the facility failed to ensure quality of discharge planning was provided to 2 of 7 sampled patients (Patient #1 and #2) as evidenced by failure to provide a choice letter for follow up care at home.


The findings included:


Facility policy titled "Case Management Discharge Planning dated 02/10/15 documents "The Case Manager will document in the medical record after their initial assessment has been completed, discussion with the patient regarding anticipated needs for surgery and any and all communication with patient and family in regards to their choices for services post discharge."

Clinical record review conducted on 08/03/17 revealed Patient #1 was admitted to the facility on 06/08/17 for a surgical procedure. Review of the Case Management/Discharge Planning Notes failed to provide evidence the patient or the patient's family was informed of their freedom to choose among participating Medicare providers of post-hospital care services.

Clinical record review conducted on 08/03/17 revealed Patient #2 was admitted to the facility on 06/12/17 for a surgical procedure. Review of the Case Management/Discharge Planning Notes failed to provide evidence the patient or the patient's family was informed of their freedom to choose among participating Medicare providers of post-hospital care services.

Interview with the Quality Manager conducted on 08/03/17 at approximately 12:38 PM confirmed Patient #1 and #2 did not receive the choice letter as the physician's office made the arrangement for home health care.

Based on record review and interview it was determined the facility failed to ensure quality of surgical care was provided to 2 of 7 sampled patients (Patient #2 and #3) as evidenced by failure to update examination of the patients, History and Physical within 24 hours after admission or prior to a surgical procedure.

The findings included:

Clinical record review conducted on 08/03/17 and 08/04/17 revealed Patient #2 was admitted to the facility on 06/12/17 for a surgical procedure. The record contained a History and Physical dated 06/01/17, the record provides no evidence an update was completed prior to the surgical procedure performed on 06/12/17.


Clinical record review conducted on 08/03/17 and 08/04/17 revealed Patient #3 was admitted to the facility on 07/06/17 for a surgical procedure. The record contained a History and Physical dated 07/03/17, the record provides no evidence an update was completed prior to the surgical procedure performed on 07/06/17.

Interview with the Quality Manager conducted on 08/04/17 at approximately 1:38 PM confirmed after further research of the clinical records there is no evidence the History and Physical related to Patient #2 and #3 were updated prior to the surgical procedure.