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Based on record review, interview, and policy review the facility failed to provide patients in need of post discharge care an effective discharge planning process. Findings include:

1. The facility failed to provide assessment and reassessment of discharge needs (See A-0800)

2. The facility failed to include the patient's family members in the discharge planning process (See A-820)

2. The facility failed to ensure the reassessment of its discharge planning process on an on-going basis (See A-843)

Based on medical record review, interview, and policy review the facility failed to identify patients at an early stage of hospitalization, in need of discharge planning, and according to their policy, for 7 of 23 patients (#1, #2, #3, #4, #5, #13, and #17). Findings include:

On 4/3/2013 at approximately 10:00 am during an interview with patient #1 it was revealed the patient was admitted on 3/31/2013 with the diagnosis of chronic obstructive pulmonary disease and shortness of breath. During the interview the patient was asked if she had been seen by the case manager. The patient stated "no". During medical chart review of the patient at approximately 10:20 am it was revealed the record failed to have notes from the case manager in reference to the patient's discharge on 4/3/2013.

On 4/3/2013 at approximately 10:30 am during an interview with patient #2 it was revealed the patient was admitted on 3/31/2013 with the diagnosis of chest pain, wheezing and shortness of breath. During the interview the patient was asked if he had been seen by the case manager. The patient stated "no". During medical chart review of the patient at approximately 10:45 am it was revealed the record failed to show evidence from the case manager in reference to the patient's discharge on 4/3/2013.

On 4/4/2013 at approximately 1:00 pm during medical chart review patient #3 it was revealed the patient was admitted on 2/5/2013 with the diagnosis of left leg cellulitis. The record failed to show evidence from the case manager in reference to the patient's discharge on 2/8/2013.

On 4/4/2013 at approximately 1:30 pm during medical chart review patient #4 it was revealed the patient was admitted on 10/29/2012 with the diagnosis of hypoxia and chronic obstructive pulmonary disease. The record failed to show evidence from the case manager in reference to the patient's discharge on 11/1/2012.

On 4/4/2013 at approximately 1:40 pm during medical chart review patient #5 it was revealed the patient was admitted on 10/21/2012 with the diagnosis of chronic obstructive pulmonary disease and lung cancer. The record failed to show evidence from the case manager in reference to the patient's discharge on 10/25/2012.

On 4/4/2013 at approximately 1:50 pm during medical chart review patient #6 it was revealed the patient was admitted on 11/30/2012 with the diagnosis of shortness of breath and atrial fibrillation. The record failed to show evidence from the case manager in reference to the patient's discharge on 12/3/2012.

On 4/4/2013 at approximately 2:05 pm during medical chart review patient #13 it was revealed the patient was admitted on 12/7/2012 with the diagnosis of pancreatitis. The record failed to show evidence from the case manager in reference to the patient's discharge on 12/10/2012.

On 4/4/2013 at approximately 1:38 pm during medical chart review patient #17 it was revealed the patient was admitted on 11/27/2012 with the diagnosis of respiratory failure. The record failed to show evidence from the case manager in reference to the patient's discharge on 11/30/2012 until 12/1/2012.

A review of the policy titled " assessment and monitoring of patients ", # 268399 it is stated that "all patients are screened to assess for needs, deficits, and risks" . The description further states the risk factors for patients needing to be screened which included " depression, low health literacy, chronic and/or acute congestive heart failure, chronic and/or acute chronic pulmonary disease, pneumonia, five or more chronic comorbid health conditions, previous admission within 30 days, suicide attempt, joint replacements procedures or orthopedic conditions requiring assistance with adult daily living activities, history of recent falls, alcohol or drug use/abuse, and diabetes. " When asked if all patients with depression, low health literacy, chronic and/or acute congestive heart failure, chronic and/or acute chronic pulmonary disease, pneumonia, five or more chronic comorbid health conditions, previous admission within 30 days, suicide attempt, joint replacements procedures or orthopedic conditions requiring assistance with adult daily living activities, history of recent falls, alcohol or drug use/abuse, and diabetes were seen by the case manager, staff E replied "no".

Based on medical record review and interview the facility failed to include the patient's family members in the discharge planning process for one (Patient #17) of 23 medical records reviewed, resulting in the potential for uninformed family members and unmet patient needs. Findings include:

On 4/4/2013 at approximately 1:35 pm during medical record review it was revealed the hospital had not included the patient #17 durable medical power of attorney (DPOA) in making discharge planning decisions. Documentation of the patient's discharge was dated on 12/1/2012 with no reference of involving the patient's DPOA or other family members.

During an interview with the patient's durable medical power of attorney (DPOA) on 4/7/2013 at approximately 7:00 pm, it was revealed she had not been included in making any decisions regarding her mother's discharge from the hospital. She had received a call from her mother on 11/30/2012 at approximately 2:00 pm asking if she could help facilitate her mother's transportation. The DPOA stated she was not able to leave work and that her mother stated she was going to be transferred by ambulance which had been her transportation during discharge on previous stays at the hospital.

Based on interview and document review the facility failed to ensure the reassessment of its discharge planning process on an on-going basis resulting in the potential for unmet patient discharge need and risk of rehospitalization. Findings include:

On 4/4/2012 at approximately 2:30 pm an interview with staff E was conducted. When asked if the discharge planning process was evaluated on an on-going basis staff E responded "no, not really". Staff E stated her job responsibilities included house supervision, case management, utilization review, and sometimes being "pulled" (reassigned) from those positions to work as a floor nurse, when help was needed in the critical care unit. Staff E stated data was collected for utilization review, but as far as reassessment of the discharge planning process it did not occur. Staff E further stated the part-time employee also designated to work as a case manager was also used as a floor nurse when the scheduled time was for case management.

On 4/4/2013 at approximately 10:30 am a review of quality meeting minutes revealed failure to show any documentation for discharge planning reassessment.