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Based on medical record review, policy review, and interview the facility failed to ensure the discharge planning process was initiated for 2 of 4 patients (#12 and #15) within 48 hours of admission resulting in the potential for failure to identify patient needs at time of discharge. Findings include:

On 8/28/2012 at approximately 3:45 PM during medical record review, it was revealed the discharge planning process had not occurred within 48 hours after admission for patient #12. Patient #12 was admitted on 5/24/2012 from an outpatient service area of the hospital to an inpatient status. Discharge planning for patient #12 was started on 6/4/2012 from a referral on 6/3/2012 according to patient support notes from discharge planning. The patient was discharged on 6/6/2012.

On 8/28/2012 at approximately 4:20 PM during medical record review, it was revealed the discharge planning process had not occurred within 48 hours after admission for patient #15. Patient #15 was admitted to the hospital on 7/20/2012. The discharge planning process was initiated on 7/24/2012. The patient was discharged on 8/28/2012.

According to facility policy #2020.00 "care management assessment process", section 1.2 "the care management assessment shall be completed by the case manager or clinical social worker within 48 hours of admission". The medical record for patient #12 and patient #15 failed to contain a care management assessment. The findings were confirmed by staff # C.

Further review of the record for patient #12 and the record for patient #15 under the nursing admission assessment failed to have any documentation under the section of discharge plan or functionality assessment. Staff C confirmed the findings.

Based on record review, policy review and interview, the facility failed to ensure that the discharge plan assessment/evaluation for 2 of 4 patients (#14, 19) contained information in regards to factors that may impact the patient's need for care after discharge. Findings include:

During review of the medical record for patient #14 on 08/28/2012, it revealed the lack of a discharge evaluation/assessment completed within 48 hours (per policy). Due to the lack of the evaluation, there was no documented evaluation by the discharge planner in regards to the patient's ability to complete activity of daily living (ADLs), mobility needs, ect... There was also a lack of information in regards to the patient's insurance coverage for post-hospitalization care.

A review of the medical record for patient #19 on 08/29/2012, revealed a lack of assessment/review in regards to the patient's ability to perform ADLs.

Review of the St. John Macomb-Oakland Hospital, Macomb Center policy 2020.00 Care Management Assessment Process on page 1 it reads in section titled Procedure "In all cases, assessment information is obtained from review of the medical record, consultation with physicians, nursing and ancillary staff, consultation with community resources, and personal/phone contact with the patient and family/significant others. Confidentiality guidelines are followed in all cases. 1. Medical-Surgical Services 1.1 To assess needs of patients on the medical-surgical service, information is obtained relevant to: 1.1.1 Level of self care and prior level of functioning. 1.1.2 Patient's living arrangements, physical environment, orientation, care needs and social situation prior to admission."

On page 1 it also reads reads in 1.2 "The Care Management Assessment shall be completed by the case Manager or Clinical Social Worker within 48 hours of admission."

During an interview with staff G & I on 08/28/2012 at 1530, staff I stated that "the Case Management and Social Work Assessment contains an area to document the insurance information but since it was not completed on the patient (#14) it was not done."

Staff G also stated that, "the form used (Care Management Assessment ) to document the assessment by the discharge planner does not contain an area in regards to the patient's ability to perform ADLs." Staff I then presented a document used by the discharge planners during "computer downtime" and it does contain an area for documentation of the patient's ability to perform ADLs.

Based on record review, interview and policy review, the facility failed to ensure that staff assigned to discharge planning completed an evaluation for 1 of 2 (#14) current in-patients meeting criteria of re-admission to the hospital within 30 days of previous discharge. The universe of records reviewed to complete the patient safety initiative workbook was four (4). Findings include:

During review of the medical record for patient #14 on 08/28/2012 at 1300, it revealed that patient #14 had previously been in the hospital and discharged on 08/08/2012 to an extended care facility (ECF). Patient #14 was then re-admitted to the hospital on 08/22/2012 into the Intensive Care Unit (ICU). Review of the patients record revealed the lack of a documented discharge assessment/evaluation.

A review of the St. John Macomb-Oakland Hospital, Macomb Center policy 2065.00 titled Discharge Planning reads in section II Procedure page 2 under Clinical Social Workers Should Routinely Open These Types of Cases #4. "All ICU patients." The policy goes on to read on page 5 D. Documentation
#2. "Complete Care Management Assessment (located in the electronic record under ad hoc charting. During downtime the goldenrod form #305231V will be used and placed on the paper chart."

A second St. John Macomb-Oakland Hospital, Macomb Center policy 2020.00 on page 1 reads 1.2 "The care Management Assessment shall be completed by the case Manager or Clinical Social Worker within 48 hours of admission."

During an interview with staff G & I on 08/22/2012 at 1500, an inquiry was made as to where the discharge planning documentation could be found on patient #14 in the medical record? Staff G responded by saying "the Care Management Assessment was not completed on the patient."

Based on record review and interview, the facility failed to ensure that the medical record for 1 of 2 (#14) patients that had been readmitted to the hospital within 30 days contained a discharge evaluation and that the results of the evaluation had been discussed with the patient or the patient's family. The universe of records reviewed was four (4) to complete the patient safety initiative workbook. Findings include:

During review of the medical record for patient #14 on 08/28/2012 at 1300, it revealed the lack of a documented discharge evaluation for the patient. The only documentation in the patient's record related to discharge was a documented conversation with the patient's son in law on 08/24/2012 at 12:26 that stated "pt is a long term resident of Henry Ford Roseville and discharge plan is to return when medically stable."

A review of the St. John Macomb-Oakland Hospital, Macomb Center policy 2065.00 titled Discharge Planning reads in section D. Documentation #2. "Complete Care Management Assessment (located in the electronic record under ad hoc charting. During downtime the goldenrod form #305231V will be used and placed on the paper chart." The policy also reads on page 4 B. Goal Setting 1. Care needs are identified and discussed with patient, family, staff and appropriate agencies involved with the patient/situation. 2. "Discharge objectives are identified and discussed with patient, family, agencies and hospital staff."
3. "All discharge plans should include Plan A and Plan B."

A second St. John Macomb-Oakland Hospital, Macomb Center policy 2020.00 on page 1 reads 1.2 "The care Management Assessment shall be completed by the case Manager or Clinical Social Worker within 48 hours of admission."

During an interview with staff G & I on 08/22/2012 at 1500, an inquiry was made as to where the discharge planning documentation could be found on patient #14 in the medical record? Staff G responded by saying "the Care Management Assessment was not completed on the patient."

Based on record review, policy review and interview, the facility failed to ensure that the medical record for 1 of 2 (#14) patients that had been readmitted to the hospital within 30 days contained a discharge evaluation. Findings include:

Patient #14 had been discharged from the hospital on 08/08/2012 and was re-admitted to the hospital on 08/22/2012 into the Intensive Care Unit (ICU). A review of the patients record on 08/28/2012, revealed the lack of a documented discharge assessment/evaluation.

A review of the St. John Macomb-Oakland Hospital, Macomb Center policy 2065.00 titled Discharge Planning reads in section II Procedure page 2 under Clinical Social Workers Should Routinely Open These Types of Cases #4. "All ICU patients." The policy goes on to read on page 5 D. Documentation
#2. "Complete Care Management Assessment (located in the electronic record under ad hoc charting. During downtime the goldenrod form #305231V will be used and placed on the paper chart."

A second St. John Macomb-Oakland Hospital, Macomb Center policy 2020.00 on page 1 reads 1.2 "The care Management Assessment shall be completed by the case Manager or Clinical Social Worker within 48 hours of admission."

During an interview with staff G & I on 08/22/2012 at 1500, an inquiry was made as to where the discharge planning documentation could be found on patient #14 in the medical record? Staff G responded by saying "the Care Management Assessment was not completed on the patient."

Based on record review, interview and policy review, the facility failed to ensure that staff assigned to discharge planning completed an evaluation for 1 of 2 (#14) current in-patients meeting criteria of re-admission to the hospital within 30 days of previous discharge. The universe of records reviewed to complete the patient safety initiative workbook was four (4). Findings include:

During review of the medical record for patient #14 on 08/28/2012 at 1300, it revealed that patient #14 had previously been in the hospital and discharged on 08/08/2012 to an extended care facility (ECF). Patient #14 was then re-admitted to the hospital on 08/22/2012 into the Intensive Care Unit (ICU). Review of the patients record revealed the lack of a documented discharge assessment/evaluation.

A review of the St. John Macomb-Oakland Hospital, Macomb Center policy 2065.00 titled Discharge Planning reads in section II Procedure page 2 under Clinical Social Workers Should Routinely Open These Types of Cases #4. "All ICU patients." The policy goes on to read on page 5 D. Documentation
#2. "Complete Care Management Assessment (located in the electronic record under ad hoc charting. During downtime the goldenrod form #305231V will be used and placed on the paper chart."

A second St. John Macomb-Oakland Hospital, Macomb Center policy 2020.00 on page 1 reads 1.2 "The care Management Assessment shall be completed by the case Manager or Clinical Social Worker within 48 hours of admission."

During an interview with staff G & I on 08/22/2012 at 1500, an inquiry was made as to where the discharge planning documentation could be found on patient #14 in the medical record? Staff G responded by saying "the Care Management Assessment was not completed on the patient."