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Based on document review and interview, it was determined that, for 1 of 3 (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to ensure the re-evaluation and modification of patient's care prior to discharge.

Findings include:

1. The Hospital's policy titled, "Discharge Planning" dated 01/2015 was reviewed. The policy included, "...As a part of Continuum of Care, discharge planning establishes a safe transition for the patient for the monitoring of short and long term medical needs ...Department Staff participates in the Treatment Team meetings to gather information which may also be used to determine if the patient is appropriate to return to the pre-hospitalization environment ...and if the initial discharge plan is still appropriate ..."

2. On 07/21/2020 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 06/04/2020 with a diagnosis of hypertensive urgency with abnormal EKG (electrocardiogram) [abnormal heart rhythm].

- The social service initial evaluation note by the Discharge Planner (E #10) dated 06/05/2020 at 2:01 PM, included, " ...Pt. [Pt. #1] states that she smokes... marijuana from time to time ...Prior function level - Able to perform activities of everyday life/independent; Tentative Discharge Destination/Additional -Pt. [Pt. #1] is from home. Pt. [Pt. #1] will be going to possibly rehab (Rehabilitation) when discharged ..."

-The discharge summary note by Attending Physician (MD #5) dated 06/07/2020 at 9:14 AM, included, " ...Discharge diagnosis: cerebral infarction (brain lesion and lack of blood supply to brain) ...acute stroke ...Plan: discharge home ...refer to out-patient physical therapy, refer to out-patient drug rehab [rehabilitation] ..."

Pt. #1's clinical record did not include prior to discharge a re-evaluation to ensure that the discharge plan was appropriate.

3. On 7/22/20 at approximately 9:54 AM, the Neurologist (MD #6) was interviewed. MD #6 stated that Pt. #1 required outpatient rehabilitation services at the time of discharge.

4. On 07/22/2020 at approximately 10:20 AM, the Discharge Planner (E #10) was interviewed. E #10 stated, "I document once every four days. I only did my initial evaluation on this patient (Pt. #1). She (Pt. #1) was discharged the third day. I do not have any notes prior to her discharge."

5. On 07/22/2020 at approximately 1:30 PM, the Senior Vice-President of Quality and Compliance (E #11) was interviewed. E #11 stated, "...the Treatment Team including the Attending Physician, the Registered Nurse, and the Discharge Planner should have discussed during the rounds and looked into patient (Pt. #1) condition prior to discharge."

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) patients' clinical records reviewed for discharge planning, the Hospital failed to ensure discharge planning evaluation was discussed with the patient or patient's representative.

Findings include:

1. On 07/21/2020 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 06/04/2020 with a diagnosis of hypertensive urgency with abnormal EKG (electrocardiogram). The clinical record indicated that Pt. #2's discharge evaluation and needs required a referral to an out-patient physical therapy and outpatient drug rehabilitation therapy. However, the clinical record lacked documentation that the discharge planning evaluation and needs were discussed with patient or patient's representative.

2. On 7/22/2020 at approximately 12:00 PM, the Hospital's policy titled, "Discharge Planning" (effective 3/2001) was reviewed and included, "... II.A. Discharge planning is the process to prepare a patient in a hospital or an individual person in an institution for return or re-entry into the community... The process of discharge planning involves the patient and/or family... IV. Procedures... C...14. Department staff facilitates family meetings with the medical staff and treatment team to maximize family's understanding of the patient's condition and discharge services..."

3. On 7/22/2020 at approximately 12:30 PM, the Hospital's job description titled, "Discharge Planner" (effective 4/2014) was reviewed and included, "... Essential Responsibilities... 2. Assist and educates patients and families through individual group conferences to help develop their plan of care and discharge plan... 6. Documents social work and discharge planning activities in patient's chart..."

4. On 7/22/2020 at approximately 10:15 AM, an interview was conducted with E #10 (Discharge Planner). E #10 stated that the discharge planning evaluation and needs was conducted for Pt. #1; however, E #10 could not provide documentation that the evaluation of Pt. #1's needs were discussed with Pt. #1 or Pt. #1's representative.

5. On 07/22/2020 at approximately 1:30 PM, the Senior Vice-President of Quality and Compliance (E #11) was interviewed. E #11 stated, "They initiated and identified the patient needs and did not follow-through the process. The treatment team including the attending physician, the registered nurse and the discharge planner should have discussed during rounds and looked into the patient condition prior to discharge."

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed, the Hospital failed to ensure the implementation of post-discharge follow-up care and referral as required.

Findings include:

1. The Hospital's policy titled, "Medication Reconciliation" dated 07/2018 was reviewed. The policy included, " ...medication reconciliation will occur at admission, transfer and discharge ...A complete history of all the patients' medications will be obtained, documented and/or updated ...C. Discharge Reconciliation: ...the physician will clarify his/her written discharge order ...for medications the patient will continue to take after discharge ...the discharge nurse should use the medication administration record, medication reconciliation form and any discharge prescription written by the physician will generate an accurate list of medication for discharge instructions ...the discharge nurse must clarify this list with the discharging physician prior to discharge ..."

2. The Hospital's document titled, "Job Description of Staff Nurse - Acute Care Unit" dated 06/2012, was reviewed. The document included, " ...9. Provides education to patient and family regarding medical condition, medications and discharge instructions ..."

3. The Hospital's document titled, "Job Description of Discharge Planner" dated 04/2014, was reviewed. The document included, "...utilizes community resources to assist patients in achieving optimum level of functioning ...upon discharge ...Documents social work and discharge planning activities in patient's chart, and discusses the outcome of these activities with all relevant parties..."

4. On 07/21/2020 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the ER (Emergency Room) by CFD (Chicago Fire Department) on 06/04/2020 at 1:01 PM with a chief complaint of shortness of breath. Pt. #1 was admitted to the Hospital on 06/04/2020 at 1:20 PM, with a diagnosis of hypertensive urgency and abnormal EKG. Pt. #1 was discharged home on 06/07/2020 at 4:39 PM.

- The physical therapy note dated 06/05/2020 at 1:17 PM, included, " ...as a result of my evaluation, ... [Pt. #1] does require PT [physical therapy], she is at high risk for fall, ...decreased standing balance, unsteadiness of gait ...discharge to rehab [rehabilitation] ..."

- The social service initial evaluation note by the Discharge Planner (E #10) dated 06/05/2020 at 2:01 PM, included, " ...Pt. [Pt. #1] states that she smokes ...and marijuana from time to time ...Prior function level - Able to perform activities of everyday life/independent; Tentative Discharge Destination/Additional -Pt. [Pt. #1] is from home. Pt. [Pt. #1] will be going to possibly rehab (Rehabilitation) when discharged ..."

- The discharge order by Attending Physician (MD #5) dated 06/07/2020 at 9:18 AM, included, "Discharge Home ..."

5. On 07/21/2020 at approximately 1:40 PM, the ACU - RN (E #3) was interviewed. E #3 stated, "I do not recall providing the patient with prescription for Home Health Care and Out-Patient Physical Therapy. I did not complete the medication reconciliation form."

6. On 07/22/2020 at approximately 10:20 AM, the Discharge Planner (E #10) was interviewed. E #10 stated, "I document every four days. She (Pt. #1) was discharged the third day. The doctor will order the out-patient physical therapy and the nurse will set it up. I do not have any notes related to setting up home health care or rehabilitation services for this patient (Pt. #1)."

7. On 07/22/2020 at approximately 1:30 PM, the Senior Vice-President of Quality and Compliance (E #11) was interviewed. E #11 stated, "They initiated and identified the patient needs and did not follow-through the process. The treatment team including the attending physician, the registered nurse and the discharge planner should have discussed during rounds and looked into the patient condition prior to discharge." Upon asking who specifically should have followed the physician's discharge plan, E #11 responded, "The ACU RN (E #3) that discharged the patient (Pt. #1)."