HospitalInspections.org

Based on staff interview, review of eleven (11) of eleven (11) medical records, and review of facility policies and procedures, it was determined the facility failed to ensure discharge planning is implemented in accordance with facility policies.

Findings include:

Reference #1: Facility policy titled, "Discharge Planning" states, "... Procedure... The patients are assessed within 24 hours of admission. ... ."

Reference #2: Facility policy titled, "Case Management - Discharge Planning and Documentation" states, "... Procedure... Conduct a Patient/Family interview to obtain the following information... Living Situation... Individual responsible for shopping/cooking... Financial needs... Educational needs... need for continued rehabilitation... ability to perform ADL's (activities of daily living)... Need for Durable Medical Equipment... Family or close friend for contact... ."

1. Review of Medical Record #1 revealed the following:

a. The patient was admitted on 1/26/22. The patient's initial assessment conducted by case management was 1/28/22, more than twenty-four (24) hours after the patient's admission.

b. Patient information that includes the individual responsible for shopping/cooking, financial needs, educational needs, need for continued rehabilitation, ability to perform ADL's, and need for Durable Medical Equipment were not documented in the Case Manager Progress Notes.

2. Review of Medical Record #2 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking, financial needs, and educational needs were not documented in the Case Manager Progress Notes.

3. Review of Medical Record #3 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking and educational needs were not documented in the Case Management Progress Notes.

4. Review of Medical Record #4 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking and educational needs were not documented in the Case Management Progress Notes.

5. Review of Medical Record #5 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking, financial needs, educational needs, ability to perform ADL's, and need for Durable Medical Equipment were not documented in the Case Management Progress Notes.

6. Review of Medical Record #6 revealed the following:

a. The patient was admitted on 3/18/22. The patient's initial assessment conducted by case management was 3/21/22, more than twenty-four (24) hours after the patient's admission.

b. Patient information that includes the individual responsible for shopping/cooking, financial needs, need for continued rehabilitation, and ability to perform ADL's were not documented in the Case Management Progress Notes.

7. Review of Medical Record #7 revealed the following:

a. The patient was admitted on 3/12/22. The patient's initial assessment conducted by case management was 3/15/22, more than twenty-four (24) hours after the patient's admission.

b. Patient information that includes the individual responsible for shopping/cooking, financial needs, ability to perform ADL's, and need for Durable Medical Equipment were not documented in the Case Management Progress Notes.

8. Review of Medical Record #8 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking, financial needs, educational needs, and ability to perform ADL's were not documented in the Case Management Progress Notes.

9. Review of Medical Record #9 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking, financial needs, educational needs, and ability to perform ADL's were not documented in the Case Management Progress Notes.

10. Review of Medical Record #10 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking, financial needs and ability to perform ADL's were not documented in the Case Management Progress Notes.

11. Review of Medical Record #11 revealed the following:

a. Patient information that includes the individual responsible for shopping/cooking, financial needs, educational needs, ability to perform ADL's, need for Durable Medical Equipment and family or close friend for contact were not documented in the Case Management Progress Notes.

12. The above findings were confirmed with Staff #3 on 3/23/22.