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Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital did not have a method to identify patients who may require discharge planning. Findings:

On 09/07/12, hospital discharge planning policies and procedures were reviewed. The policies did not stipulate a process for identifying patients with a need for discharge planning.

Clinical records for five patients were reviewed for evidence of screening for discharge planning. No documentation was found.

Interviews with staff A and B indicated the hospital had no screening tool or initial evaluation process for early discharge planning. The staff could not describe how patients were screened or evaluated for discharge planning needs.

They stated there was no formal process for staff to notify staff B of a change in a patient's status that may affect discharge planning.

Based on clinical record review, policy and procedure review and staff and patient interview, it was determined the hospital failed to provide a discharge planning evaluation. Findings:

On 09/07/12, hospital discharge planning policies and procedures were reviewed. The policies and procedures did not include a discharge evaluation process.

There was no documentation in the discharge planning policies of notice to the physician, patients, or persons acting on their behalf that they may request a discharge planning evaluation.

Five patient clinical records were reviewed. None had documentation of a formal, structured discharge planning evaluation.

A patient admission packet was reviewed for evidence of notification of the availability of a discharge planning evaluation. There was no documentation of notice to patients or person's acting on their behalf of this service.

Staff A and B stated there was no formal process to evaluate patients for discharge planning needs and no notification of patients and others of a discharge planning evaluation.

Patient #1 stated she did not know what a discharge plan was, and was not aware she could request one.

Based on policy and procedure review and staff interview, the hospital failed to determined what personnel were qualified to develop or supervise the development of a discharge plan evaluations.

Findings:

On 09/07/12, the hospital discharge planning policies were reviewed. The plan did not designate who was qualified to perform or to supervise the development of discharge planning evaluations.

The policy did not designate who had overall discharge planning responsibilities.

Staff B, a registered nurse, stated he was responsible for in-patient discharge planning. He stated there was no real job description for this.

Based on record review and staff interview, it was determined that the hospital failed to ensure a discharge planning evaluation was completed on a timely basis. Findings:

On 09/07/12, hospital discharge policies were reviewed. The policies did not designate a time frame for discharge planning evaluations.

Staff B was asked if there had been any delays in discharges because of problems with discharge planning. He stated there had been. He stated sometimes there was not enough time to finalize arrangements when the discharge plan is made the night before a planned discharge.

He was asked if delays were documented in the medical record. He stated they were not.

Based on record review and staff interview, it was determined the hospital failed to ensure the patient and/or representative was made aware of the discharge planning evaluation. Findings:

On 09/07/12, the hospital discharge planning policy and procedure was reviewed. There was no documentation the hospital discussed the discharge evaluation with the patient or the representative.

He was asked if the hospital's assessment of the patient's discharge needs were discussed with the patient and/or representative.

Staff B stated patients were made aware of discharge plans. He was asked if this was documented in the medical record. He stated it was not.

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure a discharge planning evaluation was documented in the medical record. Findings:

On 09/07/12, hospital discharge planning policies and procedures were reviewed. The policy described what criteria would be evaluated to develop a discharge plan. There was no documentation all the criteria were evaluated. There was no documentation of a determination, based on the evaluation, of the need, or lack of a need for discharge planning.

Staff B was asked where the information could be found to develop a discharge plan. He stated it could be found throughout the medical record. He was asked if a discharge plan was written based on information obtained in the medical record. He stated there was no written discharge plan.

Five clinical records were reviewed for the criteria to be evaluated according to the discharge planning policy and procedure. Some of the criteria could be found in the in-patient admission assessment. However, many of the criteria applied only to status at the time of admission and for the purpose of immediate care planning needs.

Some of the criteria assessed required only a "yes" or "no" answer and did not give details that could be used for actual discharge planning. For example, the admission assessment asked, "... Cultural / Spiritual Assessment... special diet needs related to [cultural/spiritual needs]... special beliefs about health... special spiritual / religious beliefs... yes or no..."

There was no documentation of a method to take admission status information and reassess it and evaluate discharge planning needs.

The following criteria (as determined in the discharge planning policy and procedure) was not found in the clinical record and therefore could not be evaluated for discharge planning:

~ tasks the patient can/cannot accomplish as a result of their current health problems

~ age-related issues

~ language or language barriers

~ physical limitations

~ desire or motivation to learn

~ financial resources to assist with discharge needs

~ support systems to assist patient/family/other care giver

~ level of post-hospital care needs (e.g. acute, long term)

~ nature and complexity of post-hospital care needs (e.g. safety,infection control)

~ impact of illness on lifestyle, family and necessary interventions

~ available and accessibility of adequate housing

~ access to transportation.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to develop a discharge plan. Findings:

On 09/07/12, clinical records were reviewed for five patients. None had documentation of a discharge evaluation and the development of an appropriate discharge plan.

Hospital discharge planning policies and procedures documented delegation of certain discharge tasks and responsibilities, but there was no designation of a qualified person who oversaw, developed and coordinated a discharge plan.

Staff B stated he was involved in discharge planning. He stated he was primarily responsible for implementing doctor's discharge orders. He stated he facilitated these orders, but a written discharge evaluation and plan was not done that documented what was to be carried out.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure physicians could request discharge plans for their patients. Findings:

On 09/07/12, hospital discharge planning policies and procedures were reviewed. There was no documentation of a process to notify physicians of hospital discharge planning services and no documentation of procedures to accomplish discharge planning if requested by a physician.

Staff B stated he was not aware of this requirement.

Five clinical records were reviewed for discharge plans. No discharge plans were found.

Based on record review and staff interview, it was determined the hospital failed to ensure necessary medical information was provided to healthcare entities that were to provide post-hospital care. Findings:

Clinical records were reviewed for five patients. All had referrals to HHAs or other healthcare entities, such as rehabilitation centers. There was no documentation of medical information provided to these entities.

Staff A was asked to provide a policy that outlined what medical information should be provided to other agencies providing care after hospitalization. No policy was found.

She was asked if she could determine by looking at the medical record, what information had been given to the agency to continue care for the patients. She stated she could not.

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to develop and reassess discharge plans. Findings:

On 09/07/12, hospital discharge planning polices were reviewed. There was no documentation of a process to guide the development of a discharge plan and for on-going reassessment of the plan for possible needed changes prior to discharge.

Five clinical records were reviewed for discharge plans. No discharge plans were found.

Staff B stated he was not aware a formal discharge plan was needed. He stated there was no formal process to reassess a patient's discharge planning needs.

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to provide a list of home health agencies that serve the patients' geographical areas and that participate in Medicare and/or managed care programs.

Findings:

On 09/07/12, hospital discharge policies were reviewed. The following items were not found in the policy:

~ there was no policy to provide a list of appropriate agencies within the patient's area to patients

~ the notification of the patient his/her freedom to choose the agency of choice

~ any financial interests that must be disclosed by law.

Clinical records for five patients were reviewed for evidence of referral to HHAs or SNFs. Patient #1 was to be discharged with continuing care to be provided by a home health agency. There was no documentation of a list of agencies for the patient's choice.

Staff B was asked if the hospital provided lists of agencies to patients. He stated the hospital was developing this process.

Based on record review and staff interview, it was determined the hospital failed to ensure necessary medical information was provided to healthcare entities that were to provide post-hospital care. Findings:

Clinical records were reviewed for five patients. All had referrals to HHAs or other healthcare entities, such as rehabilitation centers. There was no documentation of medical information provided to these entities.

Staff A was asked to provide a policy that outlined what medical information should be provided to other agencies providing care after hospitalization. No policy was found.

She was asked if she could determine by looking at the medical record, what information had been given to the agency to continue care for the patients. She stated she could not.

Based on review of medical records, hospital policies, meeting minutes and interviews with staff the facility failed to implement a process which evaluated the discharge planning process to ensure discharge planning met the needs of the patient.

Findings:

1. On 9/7/2012 Surveyors reviewed the policy "discharge planning-general nursing, A. Criteria Actual and potential discharge planning needs of the patient/family will be assessed on the basis of the following criteria: 1. The level of understanding by the patient/family of the medical condition and there reason for the procedure or hospitalization; 2. The patient voices his/her expectations; 3. Tasks the patient can/cannot accomplish as a result of their current health problems; 4. Expresses socio-cultural and religious practices and beliefs; 5. Age related issues; 6. Language or language barriers; 7. Physical limitations; 8. Desire and motivation of the patient to learn; 9. Emotional and mental status; 10. Financial resources available to assist with discharge needs; 11. Support systems available to assist patient/family/other care giver; 12. Level of post-hospital care needs. (e.g. acute, long term); 13. Nature and complexity of post hospital care needs. (e.g.patient safety, infection control); 14. Impact of patient illness on lifestyle family and necessary interventions; 15. Available and accessibility of adequate housing; 16. Access to transportation; 17. Readiness of family to asisst with care needs of patient at home; 18. Need for special equipment, supplies and medication; 19. Need for monitoring agent. " The policy does not indicate where the information is to be documented or how the nurse should act on assessment findings. Inpatient chart documents provided to surveyors included some of the "criteria"in the initial nursing assessment. Not all of the "criteria" listed in the policy was found in the chart packet. There is no directive to assess the "criteria" elements throughout the stay or direction to document findings or actions taken to meet changes in the discharge assessment and plan.

Further in the policy; B. Discharge Planning Overview, 2. Nurse: There is no direction for the nurse to reassess the patient to determine if needs have changed or how frequently the nurse should reevaluate the discharge plan for changes in patient needs. There is no documentation indicating who the nurse is to notify of changes in the discharge plan.

Pt. #5 was admitted to the facility for an elective orthopedic surgery. At the time of the initial assessment on admission the patient's "functional assessment" stipulated the patient did not have any problems with limb functionality. The patient underwent orthopedic surgery which impacted the patient's functional abilities. The change in the patient condition was not documented as part of a reassessment of the discharge planning process.
The documentation on history and physical indicated the patient had a history of diabetes, hypertension, and esophageal reflux disease. There was no documentation in the discharge planning process indicating the patient understood these medical conditions and how the conditions could impact the recovery process. During the inpatient stay the patient's blood sugars required sliding scale insulin coverage. The patient was readmitted two weeks later with a surgical site infection. There was no documentation the facility reviewed the discharge planning process for problems or effectiveness

Pt#4 was admitted to the facility for an elective knee replacement. At the time of the initial assessment on admission the patient's "functional assessment" documented by nursing indicated the patient did not have any problems with mobility. The patient underwent orthopedic surgery which impacted the patient's functional abilities. There was no documentation indicating there had been changes in the functional assessment. The change in the patient condition was not documented as part of a reassessment of the discharge planning process. There was no documentation the facility reviewed the discharge planning process for problems or effectiveness

Pt#2 was admitted to the facility with traumatic injuries to both hands which necessitated outpatient surgery to both extremities. There was no evaluation of the patient's functional status(amputation of fingers on both hands, pinning of open fractures both hands) and the patient's ability for self care. The patient was readmitted within 7 weeks with osteomyelitis to bilateral pinning sites. There was no documentation the facility reviewed the discharge planning process for problems or effectiveness.

2. On 9/7/2012 Staff C told surveyors the Quality Assurance Meeting Minutes included readmission information and discharge planning information. There was no information int he meeting minutes provided to surveyors which indicated the facility reviewed patient records for discharge planning problems and effectiveness. There was no information the facility reviewed readmitted patient records to reduce the number of readmissions related to discharge planning problems.

3. On 9/7 /2012 surveyors reviewed a policy "Discharge Planning-Rehabilitation Services". There is no stipulation where the ongoing reassessment of patient's discharge needs will be assessed. The policy stipulates "upon discharge, a summary of the patient's rehabilitation process is documented which includes changes in the patient performance status and goal achievement". There is no stipulation as to where staff document changes impacting readiness for discharge, who needs to be notified, and how the changes in need will be met.

4. There is no documentation in hospital meeting minutes or quality plans indicating the hospital will analyze the discharge planning process to determine effectiveness. There is no formalized process indicating patients discharged to the care of home health providers, rehabilitation units, or other facilities were provided care according to the needs of the patient and the discharge orders of the physician. There was no documentation in the patient record pertinent medical information/records was provided to the caregivers at the next level. There was no documentation in the record of report called to facilities/providers.

5. These findings were provided at the exit conference. No further documentation was provided.

Based on policy and procedure review and staff interview, the hospital failed to determined what personnel were qualified to develop or supervise the development of a discharge plan evaluations.

Findings:

On 09/07/12, the hospital discharge planning policies were reviewed. The plan did not designate who was qualified to perform or to supervise the development of discharge planning evaluations.

The policy did not designate who had overall discharge planning responsibilities.

Staff B, a registered nurse, stated he was responsible for in-patient discharge planning. He stated there was no real job description for this.