HospitalInspections.org

Based on findings from medical record (MR) review, facility document review and interview, the hospital failed to ensure the screening process and criteria used to identify a patient in need of a discharge planning evaluation was followed. This was found in 1 of 6 medical records reviewed (Patient A).

Findings include:

-- The hospital policy and procedure titled "Case Management Model," last revised 3/2014, indicated the following: Case management coordinates care for those most at risk in the emergency department (ED), observation and acute inpatient setting. Case management is consulted when a patient meets defined admission screening criteria performed within 24 hours of arrival or admission. Screening criteria include assessment of the patient's cognitive ability, functional status, type of post hospital care patient needs, availability of needed post hospital services and availability of patient, family or friends to provide support. High risk criteria include (but are not limited to) history of falls and/or impaired mobility, previous use of post hospitalization services. Those patients identified as high risk will be identified through triggers developed via the electronic medical record. Case managers review the MR on admission or transfer from ICU in order to identify patients at high risk for intensive case management and/or post hospitalization resources. Case Manager responsibilities include: performs a discharge planning evaluation on those patients identified as high risk, coordinates all returns to nursing homes, assisted living, adult homes and group homes.

--Per MR review, Patient A, with a history that included frequent falls, was admitted to this hospital on 1/4/15 at 02:04 after being transferred from another hospital (Hospital #1) for consultation with vascular surgery. Patient A was a resident of an assisted living facility prior to admission to Hospital #1. While at St. Joseph's Hospital Health Center, the patient was evaluated and determined not to be a candidate for surgical intervention and decision was made to manage medically. On 1/4/15 at 14:26 Patient A was changed to observation status. On 1/5/15 at 14:30 a discharge order was written. The patient was discharged to the assisted living facility, in which she resided prior to admission to Hospital #1, with orders to follow up with her primary care physician in 7 to 10 days.

Although Patient A met the hospital's criteria and screening process for a discharge planning evaluation, per hospital P&P, a discharge planning evaluation had not been performed.

--During interview with the Manager of Case Management on 3/3/15 at 13:45, the above findings were acknowledged.
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Based on findings from medical record (MR) review, facility document review and interview, in 1 of 2 MRs reviewed, the discharge instructions (After Visit Summary) were not provided to a patient (Patient B) upon discharge to a skilled nursing facility (SNF).

Findings include:

-- The hospital P&P titled "Discharge of Patient," last revised 10/2014, indicated that prior to discharge, the nurse will have the patient sign the AVS (After Visit Summary) Signature Receipt form and copies of the AVS and AVS Signature Receipt form are provided to the patient at the time of discharge.

-- Per MR review, Patient B was transferred to a SNF on 2/26/15 for rehabilitation. RN #1 documented "Rehab" in the signature area of the form that indicated the patient/responsible party has received the AVS. There is no documentation indicating the patient acknowledged receipt of the AVS or was provided a copy at discharge.

-- During interview with RN #2, he/she indicated that patients being discharged to SNFs do not "always" need to sign the AVS upon discharge since they are going to another facility and the instructions are sent with the MR.

--During interview with the Director of Case Management on 3/3/15 at 3:30 pm, he/she acknowledged the above finding and agreed that discharge instructions (AVS) need to be received and signed by patients at discharge.