HospitalInspections.org

Based on interview and record review, the facility failed to assure that 1 of 13 patients reviewed was identified early in the admission, of possible health consequences when discharged without proper discharge planning.

Findings include:

1) On 9/21/12 at approximately 11:10 am, an interview was conducted with the Registered Nurse Discharge Planner (B) assigned to Patient #6. She was asked if she could verify that she had done an initial assessment on the patient to identify any possible needs upon discharge. She stated, "no, and I don't have any excuse. I just dropped the ball and don't know why. I am not trying to excuse it, because there is no excuse, but that is not the usual area that I see patients. But I am not going to lie to you, I, for some reason, just didn't do anything and I didn't follow up or send anything to his home health agency either" She was asked if there was any review of his chart to assist with his discharge needs and she stated, "no, I didn't even look through his chart. I don't know what to say".

2) On 9/21/12, Review of the Discharge Planning note revealed that no discharge planning was done for 1 of 13 patients reviewed (Patient #6). Review of the discharge order from the physician also showed that the physician wrote orders for home health, but no follow up orders were written by the physician for wound care for the home health agency, and the RN Discharge Planner (B) failed to assure that the orders were obtained and forwarded to the home health agency.

Based on interview and record review, the facility failed to assure that 1 of 13 patients reviewed was provided a discharge planning evaluation and assessment of needs upon discharge from the hospital.

Findings include:

1) On 9/21/12 at approximately 11:10 am, an interview was conducted with the Registered Nurse Discharge Planner (B) assigned to Patient #6. She was asked if she could verify that she had done an initial assessment on the patient to identify any possible needs upon discharge. She stated, "no, and I don't have any excuse. I just dropped the ball and don't know why. I am not trying to excuse it, because there is no excuse, but that is not the usual area that I see patients. But I am not going to lie to you, I, for some reason, just didn't do anything and I didn't follow up or send anything to his home health agency either" She was asked if there was any review of his chart to assist with his discharge needs and she stated, "no, I didn't even look through his chart. I don't know what to say".

2) On 9/21/12, Review of the Discharge Planning note revealed that no discharge planning was done for 1 of 13 patients reviewed (Patient #6). Review of the discharge order from the physician also showed that the physician wrote orders for home health, but no follow up orders were written by the physician for wound care for the home health agency, and the RN Discharge Planner (B) failed to assure that the orders were obtained and forwarded to the home health agency.

Based on interview and record review, the facility failed to assure that 1 of 13 patients reviewed was reassessed immediately prior to discharge from the hospital.
Findings include:

1) On 9/21/12 at approximately 11:10 am, an interview was conducted with the Registered Nurse Discharge Planner (B) assigned to Patient #6. She was asked if she could verify that she had done an initial assessment on the patient to identify any possible needs upon discharge. She was asked if she returned immediately prior to discharge, as indicated in the Policy and Procedures for discharge planning, and she stated, "no, I didn't follow up. I didn't go back in".She was asked if there was any review of his chart to assist with his discharge needs and she stated, "no, I didn't even look through his chart. I don't know what to say".

2) On 9/21/12, Review of the Discharge Planning note revealed that no reassessment for discharge planning was done for 1 of 13 patients reviewed (Patient #6). Discharge Planning notes revealed no return visit to the patient immediately prior to discharge. Review of the discharge order from the physician also showed that the physician wrote orders for home health, but no follow up orders were written by the physician for wound care for the home health agency, and the RN Discharge Planner (B) failed to assure that the orders were obtained and forwarded to the home health agency.