HospitalInspections.org

Based on document review and interview, it was determined that for 1 (Pt. #1) of 10 clinical records reviewed for discharge planning, the Hospital failed to document that a reassessment was conducted, related to continuity of care needs.

Findings include:

1. On 12/10/19, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 65 year old male admitted on 4/14/19 with a diagnosis of schizophrenia (psychiatric mood disorder). Pt. #1's clinical record included:

- The "Psychosocial Assessment" dated 4/14/19, included " ...(Pt. #1) endorses return to (NH #2) ...once stable ..."

- The Discharge Plan/Social Service Notes" dated 4/15/19 included "Initial Discharge plan: Admit from (NH #2) ... (Pt. #1) able to return once stable." On 4/17/19 "(Pt. #1) under review at (NH #4)". On 4/18/19 "Pt accepted to (NH #5)." On 4/19/19 at 11:31 AM "Referral sent to (NH #3)." On 4/19/19 at 1:46 PM " ...(employee from NH #3) (indicated that) (Pt. #1) accepted."

However, the clinical record lacked documentation of a reassessment related to the reason for placing Pt. #1 at another nursing home instaed of NH #2.

2. On 12/10/19, the Hospital's policy titled "Discharge Planning Process" (rev 3/2019) was reviewed and included "...D. Reassessment and Evaluation of the Discharge Planning process will occur on a regular basis by the Case Management Department ...5. Feedback obtained from post-hospital providers ..."

3. On 12/12/19, the "Discharge Planner Job Description" (rev 2/2019) was reviewed and included "Essential Functions:...3. Documents activities relating to the discharge plan through the patient's stay."

4. On 12/11/19 at 10:38 AM, the Social Worker (E #2) was interviewed. E #2 stated that for Pt. #1 admission on 4/14/19 the initial plan was for Pt. #1 to return to NH #2. However a couple of days after the admission, E #2 received a call from NH #2 indicating that Pt. #1 could not return to their facility due to his impulsive and aggresive behavior. E #2 stated that she did not document this conversation with NH #2 as part of Pt. #1's clinical chart.

Based on document review and interview, it was determined that for 3 of 9 patients' (Pt. #1, #2 and #3) clinical records reviewed for discharge planning, the Hospital failed to document in the patients' medical record that a list of options for SNF (skilled nursing facility) was presented to the patients or to the individual acting on patients' behalf.

Findings include:

1. On 12/10/19 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed.

- Pt. #1 was admitted on 2/1/19 with a diagnosis of schizoaffective disorder (psychiatric mood disorder). The "Discharge Planning/Social Service Notes" dated 2/4/19 at 4:58 PM included "Per (staff from Nursing Home -NH #1), (Pt. #1) (is) able to return to (NH #1) however new placement is preferred. D/C (discharge) planner will work on sending (Pt. #1) referrals and will follow up.

- Pt. #1 was admitted on 4/14/19 with a diagnosis of schizoaffective disorder (psychiatric mood disorder). The "Discharge Plan/Social Service Notes" dated 4/15/19 included, "Initial Discharge plan: Admit from (NH #2) ... (Pt. #1) able to return once stable." Notes on 4/17/19 included, "(Pt. #1) under review at (NH #4)." Notes on 4/19/19 at 11:31 AM included, "Referral sent to (NH #3)." Notes on 4/19/19 at 1:46 PM included, " ...(employee from NH #3) (indicated that) (Pt. #1) accepted."

For admissions dated 2/1/19 and 4/14/19, Pt. #1's clinical record lacked documentation that a list of Skilled Nursing Facilities (SNF) options available to the Pt. #1 was provided to Pt. #1.

2. On 12/10/19 at approximately 11:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 12/5/19 with a diagnosis of bipolar disorder. Pt. #2's Comprehensive Interdisciplinary Treatment Plan dated 12/5/19 included, "... 5. Discharge Plan: Nursing Home/Intermediate Care Facility (SNF)..." Pt. #2's clinical record also indicated that referrals were sent to three SNF's dated 12/6/19. However, the clinical record lacked documentation that a list of SNFs was presented to Pt. #2 or to the individual acting on Pt. #2's behalf.

3. On 12/11/19 at approximately 10:30 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted on 12/1/19 with a diagnosis of bipolar disorder. The clinical record indicated that Pt. #3 was discharged to a SNF on 12/6/19. However, the clinical record lacked documentation that a list of SNFs was presented to Pt. #3 or to the individual acting on Pt. #3's behalf.

4. On 12/10/19 at approximately 12:00 PM, the Hospital's policy titled, "Nursing Home Placements" (reviewed by the Hospital on 3/19) was reviewed and included, "I. Policy... The Discharge Plan is a vehicle to identify and evaluate patient's needs and problems in an attempt to connect them with available and appropriate community resources needed, including placement in skilled nursing facility or Long-term Acute Facilities... The patient and or advocate will be provided with options of various skilled nursing facilities... This information will be documented in the patient's medical record..."

5. On 12/10/19 at approximately 11:35 AM, an interview was conducted with E #2 (Social Worker). E #2 stated, "We don't document that a list of nursing home facilities for possible placement was provided to patients... We probably should do that..."