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Based on record review and interview, the hospital failed to identify early in the hospitalization a patient who was likely to suffer adverse health consequences without adequate discharge planning, in that, 1 of 1 patient (Patient #10) did not receive discharge planning during the early part of her hospitalization that could cause the patient to suffer adverse health consequences.

Findings:

Patient #10 was admitted to the hospital on 7/16/2015. Review of the medical record documents indicated the first date of discharge planning by the Case Management Department to be 8/5/2015. Patient #1 was discharged on 8/7/2015 without any rehabilitative services or referral to outside sources.

The medical record documents on 7/31/2015 Occupational Therapy recommended that the patient needed rehabilitation. On 8/4/2015, Occupational Therapy recommended patient needed inpatient rehabilitation.

An interview with Staff #7 on 1/28/2016 at approximately 1:30 PM, confimed that the patient did not have a note made by the Case Management department until 8/5/2015 during the hospitalization of 7/16/2015 - 8/7/2015.

Based on chart review, policy review and interview, the hospital failed to complete a discharge evaluation in a timely basis, in that, 1 of 1 patient (Patient #10) did not have a discharge evaluation during her hospitalization of 7/16/2015 - 8/7/2015.

Findings:

Review of the medical record of Patient #10 did not document a discharge evaluation. There were notes from physicians that the patient was not safe to return to her home and notes from Occupational Therapy that the patient needed to go to inpatient rehabilitation.

Review of the policy titled Discharge Planning: Reviewed 4/8/2014 stated:
"It is the policy at Medical Center of Arlington that based upon the patient admission assessment, the registered nurse initiates discharge planning on admission, writes an ongoing discharge plan, makes referrals to the case manager/social worker and coordinates discharge planning with the patient, case manager, and family throughout hospitalization. Prior to discharge, any post-discharge continuing nursing care needs are assessed and noted in the medical record. Appropriate referrals are made as needed to facilitate a patient's post-discharge continuing nursing care needs."

An interview with Staff #7 on 1/28/2016 confirmed that there was not a discharge evaluation completed on Patient #10 during her hospitalization. No nursing referrals were made to the case manager/social worker.