HospitalInspections.org

A. Based on a review of the Rules and Regulations of the Medical Staff, clinical record review, and staff interview, it was determined that for 3 of 5 (Pt. #s 1, 8, and 9) clinical records for patients with positive and potential injuries, the physicians failed to ensure documentation of patient examinations and assessments.

Findings include:

1. The Rules and Regulations of the Medical Staff, approved 12/11/2009 were reviewed on 4/14/10 at approximately 3:00 P.M. The Rules and Regulations required, "There shall be members of the medical staff on call at all times... a member of the Medical Staff of like training... may be called to attend to... patient in an emergency...

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The clinical record included a nursing note dated 3/1/10 at 8:00 A.M. that Pt. #1 was found sitting on the floor with a bleeding wound on the top of his head, and a succeeding note at 8:30 A.M. that the on call resident physician was notified by the Supervisor. The next documented physician's note was a discharge note dated 3/1/10 at 12:00 P.M. which included that the patient tried to jump off the bed and had a head injury. The documentation also indicated that Pt. #1 had a right parietal abrasion, and that the patient was to be discharged to the nursing home that same day. The record lacked documentation of a physician's post fall and head injury examination.

3. In an interview with the E#6 (1st year resident physician) on 4/14/10 at approximately 11:45 A.M., E#6 (author of the above noted discharge note) stated that he was not there to examine Pt. #1 post-fall, but was there to examine the patient for discharge. E#6 stated that another, 1st year resident, E#8 examined Pt. #1 earlier on 3/1/10 after the fall, and reported verbally to him.

4. In an interview with E#8 (1st year resident physician) on 4/14/10 at approximately 12:30 P.M., the resident stated that she examined Pt. #1 post fall, between 8:00 and 9:00 A.M., but did not document the examination findings because she was too busy with other patients.

5. The above findings were confirmed with the Senior Vice President of Pt. Care on 4/12/10 at approximately 3:00 P.M., and the Associated Vice President of Quality & Compliance on 4/14/10 at approximately 12:30 P.M.


6. The clinical record for Pt. #8 was reviewed on 4/13/10 at approximately 10:30 AM. Pt. #8, a 34 year old male, was admitted to 4 East psychiatric unit on 2/5/10 with a diagnosis of Bipolar Disorder and placed on suicide precautions with every 15 minute safety checks. On 2/6/10 at approximately 10:30 PM, Pt. #8 had a physical altercation with Pt. #9. The nurse documented that a physician came to the unit to examine Pt. #8. The clinical record lacked a progress note by the examining physician.

7. On 4/13/10 at approximately 11:00 AM, the clinical record for Pt. #9 was reviewed. Pt. #9, a 38 year old male, was admitted to 4 East psychiatric unit on 2/4/10 with a diagnosis of Psychosis. Pt. #9 was placed on suicide precautions with every fifteen minute safety checks. On 2/6/10 at 11:50PM, Pt. #9 had a physical altercation with Pt. #8. The nurse documented that the physician on call was notified and examined Pt. #9. The clinical record lacked a physician progress note of the examination.

8. The above findings were confirmed by the Senior Vice President of Patient Care during an interview on 4/13/10 at approximately 11:30 AM
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A. Based on a review of Hospital policy, clinical record review and staff interview, it was determined that for 1 of 10 (Pt. #1) records reviewed the Hospital failed to ensure adherence to policy for the release of Medical information.

Findings include:

1. The Hospital policy titled "Guidelines for Release of Medical Information Internal and External Purposes" was reviewed on 4/13/10 at 1:00 PM. The policy required, "all correspondence is logged upon receipt, in the correspondence log...the information logged would be the patients name, hospital number, the requesters name, the date of receipt of inquiry, the material sent and the date mailed. ...he original request and consent to release information is filed in the patient's chart. It shall contain the date, the information release, and the signature of the person releasing the information...."

2. The Clinical record of Pt. #1 was reviewed, on 4/12/10 at 11:30 AM. Pt. #1 was a 70 year old male admitted on 2/22/10 with diagnosis of Change of Mental Status, Senile Dementia, Uncontrolled Diabetes Mellitus and Chronic Respiratory Failure. The clinical record contained 2 release of information documents signed by the Power of Attorney (POA), for the police and the POA, however the log lacked any documentation of the records being released.

3. The Medical Records Director was interviewed on 4/13/10 at 11:00 AM. The Director indicated that Pt. #1's POA made a request for Pt. #1's record, however, changed her mind when informed of the cost for copying the record. The record included documentation of a signed release of information consent dated 3/11/10 for the Police Department, and the request was fulfilled and documented in a computerized log. The log of released information was requested. The Director returned at 11:50 AM and stated that the computerized log did not contain documentation of Pt. #1's released record.

4. The above findings were conveyed to the Associate Vice President of Quality and Compliance during interview on 4/13/10 at 12:00 AM

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined for 1 of 2 (Pt. #1) clinical records reviewed for patients who sustained falls, the Hospital failed to ensure an "Unusual Incident Report" form was completed.

Findings include:

1. Hospital policy #RM 010 entitled, "Patient/Visitor Incident Reporting," was reviewed on 4/13/10 at approximately 1:15 P.M. The policy requires, "Every incident report shall be filled out completely, with all circumstances that apply... This report will be forwarded to the Risk Management office..."

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The Nursing Admission Assessment, dated 2/22/10 included a Falls Assessment Score of 10 (> or = 10 place patient on Falls Precaution). The clinical record further included documentation that Pt. #1 sustained a fall on 2/26/10 (night shift) without injury and on 3/1/10 (day shift) with injury (bleeding wound on the top of the head).

3. The Hospital's "Unusual Incident Reports" for October 2009-March 2010 were reviewed on 4/12/10 at approximately 11:00 A.M. An Unusual Incident Report for Pt. #1's fall on 3/1/10 was not included.

4. The above findings were confirmed with the Senior Vice President of Pt. Care on 4/12/10 at approximately 3:00 P.M.


B. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 2 of 2 (Pt. #1 and #2) clinical records reviewed for patients who sustained falls, the Hospital failed to ensure Fall Analysis Reports were completed.

Findings include:

1. Hospital policy # F-1 entitled, "Fall Prevention," was reviewed on 4/12/10 at approximately 1:00 P.M. The policy requires, "If the patient falls, fill out "Fall Analysis Report Form."

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The record included an "Assessment for Patients at High Risk for Fall" (undated), which indicated two risks checked under Category I namely, "mental status changes and debilitated or weak"; and one risk checked under Category II, "Advanced age (65 and above)". The Nursing Admission Assessment, dated 2/22/10 included a Falls Assessment Score of 10 (> or = 10 place patient on Falls Precaution). The clinical record further included documentation that Pt. #1 sustained a fall on 2/26/10 (night shift) without injury and on 3/1/10 (day shift) with injury (bleeding wound on the top of the head).

3. In an interview with the Senior Vice President of Pt. Care (SVPPC) and the 3 East Clinical Director, on 4/12/10 at approximately 1:15 P.M., the SVPPC indicated that the Fall Analysis Report Forms should have been completed, but would not be a part of the patient's clinical record. The 3 East Clinical Director stated that the Falls Analysis Report Forms were not completed for falls sustained by Pt. #1 on 2/26/10 and 3/1/10.


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4. The clinical record of Pt. #2 was reviewed on 4/12/10 at 11:30 AM. Pt. #2 was a 39 year old female admitted on 2/7/10 with the diagnosis of Schizoaffective Disorder. The clinical record included a nurses note dated 2/10/10 that Pt. #2 slipped and fell on wet floor when she got out of the shower.

5. The Incident Report dated 2/10/10 was reviewed on 4/12/10 at 1:30 PM. The report indicated that Pt. #2 fell while in the bathroom with no injury. The 4 South Clinical Director stated the Falls Analysis Report Form was not completed for the fall that occurred on 2/10/10 with Pt. #2.

6. The above findings were confirmed with the Senior Vice President of Pt. Care on 4/12/10 at approximately 3:00 P.M.

A. Based on a review of Hospital policy, Hospital stated practice, clinical record review, and staff interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for patients on 3 East, the Hospital failed to develop and implement an effective seizure policy, and failed to adhere to Hospital stated practice governing monitoring of patients on seizure precautions.

Findings include:

1. Hospital policy # TX 121 entitled, "Seizure Precautions," was reviewed on 4/12/10 at approximately 1:50 P.M. The policy requires, "Patients with a history of seizures are placed on "Seizure Precaution" (SZP), to insure [sic] their physical safety and well being." The policy failed to define what actions are required for a patient who is placed on seizure precautions, including the frequency of monitoring.

2. Hospital stated practice, per the Senior Vice President of Pt. Care is that the clinical record should include documentation of the Observation Records (checks every 15 minutes) for patients on seizure precautions.

3. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The Discharge Summary included that Pt. #1 had a history of Seizure Disorder. The record included a physician's order dated 2/22/10 for seizure precautions as well as Phenytoin (anti-seizure medication) 100 mg twice daily. The observation record lacked seizure precautions checks every 15 minutes for the following dates:

* 2/24/10 from 3:15 P.M.- 11:45 P.M.
* 2/25/10 from 12:00 A.M.- 7:00 P.M.
* 2/26/10 no documentation
* 2/27/10 no documentation
* 2/28/10 no documentation
* 3/01/10 no documentation

4. The above findings were confirmed with the Senior Vice President of Pt. Care on 4/12/10 at approximately 3:00 P.M.


B. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for patients on 3 East, the Hospital failed to develop and implement an effective fall prevention policy and required safety interventions.

Findings include:

1. Hospital policy # F-1 entitled, "Fall Prevention," was reviewed on 4/12/10 at approximately 1:00 P.M. The policy requires, "Each patient will be assessed upon admission for risk to fall using the "Assessment for Risks to Falls" tool... Patients who are identified to be at risk for falls will be placed on falls protocol... The nurse assigned a patient on falls precautions is responsible for monitoring the patient at least every 4 hours until the patient's need for safety precautions has ended... The RN or LPN assigned to a patient on falls precautions is responsible to assure that all fall precautions are documented clearly each shift." The policy failed to defined what the "protocol" entails, or what safety interventions are required.

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The record included an "Assessment for Patients at High Risk for Fall" form (undated), and two risks were checked under Category I: "mental status changes and debilitated or weak"; and one risk was checked under Category II: "Advanced age (65 and above)". The Nursing Admission Assessment, dated 2/22/10 included a Falls Assessment Score of 10 (> or = 10, place patient on Falls Precaution). The record lacked documentation of fall precautions each shift on the following dates:

* 2/22/10 (evening and night shift)
* 2/23/10 (day shift)
* 2/25/10 (evening and night shift)
* 2/26/10 (night shift)
* 2/27/10 (day shift)
* 2/28/10 (day and evening shift)
* 3/1/10 (day shift)
The clinical record included documentation that Pt. #1 sustained a fall on 2/26/10 (night shift) and on 3/1/10 (day shift) with injury (bleeding wound on the top of the head).

3. The above findings were confirmed with the Senior Vice President of Pt. Care on 4/12/10 at approximately 3:00 P.M.


C. Based on Hospital stated practice, a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 2 (Pt. #1) clinical records for patients who sustained head injuries, the Hospital failed to ensure neurological checks were done.

Findings include:

1. Per the Senior Vice President of Pt. Care, who was interviewed on 4/12/10 at approximately 3:00 P.M., Hospital stated practice, is that the nurse will perform neurological checks for any patient that sustained a head injury.

2. Hospital policy #N-2 entitled, "Neurological Vital Signs," was reviewed on 4/12/10 at approximately 2:00 P.M. The policy requires "To evaluate a patient's neurological status... Check pupils for size and briskness of reaction... check blood pressure... check pulse... test strength of extremities... evaluate level of consciousness and orientation... evaluate speech." However, the Hospital's policy failed to require neurological vital signs for patients with head injury.

3. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The Nursing Admission Assessment, dated 2/22/10 included a Falls Assessment Score of 10 (> or = 10 place patient on Falls Precaution). The clinical record included a nursing note dated 3/1/10 at 8:00 A.M. that Pt. #1 was found sitting on the floor with a bleeding wound on the top of his head. The record lacked documentation that neurological vital signs were performed in accordance with the Hospital policy.

4. The above findings were confirmed with the Senior Vice President of Pt. Care on 4/12/10 at approximately 3:00 P.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 10 (Pt. #1) clinical records reviewed the Hospital failed to ensure the nursing admission assessment was completed.

Findings include:

1. Hospital policy #A - 3.1 entitled, "Clinical Care Station Patient Admission Assessment and Reassessment," was reviewed on 4/13/10 at approximately 3:00 P.M. The policy requires "An RN must complete and sign the Admission Assessment..."

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The "Nursing Admission Assessment Notes", dated 2/22/10 required "Section C... Systems Assessment (To Be Completed By RNs Only)". This section also required assessment of the patient's skin. The Systems Assessment was incomplete for Pt. #1.

3. The above finding was confirmed with the Senior Vice President of Pt. Care on 4/12/10 at approximately 3:00 P.M.

A. Based on review of Hospital policy, review of clinical records and staff interview, it was determined that the Hospital failed to adhere to Hospital policy for completion of clinical records.

Findings include:

1. The Hospital policy titled, "Chart Analysis" was reviewed on 4/14/10 at approximately 11:00 AM. The policy included "All medical records will be analyzed within 5 days of the discharge date... Check to ensure each item is present in the chart."

2. The complete clinical record for Pt. #1 was requested on 4/12/10 at 8:50 AM and presented at 11:00 AM. Pt. #1's record was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted on 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The front cover of the clinical record was stamped "COMPLETED", however, the record lacked laboratory results ordered on 2/27/10, and the assessment and discharge plan form.

3. The Director of Medical Records was interviewed on 4/14/10 at 1:15 PM. The Director stated that when a record is completed it is stamped with the word "Completed" in red ink. The above findings were confirmed with Associate Vice President of Quality & Compliance during an interview on 4/14/10 at 2:00 PM.

A. Based on review of Hospital policy, a review of Rules and Regulations of the Medical Staff, clinical record review, and staff interview, it was determined that the Hospital failed to maintain a discharge planning process that applies to all patients. This includes failure to: ensure an initial discharge evaluation was performed by social services as required (A800); ensure the patient was evaluated for return to the pre-hospital environment (A809); ensure a discharge planning evaluation was placed in the clinical record for use in establishing an appropriate discharge plan (A811); ensure the patient's discharge plan was reassessed as required by Hospital policy (A821); ensure the patient and Power of Attorney for Health Care were counseled to prepare them for post- hospital care, as required by Hospital policy (A822). The cumulative effect of these systemic practices resulted in the Hospital's inability to ensure an adequate and safe discharge planning transition. Hence, the Hospital failed to comply with the Condition of Discharge Planning.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to ensure an initial discharge planning evaluation was performed by social services as required.

Findings include:

1. Hospital policy #D-8 entitled, "Discharge Planning," was reviewed on 4/14/10 at approximately 2:15 P.M. The policy requires, "Assess the discharge needs of the patient within 24 hours of admission... Collect information, develop health-teaching discharge goal and include in the multidisciplinary clinical plan. Document on Progress Notes that the Discharge Planning has been initiated."

2. Hospital policy #SW2004-19 entitled, "Assessments and Reassessments," was reviewed on 4/14/10 at approximately 2:50 P.M. The policy requires, "the process of the initial assessment... Department Staff reviews the patient's medical chart... speaks with the the patient their family or... designee... assess any service needs regarding the patient's hospital discharge... files the patient's initial assessment in the patient's medical chart".

3. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The record included documentation in the "Nursing Admission Assessment Notes" dated 2/22/10 that the discharge goal was Social Services/Home. The record also included that Pt. #1 had sustained 2 falls, including one on the day of discharge, with head injury. The record lacked documentation of the following:

* initial discharge assessment/evaluation
* progress note to indicate that the Discharge Planning had been initiated
* no progress note by social services until discharge on 3/1/10 at 5:30 P.M. (approximately 2.5 hours before Pt. #1's discharge).

4. In an interview with E#10 Director of Social Services, on 4/14/10 at approximately 1:20 P.M., E#10 stated that all Medical-Surgical patients, including Pt. #1 should receive an initial discharge evaluation completed within 24 hours.

5. In an interview with E#11 Social Work Services Manager, on 4/14/10 at approximately 1:40 P.M., E#10 stated that she did not complete an initial assessment for Pt. #1 because she was not following him at that time but was called to discharge the patient.

6. The above findings were confirmed during an interview with the Associated Vice President of Quality & Compliance on 4/14/10 at approximately 1:20 P.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 3 (Pt. #1) the Hospital failed to ensure the patient was evaluated for return to a safe pre-hospital environment.

Findings include:

1. Hospital policy #SW2004-19 entitled, "Assessments and Reassessments," was reviewed on 4/14/10 at approximately 2:50 P.M. The policy requires, "Assessment criteria includes updating the patient's face sheet with correct information, as well as exploring the patient's living situation, support system."

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The record included documentation on the "Resident Transfer Form" that Pt. #1 was transferred from a supportive living facility to the Hospital. However, the record included conflicting documentation by Hospital staff, that Pt. #1 was transferred from a nursing home. The record lacked documentation that Pt. #1's living situation was evaluated for appropriateness, post hospitalization.

3. An interview with the Executive Director and the Nurse Manager at the supportive living facility was conducted on 4/20/10 at approximately 11:00am. Information gathered in the interview revealed that Pt# 1 was returned to the supportive living facility on 3/1/10, without a report or paperwork. Due to the bruising and hematoma noted on patient #1, supportive living staff sent the patient to Mercy Hospital on 3/2/10, and he was admitted, one day after his discharge from Jackson Park Hospital. The Director further explained that although they were not aware of the discharge orders for intravenous medications for pt# 1, patients requiring intravenous medications cannot be medically accommodated at the supportive living facility.

4. In an interview with E#7, (attending physician) on 4/14/10 at approximately 11:30 A.M., E#7 stated that until today, 4/14/10, he thought that Pt. #1 was residing in a nursing home; that Pt. #1 was not fit to go to a supportive living facility, and that if he had known it was a supportive living facility, he would not have discharged the patient.

5. The above findings were confirmed during an interview with the Associated Vice President of Quality & Compliance on 4/14/10 at approximately 11:30 A.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to ensure a discharge planning evaluation was placed in the clinical record for use in establishing an appropriate discharge plan.

Findings include:

1. Hospital policy #SW2004-19 entitled, "Assessments and Reassessments," was reviewed on 4/14/10 at approximately 2:50 P.M. The policy requires, "Department Staff reviews the patient's medical chart... speaks with the patient, their family or... designee... assess any service needs regarding the patient's hospital discharge... files the patient's initial assessment in the patient's medical chart".

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The record included admission and discharge documentation that Pt. #1 was alert but not oriented to time or place. Pt. #1 complained of diarrhea for the past 2 weeks and vomiting occasionally, and that the patient had lost a lot of weight ("exact amount unknown"). The summary also included that Pt. #1 had leukocytosis (increased white blood cell count) likely related to bacterial etiology of the cavity in the right lung, and that the patient would be transferred back to the "nursing home" with the following antibiotics: Zosyn 3.375 mg intravenously (IV) every 8 hours, Vancomycin 1 gm IV every 24 hours with trough before the 4th dose and Flagyl 500 mg every 8 hours for 2 weeks.

The Discharge Summary further included that Pt. #1 fell on his stomach on 2/26/10, and that on 3/1/10 at 8:00 A.M., the patient tried to jump off the bed, and suffered a right parietal abrasion with some bleeding. The summary included that Pt. #1 also had a bruise under the left eye. The final diagnosis included: Right Upper Lobe Cavity, Most Probable Abscess and Severe Dementia. The clinical record failed to include a discharge planning evaluation for use in establishing an appropriate discharge plan.

3. The social work services progress note dated 3/1/10 at 5:05 P.M. included that Pt. #1 was scheduled to be discharge home. "Pt. lives in a senior supportive living facility... Pt's friend (Power of Attorney for Health Care-POAHC)... aware of Pt.'s discharge order..." The clinical record lacked documentation of a discharge planning evaluation for use in establishing an appropriate discharge plan. Although, the clinical record included that Pt. #1 had a Power of Attorney for Health Care (POAHC), the record lacked documentation that results of a discharge evaluation or discharge plan had been discussed with the POAHC prior to the date of discharge.

4. The above findings were confirmed during an interview with the Associated Vice President of Quality & Compliance on 4/14/10 at approximately 1:40 P.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to ensure the patient's discharge plan was reassessed as required by Hospital policy.

Findings include:

1. Hospital policy #SW2004-19 entitled, "Assessments and Reassessments," was reviewed on 4/14/10 at approximately 2:50 P.M. The policy requires, "Reassessment occurs in order to determine the patient's progress from the initial assessment and to modify plans as it is indicated to support the original goals or the treatment plan."

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The record included documentation that upon admission and discharge, Pt. #1 was alert but not oriented to time or place; upon admission, Pt. #1 complained of diarrhea for the past 2 weeks and vomiting occasionally, and that the patient had lost a lot of weight (exact amount unknown). The summary also included that Pt. #1 had leukocytosis (increased white blood cell count) likely related to bacterial etiology of the cavity in the right lung, and that the patient would be transferred back to the "nursing home" with with the following antibiotics: Zosyn 3.375 mg intravenously (IV) every 8 hours, Vancomycin 1 gm IV every 24 hours with trough before the 4th dose and Flagyl 500 mg every 8 hours for 2 weeks.

The Discharge Summary further included that Pt. #1 fell on his stomach on 2/26/10, and that on 3/1/10 at 8:00 A.M., the patient tried to jump off the bed, and suffered a right parietal abrasion with some bleeding. The summary included that Pt. #1 also had a bruise under the left eye. The final diagnosis included: Right Upper Lobe Cavity, Most Probable Abscess and Severe Dementia. The clinical record failed to include a discharge planning evaluation for use in establishing an appropriate discharge plan.

3. The social work services progress note dated 3/1/10 at 5:05 P.M. included that Pt. #1 was scheduled to discharge home. "Pt. lives in a senior supportive living facility."

4. In an interview with E#11 Director of Social Services, on 4/14/10 at approximately 1:40 P.M., E#10 stated that she did not complete an initial assessment for Pt. #1 because she was not following him at that time but was called to discharge the patient. E#11 further stated that although the physician's discharge order, date 3/1/10 included that Pt. #1 was to be discharged to the nursing home today, E#11 failed to follow up with the physician to determine if a supportive living facility was appropriate for Pt. #1.

5. The above findings were confirmed during an interview with the Associated Vice President of Quality & Compliance on 4/14/10 at approximately 1:40 P.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for discharge planning, the Hospital failed to ensure the patient and Power of Attorney for Health Care were counseled to prepare them for post- hospital care, as required by Hospital policy.

Findings include:

1. Hospital policy #SW2004-28 entitled, "Continuum of Care," was reviewed on 4/14/10 at approximately 3:05 P.M. The policy requires, "Prior to discharge, the staff of Social Work Services will review with the patient/family a summary of services and referrals..."

2. The clinical record for Pt. #1 was reviewed on 4/12/10 at approximately 12:00 P.M. This was a 70-year-old male admitted 2/22/10 with diagnoses of Abdominal Pain, Diarrhea, and Senile Dementia. The record included documentation that upon admission and discharge, Pt. #1 was alert but not oriented to time or place; upon admission, Pt. #1 complained of diarrhea for the past 2 weeks and vomiting occasionally, and that the patient had lost a lot of weight (exact amount unknown). The summary also included that Pt. #1 had leukocytosis (increased white blood cell count) likely related to bacterial etiology of the cavity in the right lung, and that the patient would be transferred back to the "nursing home" with with the following antibiotics: Zosyn 3.375 mg intravenously (IV) every 8 hours, Vancomycin 1 gm IV every 24 hours with trough before the 4th dose and Flagyl 500 mg every 8 hours for 2 weeks.

The Discharge Summary further included that Pt. #1 fell on his stomach on 2/26/10, and that on 3/1/10 at 8:00 A.M., the patient tried to jump off the bed, and suffered a right parietal abrasion with some bleeding. The summary included that Pt. #1 also had a bruise under the left eye. The final diagnosis included: Right Upper Lobe Cavity, Most Probable Abscess and Severe Dementia.

3. The social work services progress note dated 3/1/10 at 5:05 P.M. included that Pt. #1 was scheduled to be discharge home. "Pt. lives in a senior supportive living facility... Pt's friend (POAHC)... aware of Pt.'s discharge order..." The clinical record lacked documentation that Pt. #1 and the POAHC had been counseled by Social Wok Services to prepare them for post-hospital care.

4. The above findings were confirmed during an interview with the Associated Vice President of Quality & Compliance on 4/14/10 at approximately 1:40 P.M.