The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 June 16, 2011
VIOLATION: DISCHARGE PLAN Tag No: A0817
Based on record review and interview, the facility failed to properly discharge a patient from the hospital with a confirmed destination prior to discharging 1 patient (patient #1).

Findings:

During the record review it was revealed that patient #1 was in the process of discharge planning with the Case Managers and a destination was being investigated. Further review of the discharge documents indicated that another staff member, a Bed Control Coordinator, implemented a discharge from the facility without a confirmed destination on 6/2/11.

In interview with a Case Manager (#1) at 11:10 AM, revealed that she had been working on a discharge and had sent out a referral to a nursing home which two days later refused to accept the patient as the patient did not meet the requirements for skilled nursing care or therapy.

In interview with Case Manager (#2) at 11:20 AM, it was stated that she was called by the House Supervisor on 6-2-11 at 8:02 PM and was informed that the discharged patient had been transported to the Salvation Army shelter and that the Salvation Army had not accepted the patient because she could not care for herself. She then spoke to the staff member who had discharged the patient, a Bed Control Coordinator, and it was revealed that the Salvation Army shelter was not contacted prior to discharging the patient using a non-emergency transport.

In interview with the Bed Control Coordinator on 6-20-2011 at 2:00 PM, it was stated that he assisted with the discharge because the hospital was in a critical bed shortage.

In interview with the Executive Director of Quality Control at 11:50 AM, it was agreed that this was an improper discharge that did not follow the facility policy.

Review of the facility's policy entitled "Case Management-Discharge Planning", with a review date of 5/19/2010 revealed that "The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge." Further review of this policy revealed, "Referrals for discharge planning may also be initiated by the patient, family support systems, physician, ancillary services or community agencies." Further review of this policy failed to reveal evidence that discharge planning can be initiated by the Bed Control Coordinator.
VIOLATION: QUALIFIED PERSONNEL Tag No: A0818
Based on record review and interview, the facility failed to ensure that the staff member that improperly discharged a patient was qualified to perform discharges or had proper discharge planning training for one patient (Patient #1).

Findings:

During record review it was discovered that the person discharging patient #1 from the facility on 6/2/2011, failed to contact an agreed on destination and that the destination location/facility would accept the patient. The staff member is employed as a Bed Control Coordinator and not as a Case Manager.

Review of the facility's policy entitled "Case Management-Discharge Planning", with a review date of 5/19/2010 revealed that, "Referrals for discharge planning may also be initiated by the patient, family support systems, physician, ancillary services or community agencies." Further review of this policy failed to reveal evidence that discharge planning can be initiated and/or completed by the Bed Control Coordinator.

In interview with the Executive Director of Quality Management at 11:50 AM, it was stated that the staff member was not a Case Manager and was a Bed Control Coordinator.


In interview with the Bed Control Coordinator on 6-20-2011 at 2:00 PM, it was stated that he assisted with the discharge because the hospital was in a critical bed shortage.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record review and interview, the facility failed to implement the discharge plan for one discharged patient (patient #1).

Findings:

During the record review, it was revealed that a Case Manager had started the discharge planning and after an interview with the patient #1, had sent out a referral to a nursing home on 5-31-11 and that they were waiting on a reply. On 6-2-11, the patient was discharged without a confirmed destination and the discharge was implemented by a staff member that is not assigned to discharging patients.

In interview with Case Manager (#2) at 11:20 AM, it was stated that she was called by the House Supervisor on 6-2-11 at 8:02 PM and was informed that the discharged patient had been transported to the Salvation Army shelter and that the Salvation Army had not accepted the patient because she could not care for herself. She then spoke to the staff member who had discharged the patient, a Bed Control Coordinator, and it was revealed that the Salvation Army shelter was not contacted prior to discharging the patient using a non-emergency transport.

In interview with the Executive Director of Quality Management on 6-16-11 at 11:50 AM, it was agreed that the staff member who discharged Patient #1 does not discharge patients and the discharge policy was not followed.

Interview with the person who accepted patient #1 was conducted on 6-20-11 at 1:17 PM. According to the individual, she had no idea that the patient was being brought to her motel. She said that she had had contact earlier in the day with the patient and was told they were going to discharge her to the Salvation Army Shelter and that she did not want to go there. About 1-1/2 hours later, the patient showed up at her motel in a transport van and the patient was wheeled out and left. The driver of the van told her (complainant) that the Salvation Army would not take the patient because she could not care for herself. The person who accepted the patient did not see any paperwork and further stated that it appeared that the patient was "out of it." The patient was slurring her words and it was hard to understand her.

In interview with the Bed Control Coordinator on 6-20-2011 at 2:00 PM, it was stated that he assisted with the discharge because the hospital was in a critical bed shortage.

Review of the facility's policy entitled "Case Management-Discharge Planning", with a review date of 5/19/2010 revealed that "The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge." Further review of the policy revealed that the Case Managers would arrange for any services to meet the needs of the patients prior to discharging the patients.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record review and interview, the facility failed to ensure that the patient/family members and/or interested parties received any counseling or guidance in the continuing of care for one discharged patient (patient #1).

Findings:

During the record review, it was discovered that the facility did not contact or counsel anyone for the care of patient #1 post-discharge. The documentation in the record indicated that the location that the patient was discharged to was never contacted prior to discharging the patient there. Further review revealed that the patient had actually suggested a destination and the friend accepted the patient without any instructions for care.

In interview with the Executive Director Quality Management on 6-16-11 at 11:50 AM, it was stated that this would be considered an improper discharge.

In interview with patient #1's friend on 6-21-2011 at 1:17 PM, it was stated that when the patient reached her place of business, the patient was not really coherent and was slurring her words and acted confused. She accepted the patient because she was informed that the Salvation Army would not take her because of the lack of ability to care for herself. She did not have contact with the hospital before accepting the patient. Further interview with the patient's friend revealed that the patient did not have any documentation with her when she arrived.

In interview with the Bed Control Coordinator on 6-20-2011 at 2:00 PM, it was stated that he assisted with the discharge because the hospital was in a critical bed shortage. Further interview with the Bed Control Coordinator revealed that he did not contact the Salvation Army Shelter prior to discharging the patient via non-medical transport to that facility.