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.

CLEVELAND CLINIC INDIAN RIVER HOSPITAL 1000 36TH ST VERO BEACH, FL 32960 Aug. 4, 2017
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview it was determined the facility failed to ensure quality of discharge planning was provided to 2 of 7 sampled patients (Patient #1 and #2) as evidenced by failure to provide a choice letter for follow up care at home.


The findings included:


Facility policy titled "Case Management Discharge Planning dated 02/10/15 documents "The Case Manager will document in the medical record after their initial assessment has been completed, discussion with the patient regarding anticipated needs for surgery and any and all communication with patient and family in regards to their choices for services post discharge."

Clinical record review conducted on 08/03/17 revealed Patient #1 was admitted to the facility on [DATE] for a surgical procedure. Review of the Case Management/Discharge Planning Notes failed to provide evidence the patient or the patient's family was informed of their freedom to choose among participating Medicare providers of post-hospital care services.

Clinical record review conducted on 08/03/17 revealed Patient #2 was admitted to the facility on [DATE] for a surgical procedure. Review of the Case Management/Discharge Planning Notes failed to provide evidence the patient or the patient's family was informed of their freedom to choose among participating Medicare providers of post-hospital care services.

Interview with the Quality Manager conducted on 08/03/17 at approximately 12:38 PM confirmed Patient #1 and #2 did not receive the choice letter as the physician's office made the arrangement for home health care.
VIOLATION: HISTORY AND PHYSICAL Tag No: A0952
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview it was determined the facility failed to ensure quality of surgical care was provided to 2 of 7 sampled patients (Patient #2 and #3) as evidenced by failure to update examination of the patients, History and Physical within 24 hours after admission or prior to a surgical procedure.

The findings included:

Clinical record review conducted on 08/03/17 and 08/04/17 revealed Patient #2 was admitted to the facility on [DATE] for a surgical procedure. The record contained a History and Physical dated 06/01/17, the record provides no evidence an update was completed prior to the surgical procedure performed on 06/12/17.


Clinical record review conducted on 08/03/17 and 08/04/17 revealed Patient #3 was admitted to the facility on [DATE] for a surgical procedure. The record contained a History and Physical dated 07/03/17, the record provides no evidence an update was completed prior to the surgical procedure performed on 07/06/17.

Interview with the Quality Manager conducted on 08/04/17 at approximately 1:38 PM confirmed after further research of the clinical records there is no evidence the History and Physical related to Patient #2 and #3 were updated prior to the surgical procedure.