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.

SAINT ALPHONSUS REGIONAL MEDICAL CENTER 1055 NORTH CURTIS ROAD BOISE, ID 83706 Feb. 8, 2013
VIOLATION: DISCHARGE PLANNING Tag No: A0812
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records and hospital policies, it was determined the facility failed to ensure an identifiable discharge planning evaluation was documented in the medical record for 10 of 10 patients (Patients #1 - #10) whose records were reviewed. This had the potential to result in unidentified patient post-discharge needs. Findings include:

1. The policy Discharge "Planning for Inpatient Psychiatric Patients," dated 1/31/12, stated "The Nursing Admission Assessment and all subsequent multidisciplinary evaluations and assessments will contain trigger questions to identify the patient's need for referrals to other members of the healthcare team." The policy did not identify these "trigger questions" and did not direct staff as to how discharge planning evaluations would be documented so they would be identifiable to staff.

The Discharge Planning Team Leader was interviewed on 2/07/13 beginning at 12:50 PM. She stated the information for discharge planning evaluations was taken from various sources. She confirmed the policy did not identify these sources or how discharge planning evaluations were documented.

2. An identifiable discharge planning evaluation could not be found in 10 of 10 medical records as follows:

a. Patient #1's medical record documented an [AGE] year old male who was admitted on [DATE] and was currently a patient as of 2/06/13. His diagnoses included psychosis and possible bipolar disorder. His medical record did not contain an identifiable discharge planning evaluation.

Patient #1's medical record was reviewed with the Discharge Planner of the Behavioral Health Unit on 2/06/13 beginning at 1:00 PM. She identified plans for Patient #1's discharge but she was not able to identify the discharge planning evaluation in the medical record.

b. Patient #2's medical record documented a [AGE] year old female who was admitted to the Behavioral Health Unit of the facility on 2/01/13. Her diagnoses included major depression, rule out somatization disorder (psychiatric condition marked by multiple medically unexplained physical, or somatic, symptoms) and chronic neck pain secondary to surgery.

Patient #2's EMR was reviewed with the Nurse Manager of the Behavioral Health Unit on 2/07/13, beginning at 8:15 AM. She identified plans for Patient #2's discharge, but was not able to identify a discharge planning evaluation in the record.

c. Patient #3's medical record documented a [AGE] year old female who was admitted on [DATE] and was currently a patient as of 2/06/13. Her diagnoses was possible adjustment disorder versus major depression. Her medical record did not contain an identifiable discharge planning evaluation.

Patient #3's medical record was reviewed with the Discharge Planner of the Behavioral Health Unit on 2/06/13 beginning at 1:00 PM. She identified plans for Patient #2's discharge but she was not able to identify the discharge planning evaluation in the medical record.

d. Patient #4's medical record documented a [AGE] year old female who was admitted to the Behavioral Health Unit of the facility on 2/04/13. Her diagnoses included psychotic disorder, rule out somatic disorder (psychiatric condition marked by multiple medically unexplained physical, or somatic, symptoms), bipolar disorder, hypertension and diabetes.

Patient #4's medical record was reviewed with the Discharge Planner of the Behavioral Health Unit on 2/06/13 beginning at 1:00 PM. She identified plans for Patient #1's discharge but she was not able to identify the discharge planning evaluation in the medical record.

e. Patient #5's medical record documented a [AGE] year old male who was admitted on [DATE]. He was diagnosed with severe traumatic brain injury related to jumping from a moving vehicle. The injury resulted in surgical intervention, bilateral craniotomies with removal of hematoma, (surgical removal of part of the bone from the skull to expose the brain and remove a blood clot). Other diagnoses included a history of schizophrenia and a suicide attempt. According to the H&P, dated 1/05/13, Patient #5 was moved from the Neurological Floor to the Rehabilitation Unit on 12/29/12. On 1/04/13, he was discharged from the Rehabilitation Unit and admitted to the Behavioral Health Unit. Patient #5 was discharged from the facility on 1/09/13.

Patient #5's EMR was reviewed with the Nurse Manager of the Behavioral Health Unit. An identifiable discharge planning evaluation was not found in the record.

f. Patient #6's medical record documented a [AGE] year old female who was admitted on [DATE] and was currently a patient as of 2/06/13. Her diagnosis was bipolar disorder. Her medical record did not contain an identifiable discharge planning evaluation.

Patient #6's medical record was reviewed with the Discharge Planner of the Behavioral Health Unit on 2/06/13 beginning at 1:00 PM. She identified plans for Patient #6's discharge but she was not able to identify the discharge planning evaluation in the medical record.

g. Patient #7's medical record documented a [AGE] year old male who was transferred to the Behavioral Health Unit of the facility from the ED on 12/21/12. His diagnoses included bipolar disorder, last phase manic with psychotic features, hypertension, diabetes and obesity. Patient #7 was discharged from the facility on 1/11/13.

Patient #7's EMR was reviewed with the Nurse Manager of the Behavioral Health Unit on 2/07/13, beginning at 8:15 AM. She identified plans for Patient #7's discharge, but was not able to identify a discharge planning evaluation in the record.

h. Patient #8's medical record documented a [AGE] year old male who was admitted to Behavioral Health Unit on 1/11/13. His diagnoses included schizophrenia by history and psychosis. Patient #8 was discharged from the facility on 1/29/13.

Patient #8's EMR was reviewed with the Nurse Manager of the Behavioral Health Unit on 2/07/13, beginning at 8:15 AM. She identified plans for Patient #8's discharge, but was not able to identify a discharge planning evaluation in the record.

i. Patient #9's medical record documented a [AGE] year old male who was admitted to the Behavioral Health Unit of the facility on 12/06/12. His diagnoses included schizo-affective disorder, bipolar type and history of polysubstance abuse. Patient #9 was discharged from the facility on 12/12/12.

Patient #9's EMR was reviewed with the Nurse Manager of the Behavioral Health Unit on 2/07/13, beginning at 8:15 AM. She identified plans for Patient #9's discharge, but was not able to identify a discharge planning evaluation in the record.

j. Patient #10's medical record documented a [AGE] year old male who was admitted on [DATE]. His diagnoses included major depression, recurrent, marijuana abuse and diabetes. Patient #10 was discharged from the facility on 11/08/12.

Patient #10's EMR was reviewed with the Nurse Manager of the Behavioral Health Unit on 2/07/13, beginning at 8:15 AM. She identified plans for Patient #10's discharge, but was not able to identify a discharge planning evaluation in the record.

Identifiable discharge planning evaluations were not included in patients' medical records.