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.

ADVOCATE TRINITY HOSPITAL 2320 E 93RD ST CHICAGO, IL 60617 Nov. 9, 2017
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed of patients discharged , the Hospital failed to ensure the patient and/or family was informed of the discharge plan.

1. The Hospital policy entitled, "Discharge Planning," (last review date 8/19/16) required, "II. Policy. Discharge planning is a collaborative, coordinated approach involving the patient, family...IV. Procedure. A. 1. Discharge planning needs will be assessed upon admission and reassessed during the hospitalization ...3. The discharge plan will be discussed as early as possible with the patient/family during the hospital stay."

2. The clinical record of Pt #1 was reviewed on 11/7/17 at approximately 1:00 PM. Pt #1 was an [AGE] year old male who was admitted on [DATE] from the Emergency Department with complaints of altered mental status, lethargy and diarrhea.

A physician's order dated 10/5/17 at 1:46 PM included, "Consult to Discharge Planning, Order Details: resume Home Health."

A physician's order dated 10/6/17 at 9:06 AM included, "Discharge patient home. Resume Home Health."

3. Pt #1's clinical record contained an Occupational Therapy (OT) evaluation dated 10/6/17 at 9:59 AM that included, " ...General Information: I just feel so drained ...Discharge Recommendations - OT ...Subacute Rehabilitation ..."

4. Pt #1's clinical record contained a Physical Therapy (PT) evaluation dated 10/6/17 at 3:09 PM that included, "...General Information: Subjective: I have a fear of falling ...PT Discharge Recommendations: Subacute Rehabilitation ..."

5. Discharge Planning Documentation dated 10/6/17 included, "Comment - D/C (discharge) Plan Communication: 10/6/17 SW (social worker) met with pt at bedside. Pt is aox4 (alert and oriented times 4 - person, place, time, and situation) and ambulatory. Pt reported he does not have any home services. SW informed patient that PT (physical therapy) and OT (occupational therapy) recommend SNF (Skilled Nursing Facility). Pt reported he is in agreement but wants to discuss placement with family. SW initiated referrals via ECIN (Extended Care Information Network)." Discharge documentation included the names of 7 SNFs that were contacted for possible placement.

6. Physician documentation dated 10/7/17 at 8:56 AM included, "Spoke with nursing. Pt will be discharged home with Home Health."

7. On 11/7/17 at approximately 1:30 PM the Manager of Care Management (E #2) presented a Care Arrangements document that indicated, "10/6/17 SW met with pt (patient) at bedside. Pt is aox4 and ambulatory. Pt reports he does not have any home services. SW informed pt that PT and OT recommend SNF. Pt reported he is in agreement but wants to discuss placement with family. SW initiated referrals via ECIN." A document entitled, "Allscripts - Summary" indicated that a total of 7 SNFs were contacted for possible placement and included Referral Comment: Family to discuss placement/ please do not contact/pt is on isolation for[DIAGNOSES REDACTED] ...1st ...2nd ...3rd (family choices)."

8. On 11/7/17 at approximately 2:00 PM the Social Worker (SW) (E #3) caring for Pt #1 on the Transitional Care Unit was interviewed. E #3 stated, "I get an order for SNF placement based on the recommendation of the PT and OT evaluations. I send the referral into the Department of Aging for evaluation. According to my note the patient was alert and ambulatory. I talk to the patients and let them know what the doctor has ordered and then the patient can decide if they want to go to a SNF or have the services at home. In the mornings we have multidisciplinary rounds with Nursing, Unit Managers, Care Manager, and myself. Criteria, for skilled placement is based on the PT and OT evaluations. When a decision is made, as to where the services are to be provided, the patient lets me know. I did not talk to the family (Pt #1's) because the patient was alert and oriented and able to make his own decisions. I stated in my note, 'Family to discuss placement/ please do not contact pt/ is on isolation for d-diff/ ...' because I did not want to bombard the patient with questions and phone calls."

9. On 11/7/17 at approximately 2:30 PM the Social Worker (E #4) on duty on 10/7/17 (Saturday) was interviewed. E #4 stated, "I remember the patient, I was working on the weekend and was asked to check on a referral for rehab placement for the patient, by another SW. The Nurse caring for the patient called me and told me that he (Pt #1) was going to be discharged with Home Health Services. The Nurse then took care of calling and arranging for the service. I did not discuss the Home Health with the patient or family."

10. Pt #1's clinical record contained a Patient Summary (undated) that did not include documentation regarding Pt #1 going home with Home Health Care.

11. On 11/8/17 at approximately 1:00 PM Pt #1's Attending Physician (MD #1) was interviewed via phone. MD #1 stated that, "...I remember discussing Home Health with the family and patient. The original plan was to send the patient to a SNF but the patient's wife wanted to take him home. I only spoke with the Nurse on 10/7/17 about sending the patient home with Home Health. I did not write a note documenting the fact that the wife changed her mind about going home instead of going to a SNF."

12. On 11/9/17 at approximately 9:20 AM the Registered Nurse (E #6) on duty on 10/7/17 was interviewed. E #6 stated that he remembered the patient. E #6 stated, "Home Health was contacted by the SW or Care Manager, I did not do it. At the time of the discharge one of the family members was at the bedside. I don't know if it was the wife or daughter. The physician wanted the patient to go home with Home Health not to a SNF even though the family thought he was going to go to SNF. After I talked to the physician, it took a couple of hours to have the patient ready for discharge. I told the patient that he was going home with Home Health but did not document it."

13. During an interview on 11/9/17 at approximately 10:00 AM, The Vice President of Clinical Excellence (E #1) stated that the documentation regarding the patient's discharge is missing from the chart.