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.

IBERIA GENERAL HOSPITAL AND MEDICAL CENTER 2315 E MAIN STREET NEW IBERIA, LA 70562 July 24, 2015
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on interviews the hospital failed to ensure the designated infection control officer was qualified through education, training, experience, or certification.
Findings:

CDC (Centers for Disease Control) defined "infection control professional" as "a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control."

A list of documents for review was requested at the Entrance Conference 7/23/15 at 11:30 a.m. This list included the personnel file of S8ICOfficer ( Infection Control Officer). The personnel file of S8ICOfficer was requested 7/24/15 at 9:10 a.m. No personnel file for S8ICOfficer was provided for review during the survey.

In an interview 7/23/15 @1:45 p.m. S8ICOfficer reported she was appointed to the position of Infection Control Officer when the previous Infection Control Officer left. She reported her prior experience was limited to the times she filled in for the previous Infection Control Officer, for about a month, while she (the previous Infection Control Officer) was out last October or November. She said the previous Infection Control Officer showed her what to do. S8ICOfficer reported that she had recently joined APIC (Association for Professionals in Infection Control and Epidemiology), but had no prior infection control experience or specialized training in coordinating an infection control program.

In an interview 7/23/15 at 3:50 p.m. S2CNO (Chief Nursing Officer) reported that they (the hospital ) had not made provisions for S8ICOfficer to obtain specialized training in infection control. S2CNO verified S8ICOfficer had taken the position of Infection Control Coordinator around the end of last year.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to:
1) Identify in policy which staff are responsible for carrying out the evaluation to identify patients likely to need discharge planning as evidenced by failing to clarify which nurse, the registered nurse (RN) or the licensed practical nurse (LPN), was responsible for assessing the discharge needs of each patient at the time of admission.
2) Ensure the hospital's criteria and screening process for evaluating patients' discharge needs were applied consistently as evidenced by nursing home patients being referred to case management for discharge planning and not having a discharge planning evaluation conducted by the case manager for patients admitted from the nursing home for 1 (#1) of 1 patient record reviewed who was admitted from the nursing home from a total of 5 (#1 - #5) sampled patient records.
Findings:

1) Identify in policy which staff are responsible for carrying out the evaluation to identify patients likely to need discharge planning:
Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO (Chief Nursing Officer), revealed that the nurse who admits the patient will perform the initial Discharge Planning Screen as part of the admission history and assessment, as per hospital policy. There was no documented evidence whether the nurse had to be a RN or could be a LPN.

Review of the hospital policy titled "Assessment of Patients", presented as a current policy by S2CNO, revealed the nurse performs the initial assessment of discharge and psycho-social risk factors at the time of admission, and referrals are made to Case Management based on initial assessment triggers for those patients requiring a more extensive evaluation of needs. There was no documented evidence whether the nurse had to be a RN or could be a LPN.

In an interview on 07/24/15 at 4:25 p.m., S3CaseManager confirmed that the hospital policy doesn't designate whether the discharge planning assessment had to be conducted initially by a RN or if the LPN could conduct the assessment.

2) Ensure the hospital's criteria and screening process for evaluating patients' discharge needs were applied consistently:
Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO, revealed that the nurse who admits the patient will perform the initial Discharge Planning Screen as part of the admission history and assessment, as per hospital policy. Patients are seen according to high risk screening criteria that is identified by Nursing Initial Interview as well as by referrals/orders from doctors and nurse practitioners, other professional services, and as identified by any other health care team member.

Review of computerized screen shots, presented by S9RN, of the descriptions that are included under "Case Management Consult" revealed nursing home on discharge and existing nursing home patient were included in the list.

Review of the "High Risk Discharge Screening" computerized screen shots, presented by S9RN, revealed that age, living status, and disability were included in the screening. Further review revealed a score of 10 or more (when adding the score for each of the above three screens) will generate a notification to case management for "High Risk Discharge Screening."

Review of the "Discharge Screening Tool", presented as the tool used as the Case Management's screening tool by S3CaseManager, revealed areas to be assessed included living environment, home description, ADL (activities of daily living) assessment, DME (durable medical equipment) used by or needed by the patient, home services, knowledge of the disease process, and proposed discharge disposition.

Review of Patient #1's medical record revealed he was a [AGE] year old male admitted from the nursing home on 03/29/15 with diagnoses of Dehydration, Altered Mental Status, and Hypernatremia.

Review of Patient #1's "Initial Interview" documented on 03/29/15 at 10:00 p.m. revealed no documented evidence of a high risk discharge screening as evidenced by the spaces for scores related to age, living status, and disability being blank. Further review revealed documentation that Patient #1 required assistance with cooking, cleaning, feeding, walking/ambulation, bathing/toileting, transportation, shopping, administering medications, and ADLs. There was no documented evidence of the type and amount of assistance needed.

Review of Case Management documentation of 03/30/15 at 3:39 p.m. revealed a discharge planning reflex (referral) was noted , and there were no further needs at this time. There was no documented evidence that a discharge planning evaluation was conducted that included an evaluation of Patient #1's living environment, home description, ADL assessment, DME used by or needed by Patient #1, home services, knowledge of the disease process, and proposed discharge disposition.

In an interview on 07/24/15 at 12:50 p.m., S3CaseManager indicated questions on the initial interview that triggers a referral to Case Management were whether the patient needs DME or home health, the ADL assessment, and whether the patient came from the nursing home. She further indicated if a patient comes from the nursing home, it triggers a consult to Case Management, but a discharge planning evaluation is not completed. When asked why a nursing home patient would be a trigger to Case Management and an evaluation was not conducted by Case Management, S3CaseManager offered no explanation.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure:
1) A process was developed to inform patients that he/she or his/her representative could request a discharge planning evaluation as evidenced by interviews with 2 (R1, R2) of 2 random patients revealing the patients were not informed that they could request a discharge planning evaluation and the hospital providing no documented evidence that Patients R1 and R2 had been so instructed.
2) A discharge planning screening/evaluation included an evaluation of whether a patient's post-discharge needs could be met in the environment from which the patient entered the hospital for 4 (#1, #2, #4, #5) of 5 (#1 - #5) patients records reviewed for discharge planning from a total sample of 5 patient records.
3) Each patient was assessed for their ability to perform ADLs (activities of daily living) for 3 (#2, #4, #5) of 5 (#1 - #5) patients records reviewed for discharge planning from a total sample of 5 patient records.
4) Each patient was assessed to determine if his/her support person had the ability to provide care to the patient post-discharge for 3 (#2, #4, #5) 5 (#1 - #5) patients records reviewed for discharge planning from a total sample of 5 patient records.
5) Each patient was assessed to determine if home and/or physical environment modifications were needed for the patient to return to the environment from which he/she entered the hospital, and if needed, that the modifications could be made to safely discharge the patient for 5 (#1, #2, #3, #4, #5) of 5 (#1 - #5) patients records reviewed for discharge planning from a total sample of 5 patient records.
6) Each patient's insurance coverage was assessed as part of the discharge planning screening/evaluation to determine how coverage might or might not provide for the services needed post-discharge for 2 (#2, #5) of 5 (#1 - #5) patients records reviewed for discharge planning from a total sample of 5 patient records.
Findings:

1) A process was developed to inform patients that he/she or his/her representative could request a discharge planning evaluation:
Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO (Chief Nursing Officer), revealed that discharge planning is also available upon request of the patient, family/caregiver, and/or representative. Further review revealed no documented evidence of the process to be used to ensure a discharge planning evaluation is conducted when requested by the patient, family/caregiver, and/or representative.

In an interview on 07/24/15 at 10:35 a.m., Patient R1 and his wife were interviewed. They both confirmed that they were not informed by any hospital staff member that they could request a discharge planning evaluation. They indicated that they didn't know the hospital's process for making such a request.

In an interview on 07/24/15 at 11:10 a.m., Patient R2, her son, and her daughter were interviewed regarding discharge planning. Patient R2, her son, and her daughter indicated they had not been informed that they could request a discharge planning evaluation and the process for doing so.

In an interview on 07/24/15 at 10:46 a.m., S3CaseManager confirmed she didn't see documentation in the above patient records that they had been informed that they could request a discharge planning evaluation and the process for making such a request.

2) A discharge planning screening/evaluation included an evaluation of whether a patient's post-discharge needs could be met in the environment from which the patient entered the hospital:
Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO, revealed that the nurse who admits the patient will perform the initial Discharge Planning Screen as part of the admission history and assessment, as per hospital policy. The case Manager will begin to evaluate discharge needs within 2 working days of receiving the consult. Information regarding diagnosis, home conditions, family support, emotional status, and financial status will be collected to identify all patient needs that should be met after discharge.

Patient #1
Review of Patient #1's medical record revealed he was a [AGE] year old male admitted from the nursing home on 03/29/15 with diagnoses of Dehydration, Altered Mental Status, and Hypernatremia.

Review of Patient #1's "Initial Interview" documented on 03/29/15 at 10:00 p.m. revealed no documented evidence of a high risk discharge screening as evidenced by the spaces for scores related to age, living status, and disability being blank. Further review revealed documentation that Patient #1 required assistance with cooking, cleaning, feeding, walking/ambulation, bathing/toileting, transportation, shopping, administering medications, and ADLs. There was no documented evidence of the type and amount of assistance needed.

Review of Case Management documentation of 03/30/15 at 3:39 p.m. revealed a discharge planning reflex (referral) was noted , and there were no further needs at this time. There was no documented evidence that a discharge planning evaluation was conducted that included an evaluation of Patient #1's living environment, home description, ADL assessment, DME (durable medical equipment) used by or needed by Patient #1, home services, knowledge of the disease process, and proposed discharge disposition with documentation of whether Patient #1's post-discharge needs could be met in the environment from which he entered the hospital.

In an interview on 07/24/15 at 12:50 p.m., S3CaseManager indicated questions on the initial interview that triggers a referral to Case Management were whether the patient needs DME or home health, the ADL assessment, and whether the patient came from the nursing home. She further indicated if a patient comes from the nursing home, it triggers a consult to Case Management, but a discharge planning evaluation is not completed. When asked why a nursing home patient would be a trigger to Case Management and an evaluation was not conducted by Case Management, S3CaseManager offered no explanation.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted to address oxygen conservation in the home.

In an interview on 07/24/15 2:50 p.m., S3CaseManager indicated when a physician orders a Case Management consult for patient care equipment, the specific request is addressed, such as arranging for oxygen, but a complete discharge planning evaluation is not done. When asked how the case manager can determine if the patient's needs can be met in the home without a complete assessment of the patient's home environment and ability to perform ADLs, S3CaseManager offered no explanation or comment.

Patient #4
Review of the medical record for Patient #4 revealed she was a [AGE] year old female admitted [DATE] from home, where she lived with family, via the emergency room . Patient #4 presented with complaints of 3-4 days if persistent nausea. Her diagnoses included Chronic Atrial fibrillation, Digoxin toxicity, Urinary Tract Infection, End Stage Renal Disease, Diabetes Mellitus, Peripheral Vascular Disease, Coronary artery disease, Diabetic peripheral neuropathy, and Coumadin toxicity. Review of her medical record revealed no documented evidence of an assessment of whether Patient #4's needs could be met post-discharge in the environment in which she entered the hospital.
In an interview 7/24/15 at 4:20 p.m. S3CaseManager indicated the initial interview was the start of Discharge Planning. S3CaseManager confirmed the assessment of Patient #4 did not include all ADLs or the patient's ability to care for herself or her family's ability to care for her.
Patient #5 Patient #5 was a [AGE]-year-old male admitted on [DATE] from a rehab facility and discharged to a long term care hospital on [DATE]. Diagnoses included Acute Kidney Failure, Unspecified (present on admission); History of Chronic Renal Failure; DM (Diabetes Mellitus) Type II; Dysphagia; and a history of Transient Ischemic Attack (TIA), and Cerebral Infarction Without Residual Deficits (present on admission).
Review of Patient #5's medical record revealed a "Readmission Screening" was completed and not a discharge planning evaluation. There was no documented evidence of an assessment of whether Patient #5's needs could be met post-discharge in the environment in which he entered the hospital.
In an interview on 07/24/15 at 4:25 p. m., S3CaseManager confirmed that a "Readmission Screening" was done for Patient #5 and not a discharge planning evaluation.
3) Each patient was assessed for their ability to perform ADLs:
Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted to address oxygen conservation in the home and his ability to perform ADLs.

In an interview on 07/24/15 2:50 p.m., S3CaseManager indicated when a physician orders a Case Management consult for patient care equipment, the specific request is addressed, such as arranging for oxygen, but a complete discharge planning evaluation is not done. When asked how the case manager can determine if the patient's needs can be met in the home without a complete assessment of the patient's home environment and ability to perform ADLs, S3CaseManager offered no explanation or comment.

Patient #4
Review of the medical record for Patient #4 revealed she was a [AGE] year old female admitted [DATE] from home, where she lived with family, via the emergency room . Patient #4 presented with complaints of shortness of breath and hypoxia. Her diagnoses included Hypoxia, Obstructive Sleep Apnea Syndrome-CPAP (Continuous Positive Airway Pressure) at night, End Stage Renal Disease (on Peritoneal Hemodialysis), Diabetes Mellitus, Congestive Heart Failure, Hypertension, DVT (Deep Vein Thrombosis) Prophylaxis, Gastrointestinal Prophylaxis. Further review revealed a Nursing Assessment on admission that included an ADL assessment that read, " Ambulation; Stairs: Transfers: Requires Assistance. " No further assessment of the patient's ability to perform any other ADL was noted (eating, toileting, hygiene).
In an interview 7/24/15 at 4:20 p.m. S3CaseManager indicated the initial interview was the start of Discharge Planning. S3CaseManager confirmed the assessment of Patient #4 did not include all ADLs or the patient's ability to care for herself or her family's ability to care for her.
Patient #5 Patient #5 was a [AGE]-year-old male admitted on [DATE] from a rehab facility and discharged to a long term care hospital on [DATE]. Diagnoses included Acute Kidney Failure, Unspecified (present on admission); History of Chronic Renal Failure; DM (Diabetes Mellitus) Type II; Dysphagia; and a history of Transient Ischemic Attack (TIA), and Cerebral Infarction Without Residual Deficits (present on admission).
Review of Patient #5's "Initial Interview" conducted on 06/21/15 at 3:45 p. m. revealed Patient #5 was independent in all ADLs. Further review revealed the nurse documented that he needed assistance with cooking, cleaning, feeding, walking/ambulation, bathing/toileting, transportation, shopping, administering medications, and ADLs. Further review revealed documentation that he lived with his elderly wife who is unable to assist much anymore, and home health information was requested. There was no documented evidence of which assessment was correct and if his needs could be met in the environment from which he entered the hospital.
In an interview on 07/24/15 at 4:25 p.m., S3CaseManager confirmed that the discharge planning evaluation was not completed but rather a readmission screening.
4) Each patient was assessed to determine if his/her support person had the ability to provide care to the patient post-discharge:
Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted to address oxygen conservation in the home and his ability to perform ADLs and whether his caregiver could provide assistance if needed.

In an interview on 07/24/15 2:50 p.m., S3CaseManager indicated when a physician orders a Case Management consult for patient care equipment, the specific request is addressed, such as arranging for oxygen, but a complete discharge planning evaluation is not done. When asked how the case manager can determine if the patient's needs can be met in the home without a complete assessment of the patient's home environment and ability to perform ADLs, S3CaseManager offered no explanation or comment.

Patient #4
Review of the medical record for Patient #4 revealed she was a [AGE] year old female admitted [DATE] from home, where she lived with family, via the emergency room . Patient #4 presented with complaints of shortness of breath and hypoxia. Her diagnoses included Hypoxia, Obstructive Sleep Apnea Syndrome-CPAP (Continuous Positive Airway Pressure) at night, End Stage Renal Disease (on Peritoneal Hemodialysis), Diabetes Mellitus, Congestive Heart Failure, Hypertension, DVT (Deep Vein Thrombosis) Prophylaxis, Gastrointestinal Prophylaxis. Further review revealed a Nursing Assessment on admission that included an ADL assessment that read, " Ambulation; Stairs: Transfers: Requires Assistance. " No further assessment of the patient's ability to perform any other ADL was noted (eating, toileting, hygiene). No assessment of the patient's or her support person's ability to provide self-care/care was noted.
In an interview 7/24/15 at 4:20 p.m. S3CaseManager indicated the initial interview was the start of Discharge Planning. S3CaseManager confirmed the assessment of Patient #4 did not include all ADLs or the patient's ability to care for herself or her family's ability to care for her.
Patient #5 Patient #5 was a [AGE]-year-old male admitted on [DATE] from a rehab facility and discharged to a long term care hospital on [DATE]. Diagnoses included Acute Kidney Failure, Unspecified (present on admission); History of Chronic Renal Failure; DM (Diabetes Mellitus) Type II; Dysphagia; and a history of Transient Ischemic Attack (TIA), and Cerebral Infarction Without Residual Deficits (present on admission).
Review of Patient #5's "Initial Interview" conducted on 06/21/15 at 3:45 p. m. revealed Patient #5 was independent in all ADLs. Further review revealed the nurse documented that he needed assistance with cooking, cleaning, feeding, walking/ambulation, bathing/toileting, transportation, shopping, administering medications, and ADLs. Further review revealed documentation that he lived with his elderly wife who is unable to assist much anymore, and home health information was requested. There was no documented evidence of which assessment was correct and to what extent Patient #5's elderly wife could assist with ADLs.
In an interview on 07/24/15 at 4:25 p.m., S3CaseManager confirmed that the discharge planning evaluation was not completed but rather a readmission screening.
5) Each patient was assessed to determine if home and/or physical environment modifications were needed for the patient to return to the environment from which he/she entered the hospital, and if needed, that the modifications could be made to safely discharge the patient:
Review of the medical records of Patients #1, #2, #3, #4, and #5 revealed no documented evidence that each patient was assessed to determine if home and/or physical environment modifications were needed for the patient to return to the environment from which he/she entered the hospital. There was no documented evidence of an assessment that the required modifications, if required, could be made to safely discharge the patient.

In an interview 7/24/15 at 4:20 p.m. S3CaseManager indicated the initial interview was the start of Discharge Planning. S3CaseManager confirmed there was no documentation of an evaluation of whether or not the patient's home and/or physical environment would need to be modified on his/her discharge.
6) Each patient's insurance coverage was assessed as part of the discharge planning screening/evaluation to determine how coverage might or might not provide for the services needed post-discharge:
Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's "Patient Progress Notes" documented by the case manager revealed no documented evidence of an assessment of Patient #2's insurance coverage to determine how his coverage might or might not provide for the required oxygen.

Patient #5 Patient #5 was a [AGE]-year-old male admitted on [DATE] from a rehab facility and discharged to a long term care hospital on [DATE]. Diagnoses included Acute Kidney Failure, Unspecified (present on admission); History of Chronic Renal Failure; DM (Diabetes Mellitus) Type II; Dysphagia; and a history of Transient Ischemic Attack (TIA), and Cerebral Infarction Without Residual Deficits (present on admission).
Review of Patient #5's medical record revealed a "Readmission Screening" was completed and not a discharge planning evaluation. There was no documented evidence of an assessment of Patient #5's insurance coverage to determine how his coverage might or might not provide for a readmission to the long term acute care hospital.

In an interview on 07/24/15 at 12:50 p.m., S3CaseManager indicated the case manager doesn't always review and/or document insurance coverage in regards to coverage for identified equipment needs or patient placement.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure a discharge planning evaluation was completed on a timely basis as evidenced by failure to conduct a discharge planning evaluation when one was ordered by the physician for 1 (#2) of 1 patient record reviewed with orders for a case management consult from a total of 5 sampled patient records (#1 - #5).
Findings:

Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO (Chief Nursing Officer), revealed that patients are seen according to high risk screening criteria that is identified by Nursing Initial Interview as well as by referrals/orders from doctors and nurse practitioners.

Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME (Durable Medical Equipment) vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted to address oxygen conservation in the home.

In an interview on 07/24/15 2:50 p.m., S3CaseManager indicated when a physician orders a Case Management consult for patient care equipment, the specific request is addressed, such as arranging for oxygen, but a complete discharge planning evaluation is not done. When asked how the case manager can determine if the patient's needs can be met in the home without a complete assessment of the patient's home environment and ability to perform ADLs, S3CaseManager offered no explanation or comment.
VIOLATION: DISCHARGE PLANNING Tag No: A0812
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure a discharge planning evaluation was included in the patient's medical record as evidenced by having no documented evidence of a completed discharge planning evaluation in the records of 2 (#1, #2) of 5 patient records reviewed for discharge planning (#1 - #5) from a total sample of 5 patient records.
Findings:

Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO (Chief Nursing Officer), revealed that the nurse who admits the patient will perform the initial Discharge Planning Screen as part of the admission history and assessment, as per hospital policy. The discharge plans and and any re-evaluation or re-assessment of the plans will be documented in the medical record.

Patient #1
Review of Patient #1's medical record revealed he was a [AGE] year old male admitted from the nursing home on 03/29/15 with diagnoses of Dehydration, Altered Mental Status, and Hypernatremia.

Review of Patient #1's "Initial Interview" documented on 03/29/15 at 10:00 p.m. revealed no documented evidence of a high risk discharge screening as evidenced by the spaces for scores related to age, living status, and disability being blank. Further review revealed documentation that Patient #1 required assistance with cooking, cleaning, feeding, walking/ambulation, bathing/toileting, transportation, shopping, administering medications, and ADLs. There was no documented evidence of the type and amount of assistance needed.

Review of Case Management documentation of 03/30/15 at 3:39 p.m. revealed a discharge planning reflex (referral) was noted , and there were no further needs at this time. There was no documented evidence that a discharge planning evaluation was conducted and included in the medical record, that included an evaluation of Patient #1's living environment, home description, ADL assessment, DME used by or needed by Patient #1, home services, knowledge of the disease process, and proposed discharge disposition.

In an interview on 07/24/15 at 12:50 p.m., S3CaseManager indicated questions on the initial interview that triggers a referral to Case Management were whether the patient needs DME or home health, the ADL assessment, and whether the patient came from the nursing home. She further indicated if a patient comes from the nursing home, it triggers a consult to Case Management, but a discharge planning evaluation is not completed. When asked why a nursing home patient would be a trigger to Case Management and an evaluation was not conducted by Case Management, S3CaseManager offered no explanation.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted to address oxygen conservation in the home and included in Patient #2's medical record.

In an interview on 07/24/15 2:50 p.m., S3CaseManager indicated when a physician orders a Case Management consult for patient care equipment, the specific request is addressed, such as arranging for oxygen, but a complete discharge planning evaluation is not done. When asked how the case manager can determine if the patient's needs can be met in the home without a complete assessment of the patient's home environment and ability to perform ADLs, S3CaseManager offered no explanation or comment.
VIOLATION: QUALIFIED PERSONNEL Tag No: A0818
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure a discharge plan was developed by a registered nurse, social worker, or other appropriately qualified personnel that matched the identified needs of the patient as evidenced by failure to conduct a discharge planning evaluation and subsequent discharge plan for 2 (#1, #2) of 5 patient records reviewed for discharge planning from a total sample of 5 patient records (#1 - #5).
Findings:

Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO (Chief Nursing Officer), revealed that the nurse who admits the patient will perform the initial Discharge Planning Screen as part of the admission history and assessment, as per hospital policy. The discharge plans and any re-evaluation or re-assessment of the plans will be documented in the medical record.

Patient #1
Review of Patient #1's medical record revealed he was a [AGE] year old male admitted from the nursing home on 03/29/15 with diagnoses of Dehydration, Altered Mental Status, and Hypernatremia.

Review of Patient #1's "Initial Interview" documented on 03/29/15 at 10:00 p.m. revealed no documented evidence of a high risk discharge screening as evidenced by the spaces for scores related to age, living status, and disability being blank. Further review revealed documentation that Patient #1 required assistance with cooking, cleaning, feeding, walking/ambulation, bathing/toileting, transportation, shopping, administering medications, and ADLs. There was no documented evidence of the type and amount of assistance needed.

Review of Case Management documentation of 03/30/15 at 3:39 p.m. revealed a discharge planning reflex (referral) was noted , and there were no further needs at this time. There was no documented evidence that a discharge planning evaluation was conducted and a discharge plan was developed and included in the medical record that included an evaluation of Patient #1's living environment, home description, ADL assessment, DME used by or needed by Patient #1, home services, knowledge of the disease process, and proposed discharge disposition.

In an interview on 07/24/15 at 12:50 p.m., S3CaseManager indicated questions on the initial interview that triggers a referral to Case Management were whether the patient needs DME or home health, the ADL assessment, and whether the patient came from the nursing home. She further indicated if a patient comes from the nursing home, it triggers a consult to Case Management, but a discharge planning evaluation is not completed. When asked why a nursing home patient would be a trigger to Case Management and an evaluation was not conducted by Case Management, S3CaseManager offered no explanation.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted with the development of a discharge plan to address oxygen conservation in the home and included in Patient #2's medical record.

In an interview on 07/24/15 2:50 p.m., S3CaseManager indicated when a physician orders a Case Management consult for patient care equipment, the specific request is addressed, such as arranging for oxygen, but a complete discharge planning evaluation is not done. When asked how the case manager can determine if the patient's needs can be met in the home without a complete assessment of the patient's home environment and ability to perform ADLs, S3CaseManager offered no explanation or comment.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure:
1) Patient information was faxed/sent to the provider to which the patient was being transferred or referred for 1 (#2) of 5 (#1 - #5) patient records reviewed for discharge planning from a total of 5 sampled patient records.
2) A list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's pre-admission medications, was provided to each patient upon discharge as evidenced by failure to include the changes in the discharge medications from the
medications the patient was taking prior to admission for 2 (#4, #5) of 5 patient records reviewed for discharge planning from a total of 5 (#1 - #5) sampled patient records. Findings:

1) Patient information was faxed/sent to the provider to which the patient was being transferred or referred:
Review of the hospital policy titled "Discharge Instructions", presented as a current policy by S3CaseManager, revealed that the hospital informs other service providers who will provide care, treatment, or services to the patient about the following: the reason for a patient's discharge or transfer - the patient's physical and psychosocial status - a summary of care, treatment, and services it provided to the patient - the patient's progress towards goals - a list of community resources or referrals made or provided to the patient.

Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME (Durable Medical Equipment) vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted to address oxygen conservation in the home and included in Patient #2's medical record. Further review revealed documentation on 04/02/15 at 5:10 p.m. regarding home health services and a sleep study to be conducted post discharge.

Review of Patient #2's medical record revealed no documented evidence that Patient #2's medical information regarding oxygen needs, home health, and sleep study were faxed or sent to each respective provider.

In an interview on 07/24/15 at 4:25 p.m., S3CaseManager confirmed there was no documented evidence that Patient #2's medical information was sent to the providers that would be providing post-discharge care.

2) A list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's pre-admission medications, was provided to each patient upon discharge:
Review of the hospital policy titled "Discharge Instructions", presented as a current policy by S3CaseManager, revealed that discharge instructions ordered by the physician and the Medication Reconciliation shall be completed by a nurse. A copy of the discharge instructions and the Medication Reconciliation form is given to the patient or family member. There was no documented evidence that the policy addressed the need to include the changes in the discharge medications from the medications the patient was taking prior to admission.

Patient #4
Review of the medical record for Patient #4 revealed she was a [AGE] year old female admitted [DATE] from home, where she lived with family, via the emergency room . Patient #4 presented with complaints of 3-4 days if persistent nausea. Her diagnoses included Chronic Atrial fibrillation, Digoxin toxicity, Urinary Tract Infection, End Stage Renal Disease, Diabetes Mellitus, Peripheral Vascular Disease, Coronary artery disease, Diabetic peripheral neuropathy, and Coumadin toxicity.
Review of Patient #4's "Patient Transfer Form" dated 06/13/15 revealed a list of current medications with no documented evidence of the changes in the current medications from the home medications being taken at the time of admission.
Patient #5 Patient #5 was a [AGE]-year-old male admitted on [DATE] from a rehab facility and discharged to a long term care hospital on [DATE]. Diagnoses included Acute Kidney Failure, Unspecified (present on admission); History of Chronic Renal Failure; DM (Diabetes Mellitus) Type II; Dysphagia; and a history of Transient Ischemic Attack (TIA), and Cerebral Infarction Without Residual Deficits (present on admission). Review of his transfer form revealed no documented evidence of the changes in the current medications from the home medications being taken at the time of admission.
In an interview 7/24/15 at 4:20 p.m. S3CaseManager confirmed patients' current medications taken at discharge did not include any documentation of the changes from the patients' home medications at the time of their admission.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure that a patient's discharge plan was re-evaluated when a physician's order was received for a case management consult to evaluate for oxygen conservation in the home for 1 (#2) of 1 patient record reviewed with physician orders for a case management consult after admission from a total of 5 (#1 - #5) sampled patient records reviewed for discharge planning.
Findings:

Review of the hospital policy titled "Discharge Planning and Patient Care/Discharge Planning Meeting", presented as a current policy by S2CNO (Chief Nursing Officer), revealed that the nurse who admits the patient will perform the initial Discharge Planning Screen as part of the admission history and assessment, as per hospital policy. The discharge plans and any re-evaluation or re-assessment of the plans will be documented in the medical record.

Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Diabetes Mellitus Type 2, and Chronic Atrial Fibrillation.

Review of Patient #2's "Physician's orders" revealed an order clarification on 03/31/15 at 2:30 p.m. for home oxygen at 2 liters per nasal cannula with portable oxygen. Further review revealed an order on 04/01/15 at 1:40 p.m. for Case Management Consult for oxygen conservation at home.

Review of Patient #2's Case Management progress notes revealed on 03/31/15 at 4:24 p.m. the case manager arranged to have oxygen at home through a DME vendor. Further review revealed no documented evidence that a discharge planning evaluation was conducted with the development of a discharge plan to address oxygen conservation in the home and included in Patient #2's medical record.

In an interview on 07/24/15 2:50 p.m., S3CaseManager indicated when a physician orders a Case Management consult for patient care equipment, the specific request is addressed, such as arranging for oxygen, but a complete discharge planning evaluation is not done. When asked how the case manager can determine if the patient's needs can be met in the home without a complete assessment of the patient's home environment and ability to perform ADLs, S3CaseManager offered no explanation or comment.