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.

BETSY JOHNSON REGIONAL HOSPITAL 800 TILGHMAN DR DUNN, NC 28334 Aug. 11, 2011
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, medical records and staff interview facility staff failed to ensure timely initial discharge planning assessments for 2 of 7 records reviewed (#2, #5).

Findings included:

Review on 08/11/2011 of facility policy "Case Management/Discharge Planning Assessment" dated 01/2009 revealed "IV. Procedure: All patients admitted to (hospital name) shall be screened for high risk factors by the Registered Nurse on admission. Patients meeting one or more of the following criteria will be referred for a discharge planning assessment. 1. Serious impairment in ability to perform ADLS (activities of daily living)...4. 75 years of age or older...6. Indigent status 7. Mental illness or substance abuse (acute episode)...A. An assessment will be made by the Case Manager or Social Worker on all patients with one or more of the aforementioned risk factors. Assessments will be completed as soon as possible but at least within 72 hours of admission."

1. Closed record review for Patient #2 revealed a [AGE] year old admitted [DATE] for change in mental status, medication-induced unresponsiveness with positive urine drug screen. Review of the History and Physical dated 06/27/2011 revealed the patient had a history of at least 20 suicide attempts with right-sided weakness from an old cerebrovascular accident (CVA or stroke). Review of the nursing admission assessment dated [DATE] at 2000 revealed "Discharge Planning/Social Work...(check-mark) No needs identified on admission." Review of form "Discharge Planning/Social Work Assessment" revealed the initial discharge assessment was completed on 06/27/2011 (five days after admission). Further review revealed "High-risk criteria...(check-mark) Serious impairment in ability to perform ADLs."

Interview on 08/11/2011 at 1320 with the case management social worker (SW) revealed the SW completed the discharge planning assessment for Patient #2 on 06/27/2011. Interview revealed the staff member received the consult from the patient's primary nurse on the day the assessment was completed (five days after admission). Interview revealed the patient's primary nurse was concerned about the patient's ability to care for herself at time of discharge. Interview revealed with the patient's history of right-sided weakness, mental health history, the fact she was unresponsive related to medication ingestion and the patient's living arrangements, there should have been a trigger for the discharge planning on the day of admission. Interview revealed the patient would have met the high-risk criteria of serious impairment in ability to perform ADLs and mental illness or substance abuse on the discharge planning section of the nursing assessment. Interview revealed the registered nurse will assess for the discharge planning high-risk criteria on the admission assessment and notify case management of the need for discharge planning assessment based on meeting high risk criteria. Interview revealed case management will see the patient within 72 hours or sooner, based on the potential discharge date , for an assessment of discharge needs. Interview revealed the discharge planning assessment for Patient #2 should have been completed at least two days sooner, based on meeting the high-risk discharge planning criteria. Interview revealed the nursing staff completing the patient's initial admission assessment failed to identify the high risk criteria on the admission assessment.

2. Closed record review for Patient #5 revealed a [AGE] year old admitted [DATE] for anemia and hypertension. Review of the nursing admission assessment dated [DATE] revealed "Discharge Planning/Social Work...(check mark) 75 years of age or older...Discharge Planning/Social Work Referral initiated by whom? (Registered Nurse initials) Date 7/07/11 1800 - pt nonverbal @ this time". Further review revealed the Discharge Planning assessment was completed on 07/14/2011 (seven (7) days since the referral for discharge planning was indicated on the nursing admission assessment).

Interview on 08/11/2011 at 1400 with discharge planning management staff revealed the discharge planning assessment should be documented in the medical record within 72 hours of referral. Interview revealed there was an assessment referral indicated in the case management database system for Patient #5 on 07/07/2011. Further interview revealed the database indicated the assessment was completed on 07/08/2011. Interview revealed there was no assessment entered into the medical record for Patient #5. Interview failed to reveal any further documented evidence the discharge planning assessment was completed within 72 hours of referral for Patient #5.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, medical records and staff interviews staff failed to ensure patients had discharge planning needs reassessed per facility policy for 2 of 6 records reviewed of patients requiring discharge planning reassessment (#8, #6).

Findings included:

Review on 08/11/2011 of facility policy "Reassessment of Patients" dated 01/2009 revealed "A. After the initial assessment, patients are reassessed by a Case Manager or Social Worker at least every 7 days and prior to discharge."

1. Open medical record review for Patient #8 revealed a [AGE] year old admitted [DATE] for upper gastrointestinal bleed. Review revealed the patient had a discharge planning assessment completed on 07/28/2011 and a reassessment on 08/06/2011 (ten 10) days since admission and nine (9) days since initial discharge planning assessment).

Interview on 08/11/2011 at 1215 with discharge planning staff revealed after the initial assessment, patients are reassessed for discharge planning needs at least every 7 days . Interview revealed the discharge planning reassessment for Patient #8 was three (3) days late and should have been completed on 08/04/2011. Interview failed to reveal any further documented evidence the discharge planning reassessment was completed as per facility policy of every seven days for Patient #8.

2. Closed medical record review for Patient #6 revealed a [AGE] year old admitted [DATE] for congestive heart failure and chronic obstructive pulmonary disease. Review revealed the initial discharge planning assessment was completed 07/14/2011 and a reassessment on 07/25/2011 (11 days after the initial discharge planning assessment was completed).

Interview on 08/11/2011 at 1410 with discharge planning management staff revealed after the initial assessment, patients are reassessed for discharge planning needs at least every 7 days . Interview revealed the discharge planning reassessment for Patient #6 was four (4) days late and should have been completed on 07/21/2011. Interview failed to reveal any further documented evidence the discharge planning reassessment was completed as per facility policy of every seven days for Patient #6.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, medical records and staff interview facility staff failed to ensure patients were counseled prior to discharge for post-hospital care needs for one of five closed records reviewed (#2).

Findings included:

Review on 08/11/2011 of facility policy "Medication Administration-Injecting Insulin" dated 02/02/2010 revealed "D. Documentation...3. Record patient teaching on Education Record. E. Follow-up...2. Explain the importance of rotating sites..."

Closed medical record review on 08/11/2011 for Patient #2 revealed a [AGE] year old admitted [DATE] for change in mental status and medication-induced unresponsiveness. Review of patient's home medications prior to admission to the facility revealed the patient was on oral medications to control blood sugar related to diabetes. Review revealed at discharge the patient was ordered sliding scale insulin (insulin dose based on blood sugar reading) before meals and at bedtime by injection. Review revealed the patient was discharged from the facility to an assisted living facility on 07/08/2011. Further review of discharge planning documentation on 07/08/2011 at 1640 revealed "Pt accepted at (name of assisted living facility) but when pt (patient) arrived there (name of staff at assisted living facility) called and said they would not take her...Dr. (physician last name) consulted and orders obtained to discharge home...1700 Discharge instructions to be given to patient and boyfriend when they return to hospital by (name of Registered Nurse)." Review of the education record for the patient failed to reveal any teaching regarding self-administered insulin injections during the patient's hospital stay and prior to discharge from the facility.

Interview on 08/11/2011 at 1450 with the registered nurse (RN) who received the discharge instructions from the case manager on 07/08/2011 at 1700 revealed the RN reviewed discharge instructions with Patient #2 and the boyfriend. Interview revealed the RN was unsure as to whether the patient received education regarding giving self-administered insulin injections while a patient at the facility and prior to discharge. Interview revealed the RN did not recall the patient being discharged on sliding scale insulin injections.

Interview on 08/11/2011 at 1420 with facility quality and performance improvement staff revealed the facility has available diabetes education material for patients to review to assist with pre-discharge education. Interview revealed the standard practice if patients require education regarding self-administered insulin injections is for nursing to make available the education book and video and observe patient's self-administering insulin then document the patient education in the medical record on the education form. Interview revealed facility nursing staff should provide insulin injection education prior to discharge. Interview revealed nursing staff failed to document any evidence in the the medical record for Patient #2 that self-administered insulin injection education was provided to the patient prior to discharge from the facility.

Interview on 08/11/2011 at 1500 with discharge planning management staff revealed the facility nursing staff should provide self-administered insulin injection education prior to the patient's discharge. Interview revealed nursing staff failed to document any evidence of insulin injection education in the medical record for Patient #2 prior to the patient's discharge home from the facility on 07/08/2011.

NC 096