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.

CLEAR LAKE REGIONAL MEDICAL CENTER 500 MEDICAL CENTER BLVD WEBSTER, TX 77598 Aug. 11, 2015
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to implement an effective discharge planning policy/ process. The facility failed to ensure :

* Timely discharge planning for 4 of 10 sampled patients (Patient #3, # 4, # 6, # 7);

* A consistent understanding by staff of facility discharge planning process.

Findings include:

TX 020

Interview on 08-11-15 at 10:45 a.m. with Case Manager ( CM) # 7, she stated that discharge planning was done for every patient. A brief initial interview was conducted within 24 hours of admission to determine home situation, medical equipment, and other healthcare needs. CM # 7 said this initial assessment was documented in the Discharge Planning Progress Notes. CM # 7 said she was unsure if the facility used criteria that would trigger a more comprehensive discharge planning evaluation.

[Clinical records for Patients # 3, # 4, # 6, # 7 were reviewed on 08-11-15]

Patient # 7:

Review of Patient # 7's electronic medical record revealed he was 69 year ld male admitted to the facility on on [DATE] with left sided weakness and difficulty speaking. He was discharged to home on 05-18-15 with final diagnosis of right-sided carotid artery stenosis.

Further review of Patient # 7's clinical record with CM # 7, she was unable to locate any documentation of a discharge planning (DP) assessment or a DC Plan.

Patient # 6:

Review of Patient # 6's electronic medical record revealed she was [AGE] year old female admitted to the facility on 05-14-15 with vaginal prolapse and stress incontinence.

Review of "Discharge Planning Note," by CM # 7 , dated 05-15-15 , read: "Proposed Discharge Plan: Facility...Facility Type Needed: inpatient rehabilitation facility..."

Review of Patient # 6's Discharge Summary revealed she was discharged home on 05-18-15.

Interview with CM # 7 she said Patient # 6's condition must have changed for her to go home instead of a rehab facility. She was unable to locate an updated discharge planning progress note. CM # 7 went on to say the Discharge Plan should have been updated to reflect this change.

Patient # 3:

Review of Patient # 3's clinical record with CM # 7 revealed patient was a [AGE] year old female patient admitted on [DATE] for divertiliculits.

Interview on 08-11-15 at 10:50 a.m. with Registered Nurse (RN) # 3 she stated Patient # 3 was likely to be discharged after lunch.

CM # 7 was unable to locate any documentation of discharge planning in Patient # 3's electronic medical record.

Interview on 08-11-15 at 11:30 a.m. . with Patient # 3, she said she was going home today. She went on to say no one had spoken with her about discharge instructions as yet.

Patient # 4

Review of Patient #4's clinical record with CM # 7 revealed patient was a [AGE] year old female patient admitted on [DATE] for asthmatic bronchitis.

Interview on 08-11-15 at 10:50 a.m. with RN # 3 she stated Patient # 4 would be discharged today if the pulmonary physician saw her.

CM # 7 was unable to locate any documentation of discharge planning in Patient # 4's electronic medical record.

Interview on 08-11-15 at 11:45 a.m. with Patient # 4, she said she was going home today. She went on to say no one had spoken with her about discharge instructions as yet. Patient # 4 said she was unsure if her asthma medications would change or not.

Interview on 08-11-15 at 9:30 a.m. with RN # 6 she stated that the discharge planning process involved the physician writing the discharge order; nursing informed the patient & gave them medication prescriptions and discharge paperwork. She said the case managers made sure the patients had the equipment they needed. RN # 6 said it was not necessary to have a physician order for discharge planning.

Interview on 08-11-15 at 9:45 a.m. with RN # 5 she stated that case management started the discharge planning process. She went on to say that case management made "barrier rounds" every day. RN # 5 stated she was unsure if a physician order was needed for discharge planning or what might trigger a discharge planning evaluation.

Interview on 08-11-15 at 2:45 p.m. with Lead Case Manager # 4 she stated the case managers documented in Midas every day : UR/ insurance and discharge planning needs updates. She said nursing could view the case management documentation in Midas. Lead CM # 4 said the Medicare Office was not open on the weekends. On Monday mornings the case managers check for triggers for needed referrals, such as home health.

Record review of facility policy titled "The Role of Case Management/Social Services In The Discharge Planning Process," revised date 4/11, read: " Case managers have the responsibility for overall coordination of the discharge planning process...Procedure: 5.1...a. At the time of admission aspects of the patient's physiological, psychosocial and economic levels are assessed by a nurse ...A discharge planning assessment will be initiated within one working day of receipt of an order for services..."

Further review of this same policy failed to reveal a process for ongoing reassessment of the discharge plan based on patient condition.