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.

ASTRIA REGIONAL MEDICAL CENTER 110 SOUTH NINTH AVE YAKIMA, WA 98902 July 25, 2012
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
Based on interview and review of hospital policies and procedures, the hospital failed to develop a written policy and procedure for discharge planning that included a process for ongoing reassessment of the discharge plan based on changes in patient condition, changes in available support, and/or changes in post-hospital care requirements.

Failure to develop a discharge planning policy and procedure that included reassessment requirements in order to identify changes in patient condition and/or circumstances risks patient harm due to inadequate discharge planning and potential hospital readmission.

Findings:

Review of hospital policies and procedures on 7/24/2012 and 7/25/2012 revealed that the hospital did not have a written policy and procedure that clearly outlined a process for ongoing reassessment of the discharge plan once the discharge plan was developed.

An interview with the hospital resource manager (Staff Member #2) on 7/24/2012 confirmed the above finding.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on interview and document review, the hospital failed to implement changes in the discharge planning process when analysis of readmission data revealed areas needing improvement.

Failure to improve the discharge planning process risks inadequate discharge planning resulting in patient harm and/or hospital readmission.

Findings:

An interview with the resource manager (Staff Member #2) and the director of nursing services (Staff Member #3) on 4/24/2012 revealed that areas for improvement or further investigation of the discharge planning process had been identified through data collection and analysis (Problem #1, #2).

As reported by the resource manager (Staff Member #2) and the director of nursing services (Staff Member #3) on 4/24/2012 and 4/25/2012, the previous resource manager responsible for implementing the improvement processes left her/his position in December of 2011. The improvement processes were not implemented.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Item #1

Based on interview and medical record review, the hospital failed to ensure that all patients were screened to identify high-risk patients that needed a comprehensive discharge planning evaluation according to hospital policy for 1 of 4 patients reviewed (Patient #2)

Failure to perform a comprehensive evaluation of a patient's healthcare needs and resources risks deterioration of the patient's health following discharge from the hospital and risks hospital readmissions

Findings:

1. During an interview on 7/24/2012 at 9:45 AM, a hospital case manager (Staff Member #1) stated that nurses were expected to complete a "Triggers for Referral" form when a patient was admitted to the hospital for inpatient care. This form included a section entitled "Psychosocial/Discharge Planning Indications". This section identified twelve criteria that triggered a comprehensive discharge evaluation by a hospital case manager. The triggers included patients who were over 75 years of age and living alone

2. Patient #2 was a [AGE] year-old patient who was admitted on [DATE] for treatment of lower left leg cellulitis. The patient's admission nursing assessment indicated that the patient lived alone. There was no "Triggers for Referral" form in the patient's record. There was no evidence in the patient's record that the patient had been referred to a case manager for a comprehensive discharge plan evaluation.
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Item #2

Based on interview and review of hospital policies and procedures, the hospital failed to develop a written policy and procedure that (1) clearly outlined the discharge planning process; and (2) included a process for addressing changes in patient condition that called for development of a discharge plan in patients not previously identified as in need of one.

Failure to develop a policy and procedure to guide staff in the discharge planning process risks inability to identify patients who require a discharge plan; and risks patient harm due to inadequate discharge planning.

Findings:

Review of hospital policies and procedures on 7/24/2012 and 7/25/2012 revealed that the hospital did not have a written policy and procedure that clearly outlined the discharge planning process nor did the hospital have a written policy and procedure for identification of patients requiring a discharge plan due to a change in condition.

An interview with the hospital resource manager (Staff Member #2) on 7/24/2012 confirmed the above findings.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and medical record review, the hospital failed to ensure that all patients who met specified screening criteria were evaluated for discharge planning needs according to hospital policy for 1 of 4 patients reviewed (Patient #4)

Failure to perform a comprehensive evaluation of a patient's healthcare needs and resources risks deterioration of the patient's health following discharge from the hospital and risks hospital readmissions.

Findings:

1. During an interview on 7/24/2012 at 9:45 AM, a hospital case manager (Staff Member #1) stated that nurses were expected to complete a "Triggers for Referral" form when a patient was admitted to the hospital for inpatient care. This form included a section entitled "Psychosocial/Discharge Planning Indications". This section identified twelve criteria that triggered a comprehensive discharge evaluation by a hospital case manager. The triggers included patients who had suspected alcohol and/or chemical dependency.

2. Patient #4 was a [AGE] year-old patient who was admitted on [DATE] for treatment of cellulitis of the right forearm. On admission, the patient's physician ordered that the patient be monitored for possible alcohol withdrawal due to a suspected history of alcohol abuse. The "Suspected alcohol and/or chemical dependency" box had not been marked by the admitting nurse on the "Triggers for Referral" form in the patient's record. There was no evidence in the patient's record that the patient had been referred to a case manager for a comprehensive discharge plan evaluation.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on interview and medical record review, the hospital failed to develop a process for educating patients about medications they should take after discharge from the hospital that included a clear indication of changes from the patient's pre-admission medications, as reflected by 3 of 3 patient records reviewed (Patients #2, #3, #4).

Failure to educate patients about their prescribed medications and any changes that have been made to their medication regimen risks patients taking their medications incorrectly. This risks deterioration of the patient's health following discharge from the hospital and risks hospital readmissions.

Findings:

1. Review of the records of 3 patients who had been admitted in June and July 2012 (Patients #2, #3, #4) revealed that 3 of 3 patients had been provided at discharge with a list of medications to be taken at home. These lists did not indicate which medications had been prescribed during the patient's hospital stay and which of the patient's medication prescriptions had not been changed..

2. On 7/24/2012 at 11:30 AM, an interview with the Chief Nursing Officer and the Vice President of Risk and Quality confirmed that the hospital did not have a process for clearly identifying and educating patients about changes in their medication regimen prior to discharge from the hospital.