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.

Based on medical record review, review of facility policy and procedures and staff interviews the facility failed to provide necessary medical information to transferring facility in 1 of 10 patient records reviewed. This deficiency could possible effect all inpatients at the time of this survey.

Finding include:

Per review of facility policy on 1/15/12 at 10:30 am titled Discharge Management, dated 4/1/09 states 3. Anticipation of needs: The multidisciplinary team should make every effort of anticipating a patient's needs, rather that reacting to events that may negatively affect the patient, their care of discharge outcome. III. A. Information (verbal and written) is communicated to the next care provider once identified and agreed upon by the patient and or their family. Information will include: 1. The reason for the patients discharge or transfer. 2. Patient's physical and psychosocial status. 3. Summary of care, treatment, and services provided to the patient.

Per interview of complainant A on 1/14/12 at 11:30 am, complainant A stated that the assisted living facility was appalled at the condition pt. #1 returned in and was far beyond what they were equipped to handle. Complainant A indicated that pt. #1 was transferred to another hospital the next morning.

Per medical record review on 1/15/12 at 12:00 pm revealed communication with Assisted Living facility on 12/17/12 that pt.#1 "would be returning to facility with an order for home care physical therapy and Registered Nurse for foley care". On 12/19/12 documentation from case management indicates that facility was updated on pt. #1 returning today." Documentation of contact with assisted living facility does not indicate a verbal update regarding physical status or interventions needed to provide care to pt. #1.

Transfer referral form sent along with patient on day of discharge to assisted living facility indicates the following information: "Pt. has foley in place. Immobilizer on. Needs assist with all cares and feeding. Pt. is on full liquid diet. Also requires assistance with positioning."

Per interview with QIC B on 1/15/12 at 12:40 am, QIC B confirmed that communication between case management and assisted living facility should have including current condition of pt. #1.

Above findings are confirmed with QIC B on 1/15/12 at 12:50 pm.
Based on medical record review, facility policy and procedure and staff interviews the facility staff failed to include the patient representative in the discharge plan in 1 of 10 patient records reviewed. This deficiency could possible effect all patients in the hospital during the survey.

Finding include:

Per review of policy on 1/15/13 at 10:00 am, titled Discharge Disposition, dated 4/2011 states under Procedure: 1. Assessment A. When the multidisciplinary team determines the patient's discharge or transfer needs, this information is promptly shared with the patient and patient's family when it is involved in decision making or ongoing care. D. Prior to discharge, the patient and /or family are informed on options of continuing care, treatment and services needed.

Complainant A stated on 1/14/13 at 11:30 am, Power of Attorney for Health Care (POA-HC) had been activated in the beginning of 2012 and that the hospital did have a copy on pt. #1's chart.

Per medical record review on 1/15/13 at 12:00 pm POA-HC records were in medical record.

Complainant A stated on 1/14/13 at 11:30 am that she thought pt. #1 would be discharged to skilled nursing facility or a subacute facility until she was strong enough to return to the assisted living facility.

Per medical record review on 1/15/13 at 12:00 pm, documentation of physician order written on 12/18 12 at 1:53 pm states "Subacute Rehab placement".

Review of Discharge/Transfer summary dictated on 12/19/12 on 1/15/12 at 12:00 pm indicate "the patient will be transferred to subacute rehab in stable medical condition".

Case Management notes indicate that family was called on 12/19/12 (discharge date ) and informed of discharge plan.

QIC C confirmed in an interview on 12/19/12 at 12:45 pm that there was no documentation present of POA-HC being updated on the discharge plan by case management staff and confirmed the above findings.