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.

ADVOCATE TRINITY HOSPITAL 2320 E 93RD ST CHICAGO, IL 60617 May 16, 2019
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for that 1 of 7 (Pt #5) patient records reviewed for discharge planning, the Hospital failed to ensure timely discharge planning as required.

Findings include:

1. On 5/15/19, the Hospital's policy titled, "Discharge Planning" (8/23/17) was reviewed and required "...The Registered Nurse will provide an initial assessment of teaching/discharge needs within twenty-four (24) hours of admission..."

2. On 5/15/19, the Hospital's policy titled, "Continuum of Care" (8/23/17) was reviewed and required "...Discharge planning begins within 24 hours of admission..."

3. On 5/15/19 at 10:00 AM, Pt #5's clinical record was reviewed. Pt #5 was a [AGE] year old female admitted on [DATE] with a diagnosis of respiratory distress. Pt #5's Social Worker note dated 1/31/19, included a discharge plan communication, which indicated, "...Pt. [Pt. #5] has no homemaker or home health services. Pt. [Pt. #5] is requesting homemaker..." Pt #5's clinical record lacked documentation regarding discharge planning within 24 hours of admission.

4. On 5/15/19 at 10:30 AM, an interview was conducted with the Care Manager (E #1). E #1 stated that normally she does the discharge planning on admission.

5. On 5/15/19 at 11:00 AM, an interview was conducted with the discharge Social Worker (E #2). E #2 stated that discharge planning should be documented when the patient is admitted and documented each day until the patient is discharged .
VIOLATION: DISCHARGE PLANNING Tag No: A0812
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for that 1 of 7 (Pt #2) patient records reviewed for discharge planning, the Hospital failed to ensure documentation of a discharge plan as required.

Findings include:

1. On 5/15/19, the Hospital's policy titled, "Discharge Planning" (8/23/17) was reviewed and required "...The Registered Nurse will provide an initial assessment of teaching/discharge needs within twenty-four (24) hours of admission..."

2. On 5/15/19, the Hospital's policy titled, "Continuum of Care" (8/23/17 was reviewed and required "...Discharge planning begins within 24 hours of admission..."

3. On 5/15/19 at 10:15 AM, Pt #2's clinical record was reviewed. Pt #2 was a [AGE] year old female admitted on [DATE] with a diagnosis of pneumonia. A Physician's discharge order for 5/15/19, indicated, "...Discharge patient f/u [follow-up] in my office in 1 week." Pt #2's clinical record lacked documentation regarding discharge planning.

4. On 5/15/19 at 10:30 AM, an interview was conducted with the Case Manager (E #1). E #1 stated that normally she does the discharge planning on admission. E #1 stated that she was responsible for Pt #2's discharge plan documentation. E #1 stated that she is not sure why she did not document Pt #2's discharge plan.

5. On 5/15/19 at 11:00 AM, an interview was conducted with the discharge Social Worker (E #2). E #2 stated that discharge planning should be documented when the patient is admitted and documented each day until the patient is discharged .
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 7 (Pt. #1) patient records reviewed for discharge planning, the Hospital failed to ensure that Pt. #1 was not discharged prior to receiving insurance authorization for transfer to an Acute Rehabiliation Hospital.

Findings include:

1. On 5/15/19, the Hospital's policy titled, "Continuum of Care" (8/23/17) was reviewed. The policy included, "...F. 'Post Exit' Need Identification...To assist the physician and the primary nurse on complex patient care situations, key individuals collaborate to mobilize resources needed for post hospitalization patient care needs. These individuals are the care managers and social workers..."

2. On 5/15/19, Pt. #1's medical record was reviewed. Pt. #1 was a [AGE] year old male who was admitted on [DATE] for an acute CVA (Cerebral Vascular Accident/ decreased blood flow to the brain). Pt. #1 was discharged home on 3/14/19.

-Pt. #1's Physical Medicine and Rehabilitation Consultation/Preadmission Screen (PAS) note dated 3/13/19, included, " ...the patient [Pt. #1] would benefit from 24-hour availability of the rehabilitation team for closer medical monitoring and coordination of care with specialists ...Our Rehab [rehabilitation] team will continue to follow the patient and admit to acute rehab [rehabilitation] pending insurance approval, medical clearance, and bed availability. If insurance denial for acute rehab, recommend home with home PT/OT/RN/ST [Physical Therapy, Occupational Therapy, Registered Nurse, Speech Therapy]."

-Pt. #1's discharge planning note dated 3/14/19 at 9:25 AM, included, "f/up [follow-up] rehab per [acute rehab hospital] admission ...still awaiting for insurance approval ...states Pt. [Pt. #1] medical records forward to insurance care mgr [manager] ...expects insurance determination for today ..."

-Pt. #1's Physician progress note dated 3/14/19 at 9:25 AM, included, " ...Disposition - Insurance denies acute rehab placement - Discharge home with home health ..."

-Pt. #1's Physician orders included an order dated 3/14/19 at 3:18 PM, to discharge home with home health care.

-Pt. #1's medical record lacked documentation of insurance denial for the Acute Rehab Hospital, however, Pt. #1 was discharged on [DATE] prior to insurance notification of approval or denial.

3. Pt. #1's discharge planning note dated 3/15/19 at 11:38 AM, included, "On 3/14/19 pt. [Pt. #1] d/c [discharged home] via family transportation. On 3/15/19, call received from [acute rehab hospital] admission ...states pt. [Pt. #1] insurance approved for acute rehab placement ...insurance approval and transportation to be set-up from pt. [Pt. #1] home to [acute rehab hospital] to be paid by [referring Hospital] ...pt. [Pt. #1] wife ...notified ...per [Pt. #1's wife] pt. [Pt. #1] fell @ [at] home the a.m./unable to take care of pt. [Pt. #1] @ home ..."

4. On 5/15/19 at approximately 11:20 AM, an interview with a Care Manager (E #1) was conducted. E #1 stated that Pt. #1's insurance authorization for admission to the Acute Rehab Hospital was not denied.

5. On 5/15/19 at approximately 1:05 PM, an interview with the Hospitalist (MD #1) was conducted. MD #1 stated that the Care Manager informed her (MD #1) of Pt. #1's insurance denial for the Acute Rehab Hospital stay, therefore, Pt. #1 was discharged home.