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.

LAKELAND REGIONAL MEDICAL CENTER 1324 LAKELAND HILLS BLVD LAKELAND, FL 33805 July 15, 2020
VIOLATION: DISCHARGE PLANNING - PT RE-EVALUATION Tag No: A0802
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to re-evaluate and identify changes in the patient's function level, resulting in the failure to modify the discharge plan for one (#1) of two patients sampled.

Findings included:

A review of the facility policy and procedure titled "Case Management Plan," # AD.0052, reviewed 11/2019, showed the purpose was to provide optimized patient outcomes while facilitating patient movement through the continuum of care ..... Patients' needs are screened and assessed for discharge planning on high risk, identified needs and request. Discharge plans are established on patient needs and goals .... Discharge planning evaluations includes the patient's likely need for post hospital services .... Discharge plans help to ensure an effective transition of the patient from hospital to post- discharge, thereby assisting to reduce the factors leading to preventable hospital readmission .....

A review of Patient #1's patient care technician (PCT) documentation dated 04/22/20, showed the activity level on admission (04/22/2020) was Independent. 04/23/2020 Patient activity level changed to stand by assist. On 04/24/2020, activity level changed to one-person assist. There was no evidence that Patient #1's decline in activity level and function was addressed. Continued review of the documentation showed the patient lived alone and there was no evidence that Case Management evaluated the patient for discharge plan to prevent readmission or a negative outcome.

A review of Patient #1 discharge documentation failed to show the patient's condition on discharge. On 04/25/2020 at 8:40 AM Vital signs were taken, At 9:00 AM, documentation that the patient was not feeling well per the Patient Care Technician. No evidence found for 04/25/2020 that a shift assessed was completed, reassessed, or a discharge assessment for Patient #1.

Patient #1 discharged [DATE] at 11:52 AM

An interview on 07/14/20 at 9:50 AM, via E-Mail with Risk Manager and Director of Case Management, via E-Mail, confirmed the above medical record findings for Patient #1.