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Based on record review and interview, the Hospital failed to conduct a discharge planning evaluation that included an assessment of the patient's capacity for self-care, i.e., the ability to perform activities of daily living such as bathing, dressing, feeding, ambulation and ability to control bladder and bowel functions and the Hospital failed to include in the evaluation an assessment of the type of insurance available to meet the patients' post discharge needs and if the insurance covered post discharge requirements for five of five discharge patients ( DP #1, #2, #3, #4 and #5).
Findings include:

1. Review of the Discharge Planning Policy, with an updated review date of 5/2015, indicated that actual and potential discharge planning needs of the patient/family will be assessed on the basis of patient's stated expectation, tasks the patient can/cannot accomplish as a result of their current health problems, physical and/or cognitive limitation, financial resources available to assist patient /other caregiver social support systems available to assist patient/family/other caregiver and levels of post-hospital care needs, among many others.

2. Record review for Discharged Patients (DP) #2, #3, #4 and #5 indicated little to no evaluation of the patients' ability to participate in self care. For example:
a. For DP #1, the discharge planning assessment for prior level of functioning only indicated that the patient had "modified independence." There was no description of his/her ability to participate in self care such as was he/she continent of bowel and bladder, could he/she ambulate with or without a device prior to hospitalization or could they self feed, etc.
b. For DPs' #2, #4 and #5, there was no assessment of their prior level of functioning in the discharge planning assessment or assessment of their ability for self care.

3. Review of the discharge planning assessments completed on DPs' #1, #2, #3, #4, and #5 indicated that in the financial sections of the assessment, the only information gathered was income source such as SSDI or retirement benefits. No type of insurance was listed and no indication was made if the insurance source would cover the intended discharge plan such as home care with oxygen or skilled nursing care (SNF). For example:
a. DP #1 came from living at home and was going to a SNF. There was no indication if there were insurance resources to cover the SNF stay.
b. DP #2, was acutely ill, and returned to the acute hospital twice and was currently readmitted to the acute hospital.
c. DP #3, was admitted from home to the acute hospital, had a stay at this hospital and then was discharged back home with services from VNA that were in place prior to the hospitalization. The patient and family did request a hospital bed for home which was ordered. There was no indication if the hospital bed was covered by any insurance in place.
d. DP #4 was admitted to the acute hospital from a SNF then to this hospital for respiratory care. The discharge plan was to return to the prior SNF however, family complained of poor care there and requested placement elsewhere which was arranged. There was no indication of insurance source or if the patient had Medicare SNF days that were available for use.
e. DP #5 was admitted for respiratory care from an acute hospital but transferred to a rehabilitation hospital with in two days that was the family's first choice when a bed became available. The discharge planning assessment was incomplete.

4. During an interview on 5/27/15, at 3:00 P.M., the Chief Operating Officer, who was covering for the Director of Case Management, said that she could see on review of the assessments, that the information, as discussed, was not on the assessment and did not follow their policy.

Based on record review and interview, the Hospital failed to provide one Discharged Patient (DP#3), who was discharged to his/her home, in a total sample of 5 discharged patients, written discharge medication instructions that used non-technical jargon and listed all medications the patient should be taking after discharge with a clear indication of changes from the patient pre-admission medication. The hospital also failed to have evidence of that DP #3 or the patient's support person was provided education on medications the patient would be taking at home, such as changes in dosages and frequencies of medications, from admission medications and the reconciliation list did not have these changes highlighted as required to call attention to the changes for the patient. Findings include:

1. Record review for Discharge Patient (DP) #3 indicated the patient received a copy of the medication reconciliation report upon discharge for their medication list.

Review of the medication reconciliation report indicated it was confusing and not written in non technical jargon for patient to clearly understand. For example:
a. All medications were listed. The title of the list was discharge medications but for each medication was a line that said "continue on discharge" with a yes or no at the end. This was easily missed by the reader.
b. Each medication order contained technical jargon. For instance, medications that were meant to be taken when needed, were written with the term "prn" meaning as needed. Dosing intervals were written as "q6h" which means every six hours and should be written as every six hours for the layperson. This was done 14 times on the medication list using different time frames such as q2h, q12h, q8h, etc. The abbreviation for milligrams (mgs) was used several times without first spelling it out and the abbreviation, mcgs (micrograms) was also used three times. Confusing these two dosing measurements can be extremely dangerous depending on the medications prescribed.
c. Review of nursing documentation and the clinical record did not indicate any discharge teaching about medications to include dose, frequency, how to take, when to take and potential side effects to be aware of or to report to the physician. There was no documentation that the patient was provided any written information about the medications in the clinical record.

2. During an interview on 5/26/15 at 2:30 P.M., the Chief Operating Officer (COO) said nursing staff told her that they get medication teaching tools off the computer for each medication and make a medication schedule for patients. The COO showed the surveyor the program on the internet but said she could see in this patient's clinical record that nothing was documented about medication teaching.