HospitalInspections.org

Based on review of Hospital policy, clinical records and patient interview, it was determined that for 1 of 4 clinical records reviewed (Pt. #1), the Hospital failed to ensure staff assessed and evaluated patient discharge needs in accordance with policy.

Findings include:

1. Hospital policy titled," Discharge Planning revised 4/11" included,"Within 24 hrs of admission (except on holidays or weekends) the Case Management Department staff will make an assessment of potential patient needs."

2. The clinical record for Pt. #1 included that Pt. #1, a 61 year old female, was admitted on 7/19/12 with a diagnosis of Left Foot Gangrene. The nursing admission assessment, dated 7/19/12 contained a "Hospital Discharge Screening Criteria For High Risk Older Adults". Pt. #1 was listed as a "low risk" for post discharge intervention. The clinical record contained an RN request for a Social Service consult on 7/19/12 at 1:26 PM. There was no documentation that a consult was obtained as of 7/24/12 (5 days after admission) There was no documentation of a patient needs assessment by Social Service/Case Management.

3. On 7/24/12 at approximately 1:30 PM, Pt. #1 was interviewed. Pt. #1 stated that she will need more surgery and does not know what her home needs will be. Pt. #1 stated that she has not been evaluated by a discharge planner.

4. During record review, the Case Manager (E#3) was unable to locate a social worker evaluation.