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Based on document review and interview, staff members are not consistently following the facility's policies and procedures for discharge planning.

Findings:

The facility's policy titled Discharge Planning/Case Management (policy # SM-0001-0129) states that there will be a collaborative effort among multiple disciplines, the patient and significant others to evaluate and assess the patient's needs and assist with transition from the hospital to the next level of care. In 2 of 4 medical records reviewed, the medical records lacked documentation regarding plans and progress towards discharge and there was no evidence that the facility's high-risk screening tool had been utilized. Additionally, staff responsible for discharge planning were unable to report what plans were in place for patients.

Patient #1

The patient's medical record was reviewed on September 14, 2011, the review noted that this was the fourteenth admission since January. There was a physician order for "rehab" written by the pulmonary nurse practitioner (NP). The NP and pulmonologist were interviewed on September 15, 2011 at 0800. The NP reported that the order was for physical rehabilitation since the patient was complaining of weakness and that this patient did not qualify for pulmonary rehabilitation since the patient refused to quit smoking. The discharge planner was interviewed on September 15, 2011 at 0845. Upon direct questioning regarding the order for "rehab", the discharge planner reported that the order was for pulmonary rehabilitation and had requested that the patient be evaluated by the "pulmonary nurse". The hospitalist was interviewed on September 15, 2011 at 1215, he reported that the discharge plan was for pulmonary rehabilitation but was unable to further explain to the survey staff what the actual discharge plans were for this patient.

The facility's policy also references that the case managers and social workers are to utilize a high risk screening tool to identify patients who may have discharge planning needs. Discharge planning staff were not able to produce the tool. Additionally, although Patient #1 and Patient #2 met the criteria for high-risk screening, the medical record lacked documentation that additional screening for high risk patients had been implemented.

The facility's policy states that the discharge planning process will begin at the time of presentation to the hospital. It was confirmed on interview with emergency department and case management staff that the discharge screening process begins in the emergency department. The emergency department record has a section titled "living arrangements". Review of the medical record for Patient #2 noted that the patient had home care services but emergency department nursing staff failed to note the name of the agency in the record. Additionally, review of the record found that staff had identified at least two different agencies as providing services; the discharge instructions and the discharge summary report identified different home care agencies as providing services. At the time of discharge it was only noted by the discharge nurse that the patient was discharged with home care and oxygen, but there is no documentation to indicate the name of the agency, if services were in place and if oxygen was available in the home.

Based on medical record review and interview, the facility failed to include the patient's family in the discharge planning evaluation in 1 of 4 records reviewed.

Findings:

Patient # 4

On September 15, 2011 at 0900, the patient and patient's daughter were interviewed regarding plans for discharge. The patient was extremely hard of hearing. Upon direct questioning, the patient's daughter stated that she had not been involved in the discharge planning process and had taken the day off from work hoping to speak to someone about the patient's discharge. The patient had been admitted on September 12, 2011 and the daughter stated that she was not sure why the patient was still in the hospital. She reported that even though she visited the patient daily, hospital staff had not spoken with her or contacted her regarding the patient's discharge. The daughter stated that she felt the patient needed more assistance such as assisted living, but was not sure how to obtain additional services. Review of the patient's record noted that the plan was for physical and occupational therapy and that the patient had been receiving services through the visiting nurses association. Information in the medical record indicated that the case manager had discussed discharge plans directly with the patient even though there was a note on the patient's record that the patient was very hard of hearing and that the daughter requested to be involved with discussions with the patient.

At 1515 on September 15, 2011, survey staff returned to the nursing unit to meet with the patient and family regarding the patient's discharge. Nursing staff reported that the patient had already been discharged. Review of the medical record noted that the discharge notice was signed on the day of discharge. The staff nurse caring for the patient was interviewed regarding the discharge notice. The staff nurse stated that discharge notices are given to the patients at the time of discharge.

Based on medical record review and interview, there was no documentation that case management staff had done an evaluation in 1 of 4 records reviewed.

Findings:

Patient #2

Please see findings under A817

Based on medical record review and interview, there was no documentation that case management staff had done an evaluation in 1 of 4 records reviewed.

Findings:

Patient #2

This patient was admitted from home with multiple co-morbidities and needs. The patient had multiple diagnoses including chronic obstructive pulmonary disease, uncontrolled diabetes, morbid obesity (422 lbs.) and immobility. Although physician and nursing staff had referenced plans for discharge, a case management evaluation had not been completed. It was confirmed with the director of case management that an evaluation by the case manager was not in the patient's medical record.

Based on document review and interview, the facility is not currently reviewing the discharge planning process.

Findings:

During interview with quality assurance/risk and case management staff it was confirmed that the discharge planning process is not currently incorporated into the hospital's quality assurance program. At the present time, only a limited study regarding specific diagnoses are being reviewed. Additionally, the facility's policy for discharge planning does not address a reassessment of the discharge planning process. Review of the facility's quality assurance committee meeting minutes confirmed that the discharge planning process in not currently incorporated into the facility's quality assurance program.