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Based on hospital policy, state agency complaint information, medical record review and staff interview (A), the LTAC hospital failed to ensure that 3 of 6 patients (#'s 1, 2 and 3) had an effective discharge planning process governed by hospital policy. This occurred in 1 of 3 total patients discharged to home with supportive care, in a total sample of 6 discharged patients. This has the ability to affect the total patient census of 22 patients.

Findings include:

1) The LTAC hospital failed to ensure that it's hospital discharge planning policies included written language of which patients would be screened and what criteria would be used in the patient screening process to determine further discharge needs. (Reference A 800)

2) The LTAC hospital failed to ensure that it followed hospital discharge planning policy for evaluation of patient/patient family abilities to provide care post-discharge, and the documentation of that care. (Reference A 806)

3) The LTAC hospital failed to ensure that it followed hospital discharge planning policy for educational instruction of patient's post-discharge caregivers, and failed to document educational instruction of those caregivers. (Reference A 820)

4) The LTAC hospital failed to ensure that it's post hospital care agencies received the necessary medical information per federal regulations and facility policy. (Reference A 837)

These cumulative systemic failures provide potential for adverse patient outcomes after hospital discharge.

Based on medical record review and staff interview (A), the long term acute care (LTAC) hospital failed to ensure that 2 of 3 Medicare patients (#1 and #3) were informed of their Medicare discharge rights upon hospital discharge. This occurred in a total of 3 Medicare patients, in a total sample of 6 sampled patients, and has the ability to affect all Medicare in-patients entering this LTAC.

Findings include:

1) The 1/16/14 at approx. 1:45 p.m. medical record review of Patient #1 reflects no documentation of a Medicare Discharge IM notice being given to, or signed by this Medicare patient before hospital discharge on 7/10/13.

In interview with CNO A on 1/16/14 at approx. 4 p.m., she states that no additional information can be found.

2) The 1/16/14 at approx. 2:30 p.m. medical record review of Patient #3 reflects no documentation of a Medicare Discharge IM notice being given to or signed by before this Medicare patient before hospital discharge on 10/30/13.

In interview with CNO A on 1/16/14 at approx. 4 p.m., she states that no additional information can be found.

Based on facility grievance file review and staff interview (A), the LTAC hospital failed to ensure that written decision notice information was provided to all the complainants, and that the written notice contained the required notice information. This occurred in 1 of 1 total grievances reviewed, in a total sample of 1 patient/patient representative having a hospital complaint. This occurred in a total sample of 6 patients; having the ability to affect the total census of 22 patients.

Findings include:

The 1/15/14 at 1 p.m. review of Patient #1's "Patient/Family Complainant or Grievance Form dated 7/9/13 at 6:30 p.m. "documents under "persons voicing complaint/grievance: Family Members E and F".

The 1/15/14 at 1 p.m. review of the complaint response letter dated 7/16/16 (sic- should be 2013) written by QM Director B was addressed to "Patient #1 and family" at the patient's address. This response letter did not reach Family member/Complainant E who lives at a different address than Family Member F and Patient #1. Further review of this letter reflects no documentation of the date of completion that is required in the written decision notice.

In interview with CNO A at 4 p.m. on 1/15/14, the results of the evaluation of this patient grievance were given. CNO A stated that she would talk with QM Director B.

Based on medical record review and staff interview (A), the LTAC hospital failed to ensure that 1 of 1 patients (#1), who suffered a fall, was provided with a nursing care plan in an attempt to prevent further falls. This occurred in 1 of 1 patients suffering falls while hospitalized, in a total sample of 6 patients; having the ability to affect the total census of 22 patients.

Findings include:

The 1/16/14 at approx. 2:30 p.m. medical record review of Patient #1 documents that a fall from bed occurred on 7/8/13 at approx. 10:40 p.m..

Review of the "Transdisciplinary Plan of Care" copied by CNO A on 1/16/14 at 4:30 p.m. documented no evidence of a care planned goals or interventions for the 7/8/13 fall or the continued risk of falls, under "Problem 7: Safety".

In interview with CNO A on 1/16/14 at approx. 4 p.m., she states that no additional information can be found.

Based on review of hospital incident reporting (Patient #1) and staff interview (A), the LTAC hospital failed to ensure that 1 of 1 patients (#1)
had 1 of 1 pieces of safety equipment (bed alarms) that was maintained to ensure an acceptable level of patient safety. This occurred in 1 of 1 patients (#1) using safety equipment to prevent falls, in 1 of 1 total pieces of safety equipment (bed alarms) reviewed, in a total sample of 6 patients. This has the ability to affect all patients using bed alarms to prevent falls, in a total patient census of 22 patients.

Findings include:

The 1/16/14 at 11:30 a.m. review of Patient #1's "Incident Report" dated 7/8/13 at 10:40 p.m. documents a fall from bed. Under "Additional Comments," RN G documents "found alarm in bed not activated due to malfunction. When alarmed it stayed on continuously. NOC (night) CNA (certified nurse assistant) said day CNA told her bed alarm was not working so a tab alarm was placed which never alarmed when patient (#1) sat on edge of bed and slipped to floor".

In interview with CNO A on 1/16/14 at approx. 4 p.m., she states that the hospital has a policy for restraint use, but does not have a hospital policy for the use of bed alarms, which includes functional safety checks by hospital staff, as per manufacturer's recommendations, to ensure proper function and use.

Based on review of hospital policies and staff interview (A), the LTAC hospital failed to ensure that their discharge plan policies contained informational criteria for the screening process in order to avoid adverse health consequences in the patient discharge process. This occurred in 3 of 3 total discharge planning policies reviewed (see below), and has the ability to affect the total patient census of 22 patients.

Findings include:

CNO A on 12/23/13 at approx. 12:30 p.m. was asked for all hospital that directed discharge planning procedures in the hospital. At approx. 1:30 p.m. CNO A provided the following 3 policies:
1) "Policy 021-29-001.5- Discharge Planning, Discharge Documentation; effective March 1998, last revision date June 2011".
2) "Policy 021-24-001.3-Transdisciplinary Care Planning; effective date March 1998, last revision Dec. 2013"
3) "Policy 021-25-004- Patient and Family Conferences; effective March 1998, last revised January 2004".

The 1/15/14 review of the above policies at 2 p.m. reflects the following required policies failed to specify in writing all of the important screening criteria that it's patients are likely to need in the discharge planning process. These policies lacked the following:
1) evaluation of the cognitive ability or mental limitation of the patient,
2) patient's ability for self care,
3) functional capabilities of family or significant others involved in patient care if patient is home-bound, or going to an environment where skilled care is intermittent or not given, and
4) availability of needed discharge services.

In interview with CNO A on 1/16//14 at approx. 3:30 p.m. she states that all patients admitted to this hospital are screened and provided with discharge planning, but acknowledged that the policies did not say so.

Based on hospital policy, state agency complaint information, medical record review and staff interview (A), the LTAC hospital failed to ensure that 1 of 1 patients (#1) received a discharge planning evaluation, that informed the patient's caregivers (family) of patient care needs upon discharge to home, per hospital policy. This occurred in 1 of 3 total patients discharged to home with supportive care, in a total sample of 6 discharged patients. This has the ability to affect the total patient census of 22 patients.

Findings include:

Hospital policy "021-29-001.5- Discharge Planning, Discharge Documentation, effective March 1998, revised June 2011" reviewed on 1/15/13 at 2 p.m. states under "C.1. When the hospital determines the patient's discharge or transfer needs, the Case manager/Social Worker promptly shares this information with the patient, and also the patient's family when it is involved in decision making or ongoing care. C.2. Before the patient is discharged, the hospital informs the patient, and also the patient's family when it is involved in decision-making or ongoing care, of the kinds of continuing care, treatment and services the patient will need.".

Medical record review conducted on 1/15/14 review at approx. 2:30 p.m.
shows that Patient #1 was discharged to home with hospice care on 7/10/13.

Complainant #7's (Patient #1's family member) documentation to the state agency on 10/14/13 at 9:32 a.m. reflects that the complainant and other family members were not informed of the discharge needs for Patient #1.

Medical record review conducted on 1/15/14 review at approx. 2:30 p.m. of Patient #1's "Case Management Assessment", "Case Management Progress Notes" dated 6/28/13 at 1 p.m. through 7/15/13 at 9 a.m., The "Discharge Order and Instruction Form" dated 7/10/13 (no time recorded), and the "Transdisciplinary Patient/Family Education Record" reflects no documentation of the ability of the "family support system- persons providing direct care to patient at discharge" to care for this patient after discharge. There is no documentation of what care education aspects that patient or family members need to be successful after discharge.

In interview with CNO A on 1/16/13 at approx. 4 p.m. she acknowledged that CM D's (case manager of the discharge) documentation was lacking.

Based on hospital policy, state agency complaint information, medical record review and staff interview (A), the LTAC hospital failed to ensure that 1 of 1 patient's (#1) family/caregivers were informed and received education on post hospital discharge care needs, per hospital policy. This occurred in 1 of 3 total patients discharged to home with supportive care, in a total sample of 6 discharged patients. This has the ability to affect the total patient census of 22 patients.

Findings include:

Medical record review conducted on 1/15/14 review at approx. 2:30 p.m.
shows that Patient #1 was discharged to home with hospice care on 7/10/13.

Complainant #7's (Patient #1's family member) documentation to the state agency on 10/14/13 at 9:32 a.m. reflects that the complainant and other family members were not informed of the discharge needs for Patient #1.

Hospital policy "021-29-001.5- Discharge Planning, Discharge Documentation, effective March 1998, revised June 2011" reviewed on 1/15/13 at 2 p.m. states under "E. Educational needs of the patient, legal representative and the family are identified as early as possible beginning in the evaluation phase. A plan to address any educational needs is identified and put in place to assure the patient and family/care giver have sufficient knowledge and understanding to achieve a successful transition to the expected discharge location and level of care. The Case Manager/Social Worker educates the patient, and also the patient's family when it is involved in decision making or ongoing care, about how to obtain any continuing care, treatment, and services that the patient will need.".

Medical record review conducted on 1/15/14 review at approx. 2:30 p.m. of the "Discharge Order and Instruction Form" (used to provide and validate transfer of information at discharge) dated 7/10/13 (no time recorded), documents no review of nutritional service, respiratory service, physical therapy service, occupational therapy service, speech therapy services or nursing services care (inclusive of this patient's pressure ulcer wound care and medication listing) instructions being reviewed with/or given to patient or family at discharge. There was no documented evidence of the evaluation or need for DME supplies to support the patient and family until the hospice agency could evaluate home needs.

Interview with CNO A on 1/16/13 at approx. 4 p.m. reflects that the above form was not acknowledged by patient or family signature or notation from CM or nursing staff to show this information was reviewed. In interview with CNO A on 1/16/13 at approx. 4 p.m. she acknowledged that CM D's documentation was lacking.

Based on hospital policy review, review of state agency complaint data, medical record review and staff interview(A), the LTAC hospital failed to ensure that 3 of 6 discharged patients (#'s 1, 2,and 3), needing supportive care post discharge from other agencies, had the necessary medical information transferred to those agencies. This occurred in a total of 4 patients needing supportive care from outside agencies, in a total of 6 discharged patients reviewed. This has the ability to affect the total patient census of 22 patients.

Findings include:

1) Medical record review conducted on 1/15/14 review at approx. 2:30 p.m.
shows that Patient #1 was discharged to home with hospice care on 7/10/13.

Complainant #7's (Patient #1's family member) documentation to the state agency on 10/14/13 at 9:32 a.m. reflects that the complainant alleges that family members and the hospice staff responding to Patient #1's home on 7/10/13 at approx. 4 p.m. were not provided with necessary medical information needed for transfer of care from hospital to home.

Medical record review conducted on 1/15/14 review at approx. 2:30 p.m. of Patient #1's medical record reflects a fax sheet cover page, that was sent to the patient's chosen hospice agency on 7/10/13 at 10:53 a.m. This fax cover page documents that 5 pages of unknown information were sent. There is no documented evidence in this patient's medical record that the following necessary "medical information", per federal Medicare regulations for hospitals, was given to the hospice agency or the patient/patient family members, which includes but is not limited to:
1) brief reason for hospitalization,
2) brief description of hospital course of treatment,
3) patient condition at discharge including cognitive and functional status and social supports needed,
4) medication list, inclusive of list showing what was given at hospital on day of discharge,
5) list of allergies/ drug interactions,
6) pending labwork and significant test results,
7) care instructions and and training provided to patient's caregivers,
8) any follow-up medical appointments, and
9) the name and contact numbers of any referred caregiver agencies needed to provide discharge care.

On 1/15/13 at approx. 3:30 p.m. information provided by CNO A was reviewed. CNO A stated, at the above time, that she had contacted Patient #1's hospice, and requested that they send all the paperwork that was faxed to the hospice from the hospital. Review of the 52 page document from the hospice dated "1/2/13(sic-should be 2014)" reflects that the following pages are missing: pages 3 -10. This faxed information was not inclusive of the following:
1) the LTAC hospital's discharge summary describing reason for hospitalization and medical care course of treatment, inclusive of discharge treatment orders.
2) social supports needed,
3) care instructions and and training provided to patient's caregivers,
4) any follow-up medical appointments,
5) the name and contact numbers of any referred caregiver agencies needed to provide discharge care.

Hospital policy "021-29-001.5- Discharge Planning, Discharge Documentation, effective March 1998, revised June 2011" reviewed on 1/15/13 at 2 p.m. states under "M. Documentation for nursing home placement, rehab facility, or short term care facility include at least the following:
1. Required admission forms as applicable
2. History and physical
3. Face Sheet
4. List of discharge medications
5. Discharge summary from physician
6. Copy of discharge orders
7. Memorandum of Transfer (Hospital Transfer only)

N. Referrals made to Hospice services are as follows:
1. requires a physician order and prognosis of 6 months or less
2. Contact the Hospice of patient/family choice
3. Recommend Hospice Nurse or volunteer make an on-site visit to the hospital prior to discharge
4. Provide requested documentation to Hospice
5. List of discharge medications."
This policy is not inclusive of the "necessary medical information" that is necessary for transfer as above.

Interview with CNO A on 1/16/13 at approx. 4 p.m. reflects that the hospital does not have a process for documenting the specific documents sent with the patient or given to the patient/patient families/ significant others to ensure that the "necessary medical information" is transmitted to the appropriate person(s).

2) Medical record review conducted on 1/16/14 review at approx. 2 p.m. of Patient #2's medical record reflects a fax sheet cover page, that was sent to the patient's chosen HAH on 11/13/13 at 1:34 p.m. This fax cover page documents that 3 pages of unknown information were sent. There is no documented evidence in this patient's medical record that the following necessary "medical information" was given to the HHA or the patient upon discharge, when Patient #2 went home with HHA support at 6 p.m. on 11/13/13:
1) brief reason for hospitalization,
2) brief description of hospital course of treatment,
3) patient condition at discharge including cognitive and functional status and social supports needed,
4) pending labwork and significant test results,
5) any follow-up medical appointments, and
6) the name and contact numbers of any referred caregiver agencies needed to provide discharge care.

Interview with CNO A on 1/16/13 at approx. 4 p.m. reflects that the hospital does not have a process for documenting the specific documents sent with the patient or given to the patient/patient families/ significant others to ensure that the "necessary medical information" is transmitted to the appropriate person(s).

3) Medical record review conducted on 1/16/14 review at approx. 2:30 p.m. of Patient #3's medical record reflects a fax sheet cover page, that was sent to the patient's chosen hospice care facility on 10/29/13 at 11:52 a.m. This fax cover page documents that 19 pages of unknown information were sent. This faxed cover page documents "progress notes and MAR (medication list)" were faxed to the hospice agency, but does not delineate which "progress notes" were provided. There is no documented evidence in this patient's medical record that the following necessary "medical information" was given to the HHA or the patient/patient family members:
1) brief reason for hospitalization,
2) brief description of hospital course of treatment,
3) patient condition at discharge including cognitive and functional status and social supports needed,
4) pending labwork and significant test results, and
5) care instructions.
This patient was recorded in the "daily nursing assessment" as leaving the facility at 12 noon on 10/30/13.

Interview with CNO A on 1/16/13 at approx. 4 p.m. reflects that the hospital does not have a process for documenting the specific documents sent with the patient or given to the patient/patient families/ significant others to ensure that the "necessary medical information" is transmitted to the appropriate person(s).