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Based on review of facility discharge planning policy and procedures, interview, personnel file review, review of medical records (MR), and review of the facility Quality Assurance Performance Improvement (QAPI) documentation the facility did not have coordinated discharge policies and procedures, QAPI for review of the discharge process, and documented qualified discharge planners. This affected MR # 3 and MR # 7 (2 of 8 MRs reviewed) and had the potential to affect all patients requiring discharge planning.

The findings include:

REFER to: A 800, A806, A807, A820, and A 843.

Based on interviews, medical record (MR) review, and review of facility policies and procedures, the facility failed to document the specific colostomy teaching and patient goal directed discharge planning for a patient (MR# 3) with a new colostomy and a patient with a negative pressure wound dressing (MR # 7). This affected 2 of 8 MRs reviewed and had the potential to affect all patients who are discharged from this facility.

The findings include:


Policy # ST-PC-505
Policy Title: Utilizations Management Plan
Revised: 6/2012
IX. Discharge Planning/ Social Services
The process of discharge planning begins prior to, or at admission, for all acute care medical surgical patients. The Case Manager screens all patients to assess their potential post- hospitalization needs. The following factors are considered when assessing the patient's discharge needs: functional status, cognitive ability of the patient, and family support. They work with attending physicians, patients and families to assure continuity of care after discharge ... The Case Manager assesses discharge planning needs within one working day of the patient's admission and initiates discharge planning when post- acute care needs are identified to include nursing home or rehabilitation placement, durable medical equipment, home health care, hospice or transportation is needed. Discharge planning activities include provisions for, or referral to, services required to improve or maintain health status after discharge...

A discharge planning evaluation will be provided to the patient's identified needing post hospitalization needs ... A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of the evaluation.

During the process of concurrent review, the Case Manager or qualified personnel will reassess discharge planning needs as necessitated by changes in patient/family conditions. The Case Manager, registered nurse, social worker, or other appropriately qualified personnel will develop, or supervise the development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan. The Case Manager or qualified personnel assists those patients in need of additional resource. These include, but are not limited to: financial assistance, emotional support, counseling, and Medicaid and guardianship programs. All discharge planning activities will be clearly documented in the patient's medical record.


Policy # ST-PC-510
Policy Title: Discharge Planning and Referrals of Patients to Post discharge Providers
Revised: 11/2012
4.0 Policy ... Discharge planning is performed on all in-patients. Discharge planning reassessment is performed if there are any factors that may affect continuing care needs of the plan's appropriateness. Patients will be informed of their options as to their post discharge needs and have the ultimate choice in selecting the Provider/Service.

1. MR # 3 was admitted to the facility on 7/24/13 with diagnosis of Abdominal Pain and Colon Lesion. MR # 3 had surgery and a Colostomy was placed on 7/26/13. MR # 3 was discharged on 7/30/13.

The MR was reviewed and there was no documentation provided to indicate a return demonstration of colostomy care or if additional instruction was needed prior to discharge. The MR did not indicate whether the patient or caregiver would be providing the care when MR # 3 was discharged.

MR # 3 stated during a telephone interview on 8/30/13 at 12:26 PM, the hospital had not given her any instruction on how to care for her colostomy when she went home. She stated the hospital did not send any supplies home with her to use until the Home Health arrived the next morning. MR # 3 went home on 7/26/13 and during the night the colostomy bag busted and the contents spilled out onto everything. She did not have another bag or know how to care for herself and she called the Home Health which came out in the middle of the night to care for her. MR # 3 stated if she had been taught how to care for the colostomy and had the supplies she would not have had to call the Home Health in the middle of the night.

The facility failed to supply MR # 3 with sufficient colostomy supplies until the home health admission. The facility also failed to document the specific colostomy care taught and MR # 3's response to the teaching to ensure MR # 3 was appropriate for discharge.

2. MR # 7 was admitted to the facility on 8/24/13 with diagnosis of Perforated Colon Status Post Right Hemicolectomy 8/25/13. MR # 7 was discharged home on 9/3/13.

The MR was reviewed and there was no documentation provided to indicate a return demonstration of wound care or if additional instruction was needed prior to discharge. The MR did not indicate whether the patient or caregiver would be providing the care when MR # 7 was discharged.

During a telephone interview on 9/17/13 at 9:00 AM, MR # 7 stated the hospital did not send extra wound supplies to apply if the negative pressure dressing failed (wound spray cleanser to clean the wound or other wound care supplies) prior to home health arriving the next day.

The facility failed to supply MR # 7 with sufficient wound care supplies until the home health admission. The facility also failed to document the specific wound care taught and MR # 7's response to the teaching to ensure MR # 7 was appropriate for discharge.

On 9/5/13 at 9:20 AM, Employee Identifier (EI) # 7, Case Manager for 3rd Floor Short Stay Unit, was interviewed and verified documentation of the education and discharge planning would be documented in the patient MR.

EI # 8, the Education Director, was interviewed on 9/5/13 at 12:20 PM, and verified documentation of teaching and discharge planning would be in the MR under several different tabs.

MR # 3 and MR # 7 charts were reviewed and the specific teaching and patient responses were not documented to ensure MR # 3 and MR # 7 were appropriate for discharge home.

Based on medical record (MR) review, interview, and review of the facility policy and procedures, the facility failed to document MR # 3's self care deficits and the teaching provided to enhance MR # 3's self care with a new colostomy. The facility also failed to document wound self care by MR # 7 prior to discharge, to ensure MR # 7 could safely change a negative pressure dressing. This affected MR # 3 and MR # 7 (2 of 8 MRs) and had the potential to affect all discharged patients.


The findings include:

Policy # ST-PC-505
Policy Title: Utilizations Management Plan
Revised: 6/2012
IX. Discharge Planning/ Social Services
The process of discharge planning begins prior to, or at admission, for all acute care medical surgical patients. The Case Manager screens all patients to assess their potential post- hospitalization needs. The following factors are considered when assessing the patient's discharge needs: functional status, cognitive ability of the patient, and family support. They work with attending physicians, patients and families to assure continuity of care after discharge ... The Case Manager assess discharge planning needs within one working day of the patient's admission and initiates discharge planning when post- acute care needs are identified to include nursing home or rehabilitation placement, durable medical equipment, home health care, hospice or transportation is needed. Discharge planning activities include provisions for, or referral to, services required to improve or maintain health status after discharge...

A discharge planning evaluation will be provided to the patient's identified needing post hospitalization needs ... A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of the evaluation.

During the process of concurrent review, the Case Manager or qualified personnel will reassess discharge planning needs as necessitated by changes in patient/family conditions. The Case Manager, registered nurse, social worker, or other appropriately qualified personnel will develop, or supervise the development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan. The Case Manager or qualified personnel assists those patients in need of additional resource. These include, but are not limited to: financial assistance, emotional support, counseling, and Medicaid and guardianship programs. All discharge planning activities will be clearly documented in the patient's medical record.


1. MR # 3 was admitted to the facility on 7/24/13 with diagnosis of Abdominal Pain and Colon Lesion. MR # 3 had surgery and a Colostomy was placed on 7/26/13. MR # 3 was discharged on 7/30/13.

The MR was reviewed and there was no documentation to indicate a return demonstration of colostomy care or if additional instruction was needed prior to discharge. The MR did not indicate whether the patient or caregiver would be providing the care or if they had the capacity to provide care of the new colostomy when MR # 3 was discharged home.

MR # 3 stated during a telephone interview on 8/30/13 at 12:26 PM, the hospital had not given her any instruction on how to care for her colostomy when she went home. She stated the hospital did not send any supplies home with her to use until the Home Health arrived the next morning. MR # 3 went home on 7/26/13 and during the night the colostomy bag busted and the contents spilled out onto everything. She did not have another bag or know how to care for herself and she called the Home Health which came out in the middle of the night to care for her. MR # 3 stated if she had been taught how to care for the colostomy and had the supplies she would not have had to call the Home Health in the middle of the night.

2. MR # 7 was admitted to the facility on 8/24/13 with diagnosis of Perforated Colon Status Post Right Hemicolectomy 8/25/13. MR # 7 was discharged home on 9/3/13.

The MR was reviewed and there was no documentation provided to indicate a return demonstration of wound care if the negative pressure wound system failed or if additional instruction was needed prior to discharge. The MR did not indicate whether the patient or caregiver would be providing care when MR # 7 was discharged home with home health services.

During a telephone interview on 9/17/13 at 9:00 AM, MR # 7 stated the hospital did not send extra wound supplies (wound spray cleanser to clean the wound or other wound care supplies) to apply if the negative pressure dressing failed prior to home health arriving the next day.

Based on review of facility policy and procedures, job descriptions, and review Case Managers / Discharge Planners personnel files revealed the facility failed to provide documentation 3 of 3 Case Manager/ Discharge Planners were qualified to provide discharge planning for all patients in the facility needing discharge planning. This had the potential to negatively affect all patients requiring discharge planning.

The findings include:

Policy # ST-PC-505
Policy Title: Utilizations Management Plan
Revised: 6/2012
IX. Discharge Planning/ Social Services
A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of the evaluation.

Personnel File Review:
A review of the "Position Description/Competency Based Evaluation- Case Manager (Discharge Planning)" contained information that included:

Position Purpose: Reporting to the Director of Case Management, The Discharge Planning Case Manager is responsive to assist in the development, planning, coordination and administration of the activities of discharge planning.

Experience: Three years experience in case management or utilization management preferred. Registered Nurse with at least one year clinical experience on a medical/surgical unit with excellent communication skills and ability to work collaboratively with all members of the health team.


General Duties: ... 7. Competently coordinates the discharge planning and social services function to ensure a timely, safe discharge ... 14. Coordinate post discharge services to include: communicating discharge plans and changes to physicians, nursing staff, patient, family members and outside agencies and leave detailed communication of plans for after hours and weekend discharges with nursing staff and week end case managers. 15. Maintains accurate, detailed files and/or records as appropriate.

Department/ Job Specific Competencies: 1. Completes discharge planning assessment and documents in the patient's record in the defined time frame ... 4. Correctly obtains the patient's/client's preference for post discharge treatment in reference to skill nursing care, home health needs, and durable medical equipment.

A review of 3 Case Managers personnel files revealed there was no documentation of specific competencies related to discharge planning.

The Quality Director, Employee Identifier # 1, was interviewed on 9/5/13 at 2:05 PM, and during the interview verified the Case Manager personnel files reviewed did not contain specific competencies related to discharge planning.

Based on medical record (MR) review, review of policy and procedures and interviews, the hospital staff failed to document the colostomy care training for MR # 3 and wound care instructions for MR # 7. This affected 2 (MR # 3 and MR # 7) of 8 medical records reviewed and had the potential to negatively affect all patients discharged from the hospital.

The findings include:

Policy # ST-PC-505
Policy Title: Utilizations Management Plan
Revised: 6/2012
IX. Discharge Planning/ Social Services
The process of discharge planning begins prior to, or at admission, for all acute care medical surgical patients. The Case Manager screens all patients to assess their potential post- hospitalization needs. The following factors are considered when assessing the patient's discharge needs: functional status, cognitive ability of the patient, and family support. They work with attending physicians, patients and families to assure continuity of care after discharge ... The Case Manager assess discharge planning needs within one working day of the patient's admission and initiates discharge planning when post- acute care needs are identified to include ... durable medical equipment, home health care... Discharge planning activities include provisions for, or referral to, services required to improve or maintain health status after discharge...

During the process of concurrent review, the Case Manager or qualified personnel will reassess discharge planning needs as necessitated by changes in patient/family condition ... all discharge planning activities will be clearly documented in the patient's medical record.


1. MR # 3 was admitted to the facility on 7/24/13 with diagnosis of Abdominal Pain and Colon Lesion. MR # 3 had surgery and a Colostomy was placed on 7/26/13. MR # 3 was discharged on 7/30/13.

The MR was reviewed and there was no documentation provided to indicate a return demonstration of colostomy care or if additional instruction was needed prior to discharge. The MR did not indicate whether the patient or caregiver would be providing the care when MR # 3 was discharged.

MR # 3 stated during a telephone interview on 8/30/13 at 12:26 PM, the hospital had not given her any instruction on how to care for her colostomy when she went home. She stated the hospital did not send any supplies home with her to use until the Home Health arrived the next morning. MR # 3 went home on 7/26/13 and during the night the colostomy bag busted and the contents spilled out onto everything. She did not have another bag or know how to care for herself and she called the Home Health which came out in the middle of the night to care for her. MR # 3 stated if she had been taught how to care for the colostomy and had the supplies she would not have had to call the Home Health in the middle of the night.

The facility failed to document the specific colostomy care taught and MR # 3's response to the teaching to ensure MR # 3 was appropriate for discharge.


2. MR # 7 was admitted to the facility on 8/24/13 with diagnosis of Perforated Colon Status Post Right Hemicolectomy 8/25/13. MR # 7 was discharged home on 9/3/13.

The MR was reviewed and there was no documentation provided to indicate a return demonstration of wound care or if additional instruction was needed prior to discharge. The MR did not indicate whether the patient or caregiver would be providing the care when MR # 7 was discharged.

During a telephone interview on 9/17/13 at 9:00 AM, MR # 7 stated the hospital did not send extra wound supplies to apply if the negative pressure dressing failed (wound spray cleanser to clean the wound or other wound care supplies) prior to home health arriving the next day.

The facility failed to document the specific wound care taught and MR # 7's response to the teaching to ensure MR # 7 was appropriate for discharge.

On 9/5/13 at 9:20 AM, Employee Identifier (EI) # 7, Case Manager for 3rd Floor Short Stay Unit, was interviewed and verified documentation of the education and discharge planning would be documented in the patient MR.

EI # 8, the Education Director, was interviewed on 9/5/13 at 12:20 PM, and verified documentation of teaching and discharge planning would be in the MR under several different tabs.

Based on interview, review of facility policy and procedures, review of the facility Quality Assurance Performance Improvement (QAPI) documentation for the process of discharge planning revealed the facility did not have a process in place to review the discharge planning data. This had the potential to affect all patients in the facility needing discharge planning.


The findings include:

Policy # ST-PI-140
Policy Title: Performance Improvement Plan- CMC 2013
Revised: 4/2013

III. Purpose: The Quality Improvement Program is designed to provide a systematic and organized mechanism to promote safe and quality patient care and services. Through an integrated, interdisciplinary process, patient care and services shall be continuously monitored and evaluated to promote optimum outcomes...
VII. Organization and Responsibility:
D. Hospital Departments:
The Department Directors are accountable to Administration ... Department Directors are responsible for the systematic monitoring and evaluation of the quality and safety of care/services provided by their staff. They discharge this responsibility by: ... Promoting the development of standards of care and criteria to objectively measure the quality and safety of care/services rendered in their department -- Monitoring the care processes in their departments ---Promoting integration of departmental evaluation activities with those of all other departments or services and the Medical Staff through participation in quality improvement teams.

VIII. Ongoing Professional Performance Evaluation Committee
The Ongoing Professional Performance Evaluation Committee is the multidisciplinary body charged by the Governing Board with oversight of all aspects of the Quality Improvement Program throughout the facility. The Council accomplishes the oversight function through: Implementing a systematic continuous improvement process.... Maintaining a permanent record of its proceedings...
B. Function ... Establishing guidelines for hospital- wide monitoring and evaluation of patient care and services...
E. Reporting... On a bi-monthly basis, the Ongoing Professional Performance Evaluation Committee reports findings, conclusions, recommendations, actions and results of sections related to all patient care and other services. Reports are forwarded to the Executive committee of Medical Staff, Administration, and Governing Body...

IX. Quality Improvement Teams
A. Composition ... Team Members ... It is the responsibility of Team Members to: ... Participate in evaluation of problems and determine root causes. Participate in setting goals and developing action plans for the team...
B. Team Actions ... Suggested actions based upon problems that involve system deficiencies include: ... Adding or revising policies and procedures ... Suggested actions based upon problems in staff knowledge include: ... Focused in-service education. Focused continuing education...

XIII. Annual Appraisal: At least annually the Clinical Outcomes Department will prepare an annual appraisal of the Performance Improvement Program. The Ongoing Professional Performance Evaluation Committee, Medical Staff and Governing Body will evaluate the effectiveness of the Quality Improvement Program at least annually. The program will be evaluated based on the collaborative, interdisciplinary involvement of all departments or services and the impact on patient care and services through improvement in processes and outcomes.

On 9/5/13 the surveyor requested the hospital QAPI plan for 2013. Employee Identifier (EI) # 1, the Quality Director, supplied the documentation. During the review there was no discharge planning process reassessment documented.

The Quality Director, EI # 1, was interviewed on 9/5/13 at 2:05 PM, and during the interview verified the Case Manager Director, EI # 6, did not have QAPI goals for the discharge process and did not have a QAPI plan for review of the discharge process at this time.