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Based on record review and staff interview, the facility failed to discuss the results of the discharge planning evaluation with the patient for 1 out of 4 patients (#1).

Findings include:

Patient #1

Patient #1 was admitted to the facility on 7/19/12, with diagnoses including chronic obstructive pulmonary disease and congestive heart failure.

Record review revealed the discharge planning evaluation dated 7/19/12, was not reviewed with Patient #1.

During an interview with the discharge planning nurse, Employee #1, on 7/31/12, she reported she sometimes does not talk to the patient or family to evaluate the patient's discharge needs. The nurse reported she sometimes relies on chart review to determine the patient's discharge needs. The nurse reviewed Patient #1's record during the interview and did not find evidence of a review with Patient #1.

Review of the facility's policy entitled "Case Management Discharge Planning" section IV, effective date 8/1/2011, revealed "Discuss the results of the discharge planning evaluation with the patient or individual acting on his or her behalf and prepare them for post hospital care."

Patient #1 was readmitted to the hospital on 7/27/12.