HospitalInspections.org

Based on record review, interview and policy review, the facility failed to identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge without adequate discharge planning, in 3 of 15 medical records reviewed (#2, #10, #15). Findings include:

On 1/5/10 at approximately 11:20 am during the review of patient #2's medical record, the absence of a social worker assessment and/or consult was noted. Patient #2 was admitted on 12/28/09 from a nursing home and was diagnosed with Huntington's chorea, hip fracture, and a stage IV decubitus ulcer .

On 1/5/10 at approximately 11:30 am an interview with the Clinical Manager of 5 West confirmed the absence.

On 1/5/10 at approximately 2:00 pm upon review of patient #10's medical record, the absence of an initial assessment within 48 hours was noted. Patient #10 was admitted on 10/30/2009 with a diagnosis of CVA and received a social worker consult on 11/4/09.

On 1/6/10 at approximately 11:45 am 5 West Social Worker confirmed the absence.

On 1/6/10 at approximately 12:15 pm upon review of patient #15's medical record, no evidence of an initial assessment was present by a social worker. The first social worker consult was performed on 1/6/10. Patient #15 was admitted on 12/12/09 with a brain tumor and received a craniotomy.

On 1/6/10 at approximately 12:20 pm during an interview with Intensive Care Units Social Worker the absence was confirmed.

On 1/6/10 at approximately 9:15 am upon review of the policy and procedure titled "Initial Social Work Assessment", it indicates that "Patients will be assessed based on the following trigger criteria for their need for services. Assessments should be completed either after consultation or within 48 hours of admission." The policy also reveals that a "trigger" consists of chronic diseases, suspected cases of abuse, cancer, and stroke.

Based on interview and medical record review, the facility failed to coordinate a timely discharge for 2 (#5, #8) of 15 patients reviewed. Findings include:

During tour of unit 5 West (5W) on 1/5/10 at approximately 11:00 a.m., patient #5 was observed dressed with his belonging packed up. Interview with patient #5 at that time revealed that he was supposed to go home yesterday and didn't know why there was a delay. Interview with his nurse, RN #D shortly after revealed that he had been cleared for discharge and was ready to to go home. Medical Record review with the 5W Clinical Coordinator revealed that the the formal order had not been written. The patient was on the "B" service which meant that the physician assistant (PA) was writing orders. Interview with the Physician Assistant, on 1/5/10 at approximately 11:15 a.m., revealed that the PA for 5W had been ill and the order had not been written by the covering PA or attending physician.

Interview with the Case Management Specialist, on 1/5/10 at approximately 12:10 p.m., revealed that patient #8 was to be discharged today. Review of the medical record with the 5W Social Worker, on 1/5/10 at approximately 12:20 p.m., revealed that the order was written for discharge yesterday. Further interview with the Social Worker revealed that the discharge could not be done due to lack of continuing care documentation by the PA or attending physician.

Based on interview and medical record review, the facility failed to document the patient's discharge evaluation and discharge plan in the patient's medical record for 2 (#3, #10) of 15 patients reviewed. Findings include:

Medical Record review (hard copy and electronic) of patient #3's hospitalization with the 5 West Clinical Coordinator, on 1/5/10 at approximately 11:30 a.m., revealed that the patient was a 79 year old female admitted on 12/23/09. Review of the record revealed that a discharge evaluation and discharge plan had not been documented in the medical record (13 days after admission). Interview with the 5 West Social Worker at that time revealed that she had documented the plan in another computerized system which was not visible to the Interdisciplinary Team. The Social Worker stated that she generally prints off the evaluation and places it in the chart. The evaluation and plan had not been placed in the chart until requested.

Medical record review (hard copy) of patient # 10's hospitalization with the 5 West Social Worker on 1/6/10 at approximately 12:00 pm revealed that the patient was a 59 year old female admitted on 10/30/09. Review of the record revealed that a discharge evaluation and discharge plan had not been documented in the medical record (5 days after admission). Interview with 5 West Social Worker at that time revealed that she had documented the plan in another computerized system which was not visible to the Interdisciplinary Team. The 5 West Social Worker stated that she doesn't normally document in the progress notes of the medical record but, generally prints off the evaluation from another computerized system and places it in the chart. The evaluation and plan had not been placed in the chart until requested.

Based on interview and record review, the facility failed to reassess the discharge plan for 4 (#2, #3, #4, #10) of 15 patients reviewed. Findings include:

Medical Record review (hard copy and electronic) of patient #3's hospitalization with the 5 West Clinical Coordinator, on 1/5/10 at approximately 11:30 a.m., revealed that the patient was a 79 year old female admitted on 12/23/09. Review of the record revealed that there was not a documented discharge plan or documented reassessment of the patient's discharge plan 13 days after admission. Interview with the 5 West Social Worker at that time revealed that she she had done an initial plan that had not been placed in the medical record. Home care supplies may or may not have been needed. Reassessment and revisions to the discharge plan had not documented.

On 1/5/10 at approximately 11:20 am during the review of patient #2's medical record, the social worker initial assessment and/or consult, had not been documented. In addition, reassessment and revisions to the discharge plan had not documented.

On 1/5/10 at approximately 11:30 am an interview with the Clinical Manager of 5 West confirmed the absence.

On 1/5/10 at approximately 11:35 am during the review of patient # 4's medical record, reassessment and revisions to the discharge plan had not documented.

On 1/5/10 at approximately 11:40 am an interview with the Clinical Manager of 5 West confirmed the absence.

On 1/5/10 at approximately 2:00 pm upon review of patient #10's medical record, the absence of an initial assessment within 48 hours was noted. Patient #10 was admitted on 10/30/2009 with a diagnosis of CVA and received a social worker consult on 11/4/09. Reassessment and revisions to the discharge plan had not documented.

On 1/6/10 at approximately 11:45 am with the 5 West Social Worker confirmed the absence.

Based on record review and interview the facility failed to provide the patient, family members, or interested persons with counseling in preparation for post-hospital care in 1 of 15 medical records (#10). Findings include:

On 1/6/10 at approximately 11:00 am upon review of patient #10's medical record, the consult was missing from the medical record and later retrieved a report printed from another computerized system. The report contained a referral for home physical therapy but, the discharge instructions that were delivered to the patient for teaching was absent of the referral and information about the referral. Medication review for post-hospitalization was also missing.

On 1/6/10 at approximately 11:45 am 5 West Social Worker confirmed the absence.