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Based on personnel record review and staff interview, it was determined the hospital failed to ensure an appropriately qualified person developed, implemented and evaluated the discharge planning for patients. Findings:

A hospital policy titled, Discharge Plan, documented,"... A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of a discharge plan if the discharge planning evaluation indicates a need for a discharge plan..."

On 06/18/12, Staff A identified herself as the discharge planner. She stated she was in charge of developing and implementing discharge plans for patients. She stated she was solely responsible for the discharge planning activities at the hospital.

The personnel file for Staff A was reviewed.

The file had no documentation of a current LPN license and no documentation of prior job experience as a discharge planner.

There was no documentation of specialized training or continuing education in discharge planning.

There was no job description for discharge planning found in the personnel file.

There was no documentation of orientation to the position of discharge planner.

There was no documentation of demonstrated competency in the essential functions of the job.

There was no documentation of periodic evaluation of job performance as a discharge planner.

The CEO was asked if the discharge planner had the experience and qualifications necessary to perform the essential functions of the position. She stated she would look into that.

Based on clinical record review and staff interview, it was determined the hospital failed to develop an appropriate discharge plan for three (#1, 2 and #3) of three patients reviewed for discharge planning needs. Findings:

A hospital policy titled, Discharge Plan, documented,"... The hospital must reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan..."

1. The clinical record for patient #1 was reviewed for discharge planning activities. No Initial Evaluation and Discharge Plan form was found in the record.

A Discharge Planning Options form found in the record had no documentation of anticipated patient needs specific to the continuum of care.

An Interdisciplinary Team Meeting form, dated 05/09/12, had no anticipated discharge date and had no documentation of case management/discharge needs. There was no documentation of the development of a discharge plan.

On 06/18/12, the discharge planner was asked if she had completely developed and documented a discharge plan. She stated, "If it's not documented, it's not done."

There was no documentation of the coordination of home health services or oxygen therapy services found in the clinical record.

There was no documentation information about home health and oxygen therapy services had been communicated to the caregivers.

2. Patient #2 was discharged to a SNF at a local nursing home. The clinical record documented on an Initial Evaluation and Discharge Plan form the patient was returning to assisted living.

There was no documentation the discharge plan was modified and what coordination of services was anticipated. There was no other discharge planning activities found in the clinical record.

3. Patient #3 was discharged home. There was no documentation of an Initial Evaluation and Discharge Plan.

There was no documentation of coordination of home health services.

There were no other discharge planning activities found in the clinical record.

Based on personnel record review and staff interview, it was determined the hospital failed to ensure an appropriately qualified person developed, supervised, implemented and evlauated the discharge planning for patients. Findings:

A hospital policy titled, Discharge Plan, documented,"... A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of a discharge plan if the discharge planning evaluation indicates a need for a discharge plan..."

On 06/18/12, Staff A identified herself as the discharge planner. She stated she was in charge of developing and implementing discharge plans for patients. She stated she was solely responsible for the discharge planning activities for the hospital.

The personnel file for Staff A was reviewed.

The file had no documentation of a current LPN license and no documentation of prior job experience as a discharge planner.

There was no documentation of specialized training or continuing education in discharge planning.

There was no job description for discharge planning found in the personnel file.

There was no documentation of orientation to the position of discharge planner.

There was no documentation of demonstrated competency in the essential functions of the job.

There was no documentation of periodic evaluation of job performance as a discharge planner.

The CEO was asked if the discharge planner had the experience and qualifications necessary to perform the essential functions of the position. She stated she would look into that.

Based on clinical record review and staff interview, it was determined the hospital failed to implement an appropriate discharge plan for three (#1, 2 and #3) of three patients reviewed for discharge planning needs. Findings:

1. The clinical record for patient #1 was reviewed for discharge planning activities.

A physician's telephone order, dated 05/11/12, documented, "... Follow-up with GI physician [related to] MIC-KEY button..." There was no documentation found in the clinical record that indicated a follow-up appointment had been made or that this information had been communicated to the next caregivers.

A Discharge Plan of Care and Transfer form, dated 05/11/12, had no reference to the follow-up physician's appointment.

The form documented the patient was being discharged with a Foley catheter. The form did not provide instructions or physician's orders on how to care for the Foley catheter. (The patient was not admitted with a Foley catheter).

The form also documented the patient was being discharged with oxygen per nasal cannula at three liters per minute. The last physician's orders regarding oxygen therapy indicated the patient should have oxygen administered at two liters per minute.

The form documented no home health services were needed.

The form did not document the patient's pertinent discharge diagnoses which included chronic infections of the bladder (UTI)and lungs (pneumonia) with continuing fever.

On 06/18/12, the discharge planner was asked if she had documentation of information given to the next caregivers. She stated the only information provided was on the forms faxed to the home and the form sent with the patient at the time of discharge.

There was no documentation of the coordination of home health services or oxygen therapy services found in the clinical record and no documentation that any information was communicated to the next caregivers.

2. Patient #2 was discharged to a SNF at a local nursing home. The clinical record documented on an Initial Evaluation and Discharge Plan form the patient was returning to assisted living.

There was no documentation the discharge plan was modified and what coordination of services was anticipated. There was no other discharge planning activities found in the clinical record.

3. Patient #3 was discharged home. There was no documentation of an Initial Evaluation and Discharge Plan.

The Discharge Plan of Care and Transfer form was incomplete. There was no documentation prescriptions for home medications were given to the patient. The form did not document the patient's leg should be elevated as much as possible.

The form did not include information about home health services or wound care. The discharge form did not include information given to the patient about follow-up wound care physician appointments.