HospitalInspections.org

Based on policy and procedure review, review of the (Electronic Medical Record) EMR template, and interview, the facility failed to have a process in place to document comprehensive discharge planning assessments by a qualified health professional in a timely manner in the medical record. The failed practice did not ensure continuity of care and appropriate follow-up for patients upon their departure from the facility and had the likelihood of affecting all patients in the facility triaged and/or placed on observation in the facility. Findings follow:

A. Review of Discharge Planning Policy dated 12/6/24 showed, "Policy Statement-Eureka Springs Hospital is committed to providing safe and effective discharge planning for all patients seeking care, treatment and services. This policy outlines the procedures and responsibilities involved in the discharge planning process to ensure continuity of care and appropriate follow-up for patients upon their departure from the Eureka Springs Hospital to post-discharge care and reduce factors leading to preventable additional healthcare encounters including admissions or readmissions to other facilities. Procedure-1. Discharge Planning Process A) All patients seeking services in the ED (Emergency Department) or placed in observation will undergo an initial assessment to determine their medical condition and treatment requirements. B) Patients identified for discharge needs will receive a comprehensive discharge planning assessment by a qualified professional. Plans of care and discharge plans may be modified as patient care needs change. C) Discharge planning will be patient-centered and individualized based on the patient's medical condition, social determinants of health and available resources. D) Discharge planning will be completed in a timely manner to ensure that the organization can arrange for the patient's care needs and avoid unnecessary delays. 3. Documentation-A) All aspects of the discharge planning process will be documented in the patient's medical record, including assessments, interventions, referrals, and patient education provided."
B. During a review of the EMR template, and interview with the CNO (Chief Nursing Officer) on 2/5/25 at 1:45 PM, the CNO could not provide evidence of a place for documentation in the EMR template for initial and ongoing discharge planning assessments and could not verbalize where in the EMR the assessments should be documented.
C. The findings in A and B were confirmed and verified with the CNO, CEO (Chief Executive Officer), and CFO (Chief Financial Officer) at the time of the findings.