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Based on observation, interview, and record review, the facility failed to ensure that an accurate list of home health agencies (HHAs) was included in the discharge plan for one patient (#2) of eight patients' medical records reviewed for discharge planning. This failure potentially affected all patients requiring post-discharge home health care. The facility census was 31.

Findings included:

1. The facility did not have a policy or procedure regarding generation and maintenance of appropriate post-discharge healthcare provider lists (including home health agencies) for presentation to patients, and did not have a process for assuring accuracy of the provider information included in discharge plans.

2. Record review of discharged Patient #2's medical record showed the following:
- A Staffing Summary dated 10/04/11 stated referrals were completed for home health care and therapies, including lab work and wound care after discharge.

During an interview on 11/02/11 at 1:40 PM, Staff B, Manager of Case Management, stated the following:
- Lists of providers for post-discharge health care, including home health and skilled nursing care, were generated by pulling provider names from the internet and sorting them by the county of the patient's residence.
- The social worker or case manager then crossed off any resources on the list that would not accept the patient's pay source or did not provide the necessary services.
- The list was presented to the patient/family and they were asked to number the providers by order of preference.
- Each patient was issued a binder of documents at admission that provided information about the facility, a list of patient rights, educational materials, rehabilitation plans, etc. The patient was encouraged to add materials to it so that reference documents about their stay were organized in one place. This binder was kept at the patient's bedside for easy review by the patient and/or family, and was sent with patient at the time of discharge. The list indicating patient preferences for post-discharge healthcare providers was placed in the patient's resource binder after decisions were made, and the original document was kept in the social worker's working file.

Review of the medical record, discharge plan, and social worker's file failed to show evidence that a list of appropriate home health agencies was generated or provided to Patient #2.

3. The medical records and social work files of seven additional patients (#4, #5, #6, #7, #8, #9, and #10) were reviewed for evidence that post-discharge provider lists were generated and provided to these patients for indication their preferences. There was no evidence to indicate that these patients were offered a choice of post-discharge healthcare providers.

Based on observation, interview, and record review, the facility failed to:
- Provide accurate post-hospital provider contact information in eight (#2, #4, #5, #6, #7, #8, #9, and #10) of eight discharged patients' medical records reviewed for discharge planning. This failure potentially affected all patients in the facility.
- Provide appropriate and comprehensive hospital discharge instructions for one patient (#2) of eight discharged patients' medical records reviewed for discharge planning. Failure to document wounds and wound care instructions at discharge puts patients at risk of complications such as worsening of the wound or infection, and potentially impairs the continuity and appropriateness of wound care by the patient, the family, and post-discharge agencies.

The facility census was 31.

Findings included:

1. The facility did not have a policy or procedure regarding generation and maintenance of post-discharge healthcare provider lists for presentation to patients, did not have a process for assuring accuracy of the provider information included in discharge plans, and did not have a process to survey post-discharge providers regarding the discharge plan to determine its effectiveness.

2. Record review of Patient #2's medical record showed the following:
- A document titled "Discharge Recommendation & Arrangements" was utilized to record the patient's discharge instructions, and a copy of this form was provided to patients when they discharged from the facility. The following information was listed on the document prepared for Patient #2:
- The home health agency listed was "Vernon County Home Health." Research by surveyor revealed that the correct name of this agency was "Nevada Regional Medical Center Home Health." The address and phone number were correct.
- The Division of Aging was listed as a resource for patients regarding assistance with personal care, homemaker care, home-delivered meals, etc. The Missouri Division of Aging ceased existence approximately seven years ago. The phone number listed for the defunct agency was dialed by surveyor and it connected to the Senior & Disability Hotline number for reporting abuse and neglect concerns.

During an interview on 11/02/11 9:05 AM, Staff E, Director of Nursing, stated that the Division of Aging was listed on every patient discharge plan. This information was part of the computer generated discharge plan and Staff E indicated it would be corrected immediately in the computer database.
- "Independent Living Center" was listed as a resource for assisting with personal care attendants, equipment, special programs, etc. "On My Own" was listed as the Independent Living Center for the county of the patient's residence. The street address listed for On My Own was 111 N. Elm. Research by this surveyor revealed that the correct street address was 428 E. Highland. The phone number remained the same and was verified correct by this surveyor.
- A document titled "Staffing Summary" was used by the facility to consolidate documentation of a patient's progress toward discharge as discussed during weekly multidisciplinary team meetings. The Staffing Summary for Patient #2 dated 10/04/11 showed a notation by "Nursing" that the patient was educated on skin care and was instructed to apply mepilex (an absorbent foam dressing) to the coccyx (tailbone) area (where Patient #2 had an area of missing skin). The patient was also instructed to follow up with the Primary Care Physician regarding treatment for this wound after discharge. There was no mention of this wound on the Discharge Recommendation and Arrangements form, and wound care instructions were not documented on this form.
- A document titled, "Physician's Discharge Orders/Instructions" listed instructions regarding diet, physician follow-up, dressing/wound care, medications, and additional instructions/orders (such as labwork) after discharge. The section titled Dressing/Wound Care instructed Patient #2 to turn every two hours to relieve pressure and to keep the skin clean and dry. There was no mention of a wound on Patient #2's coccyx and no wound care instructions.

Based on observation, interview, and record review, the facility failed to:
- Ensure that one patient (#2) of eight patients' medical records were reviewed for need of post-discharge health care were provided with an appropriate list of agencies to select from;
- Document in the medical record that the patient or the individual acting on the patient's behalf was provided with a list of providers to choose from;
- Document the patient's choice of providers for post-discharge health care in the medical record.
These failures potentially affected all patients in the facility. The facility census was 31.

Findings included:

1. The facility did not have a written policy or procedure for assessing whether patients were provided with an appropriate list of potential post-discharge providers, or for documenting the patient's preference of post-discharge healthcare providers.

2. During an interview on 11/02/11 at 1:40 PM, Staff B, Manager of Case Management, stated the following:
- Each patient was issued a binder of documents at admission that provided information about the facility, a list of patient rights, educational materials, rehabilitation plans, etc. The patient was encouraged to add materials to it so that reference documents about their stay were organized in one place. This binder was kept at the patient's bedside for easy review by the patient and/or family, and was sent with patient at the time of discharge.
- When post-discharge care was indicated, a provider list was generated and presented to the patient/family by the Social worker and the patient/family were asked to number the providers by order of preference. The list was placed in the patient's resource binder after decisions were made, and the original document was kept in the social worker's working file because it was not considered to be part of the patient's medical record.

During an interview on 11/03/11 at 1:00 PM, Staff B, Manager of Case Management, stated the following:
- Patient #2 was presented a list of providers who could assist him after discharge. He chose his own providers and told the social worker what he wanted.

3. Record review of Patient #2's medical record showed no evidence that a list of potential post-discharge providers was offered to Patient #2, and no evidence of which providers were selected by the patient or his family. Record review of the "working" file kept by the social worker in the Social Work office also showed no evidence that provider lists were provided to Patient #2 for selection of providers post-discharge.