HospitalInspections.org

Based on document review and interview, the facility failed to ensure that when an acute level of care was no longer required that staff followed established policy/procedures to refer patients and necessary medical information to agencies needed to provide care to the patient prior to discharge for 1 of 5 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of policy/procedure D03-G, Discharge, Discharge Planning and Instruction Form, indicated the following;
" 4. Upon receipt of the physician ' s order for discharge, nursing will notify the internal case manager. The case manager will insure that arrangements for transportation and home care if necessary are complete and that all necessary parties are notified. "
This policy/procedure was last reviewed/revised on 03-22-2012.

2. Review of patient #1 ' s MR indicated the patient ' s mobility was non weight bearing with being dependent of minimum assist x 2 on 05-10-12. The patient ' s Discharge Planning DC Summary dated 05-10-12 at 1600 hours indicated the patient was to be discharged to home with Home Health Service Organization. The physician wrote the following order on 05-10-12 at 1715 hours; Patient may be discharged home in AM. The patient ' s MR lacked documentation that the Home Health Service Organization was notified of the patient need for services.

3. On 06-07-12 at 1115 hours staff #42 confirmed that patient #1 ' s MR lacked documentation that the Home Health Service Organization was notified of the need of services for the patient.