HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to ensure each patient requiring a discharge planning assessment actually had such an assessment performed and documented in the patient record for 1 of 10 patients (Patient #1).

Findings were:

Facility policy #CMT.103 entitled Hospital Case Management Transition Planning, effective date 05-18-17, included the following:
"The purpose of this policy is to ensure transition management is conducted in accordance with regulatory requirements and accreditation standards for patients admitted to Inpatient ...status ...
A Case Management Registered Nurse or Social Worker will complete an initial Adult or Infant/Child Transition Evaluation and make his or her best efforts to complete the initial assessment within 24 but no later than 48 hours of admission or registration to develop an initial discharge plan for patients admitted to Inpatient or Outpatient Observation status based on the goals, preferences and needs for each applicable patient ...
V. Procedure: A. Case Management staff will perform and document all Transition Management processes and enter the documentation into the patient's medical record ..."

Patient #1 was a 90-year-old patient admitted to Sierra Providence East Medical Center from a home care facility. She was diagnosed with a urinary tract infection. A review of her record revealed no discharge planning assessment.

In an interview with Staff #8, LMSW Case Manager involved in the discharge of Patient #1, on the afternoon of 10/10/17 in the facility small meeting room, he was asked if an adult transition assessment - a discharge planning assessment - had been performed on Patient #1. He stated, "Unfortunately, in this particular case, a discharge assessment wasn't done ..."