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Based on interview and record review, the hospital failed to ensure Case Management staff provided an ongoing reassessment for one of 27 sampled patients (Patient 101) to ensure their continuing discharge needs were met and failed to maintain complete and accurate information of the patient's progress and discharge needs to accurately inform the patient and their representative(s). Patient 101's family member was told on two separate occasions by hospital case managers the patient was to be transferred to a skilled nursing facility. Both times the family member went to the facility, waited, and the patient was not transferred. The family member was not informed of the cancellations.

Findings:

On 6/11/12, review of the hospital's P&P (H-ML 10-013, revised on 8/12) for Discharge Planning showed Case Managers would provide individual discharge planning to each patient through assessment of discharge needs at admission, development of a discharge plan, implementation of the plan, evaluation of the appropriateness of the plan with an on-going monitoring, and the coordination of final preparations for discharge.

Procedure no. 4 showed the Case Manager would implement the discharge plan after an interdisciplinary team assessment and authorization from all interested participants and document the discharge plan and a tentative date for discharge in the progress notes. The Case Manager would complete ongoing monitoring and evaluation of the appropriateness of the discharge plan. Appropriateness would be determined by reassessment of the medical condition, review of current patient, family, physician, specialists and ancillary staff and criteria for appropriateness of current level of care. If the current plan was no longer appropriate, the Case Manager would modify the plan as needed. The modification would be documented in the progress notes.

On 6/11/13, record review for Patient 101 showed a physician's order dated 3/13/13, for an x-ray of the patient's hip to rule out dislocation of the prosthesis. If the x-ray of the right hip prosthesis did not show any dislocation, Patient 101 could be discharged to a SNF.

Review of the Case Manager's notes dated 3/13/13, showed the following documentation: Patient 101 would be discharged to a SNF via ambulance; the contact isolation currently in place for the patient was discontinued; the patient's family member was contacted and made aware of the discharge; the phone number for the SNF; an ambulance company was to transport the patient; and the discharge plan was discussed with nursing staff at the receiving SNF.

In a telephone interview with Patient 101's family member on 6/11/13 at 1115 hours, she stated she had hoped a list of available SNFs would be presented by the Case Manager; however, only the name of one SNF was presented to her. On 3/13/13, after agreeing to the transfer and the details of the itinerary, the family member drove to the SNF and waited for Patient 101. However, she stated Patient 101 never came. Inquiring inside the receiving SNF, the family member discovered the SNF was not aware of the transfer. The family member then called the hospital and was told the transfer of Patient 101 did not go through; however, no one knew the reason why.

Review of the Case Manager's notes dated the following day on 3/14/13 at 1534 hours, showed the discharge process was held due to a wound culture positive for MRSA.

Review of the primary physician's note dated 3/14/13 at 1830 hours, showed the plan was to consult with a physician who specialized in treating complicated infections and to confirm if it was appropriate to transfer Patient 101 at this time. The progress notes did not show if the patient's family member was updated regarding Patient 101's current transfer status.

There was no documentation located in Patient 101's record to show interdisciplinary team discussions took place or documentation of communication among the staff regarding the patient.

On 3/15/13 at 1113 hours, the Case Manager again contacted the family member of Patient 101 regarding the patient's discharge to a SNF. The ambulance company was contacted and scheduled to pick up Patient 101 at 1300 hours. Additionally, the Case Manager was waiting for a call regarding a follow-up medical appointment in order for Patient 101 to see the orthopedic surgeon.

On 3/15/13, Patient 101's family member waited again at the receiving SNF but Patient 101 never showed up. Patient 101 was never transferred to the SNF. The patient was transferred to a different acute care hospital on 3/28/13, in order for the orthopedic surgeon to surgically clean Patient 101's right heel wound.

On 6/11/13 at 1515 hours, the Case Manager in-charge of Patient 101's discharge was interviewed. The Case Manager was asked if Patient 101's family member was notified when the patient's two attempted SNF transfers were canceled. The Case Manager stated she was unable to remember.

The Discharge Planning Case Management documentation was reviewed with RN 1 and the Case Management Director on 6/12/13 at 0845 hours. Both staff confirmed the two attempted transfer events, including reassessments, were poorly documented with regard to discharge planning, coordination and informing the patient's representative.