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Based on observation, interview, and record review, the facility failed to ensure a discharge assessment was completed in a timely basis to assess the patient's post discharge needs.

Findings:

On July 9, 2012, Patient 5 was observed lying in bed watching the television. On the same day, at 9:48 a.m., during an interview, Patient 5 stated he had a back surgery and was feeling good. According to Patient 5, he cared for his disabled wife and son and his concern was being able to care for them when he was discharged home.

On July 9, 2012, Patient 5's medical record was reviewed. The admission face sheet indicated Patient 5 was admitted to the facility on July 9, 2012, at for back surgery.

A review of an Initial Nursing Assessment dated July 9, 2012 at 5:35 p.m., indicated the patient was independent in ambulation, mobility, and personal hygiene. Section Eight of the Initial Nursing Assessment, "Discharge Planning" was left blank.

A review of the medical record also revealed the Discharge Planning Assessment document was blank.

On July 10, 2012, when interviewed at 9:58 p.m., the chief nursing officer (CNO) stated the Discharge Planning Assessment should be done on the first day of admission. At 10 a.m., the CNO stated the Discharge Planning Assessment should be done within 24 hours of admission.

A review of the facility's policy and procedure titled, "Discharge Planning" dated March 2010 stipulated the initial assessment/evaluation for discharge planning needs is conducted during the nursing admission assessment or prior to admission.

Based on record review and interview, the facility failed to ensure the patient received after care instructions at the time of discharge. Patient 4 was discharged from the facility without evidence of education on the care of the neck incision dressing.

Findings:

On July 9, 2012, a review of Patient 4's medical record indicated she was admitted to the facility on January 12, 2011. According to the medical record, Patient 4 underwent a neck surgery and had a surgical incision on her cervical neck area.

A review of a Discharge Instructions Patient and/or Family dated January 16, 2011, indicated the discharge instructions for diet, activity, and reportable symptoms. The Discharge Instructions Patient and/or Family document did not have evidence in the dressings section that the patient or a representative received instructions on the care of the neck incision dressing.

A review of a face sheet indicated Patient 4 was discharged from the facility on January 16, 2011.

On July 10, 2012, a review of Patient 4's medical record indicated she was readmitted to the facility on January 31, 2011 (approximately 2 weeks later). According to the patient's medical record, the patient returned with redness and signs of infection to the neck surgical incision site.

On July 10, 2012, the chief nursing officer (CNO) reviewed the patient's medical record and could not produce evidence of dressing care education. When interviewed at 10:58 am., the CNO stated the staff member should have documented the education given to the patient regarding dressing care.

A review of a policy and procedure titled, "Discharge Planning" dated March 2010 stipulated the patient would receive education in self care in the home situation. In addition, the policy stated the discharge instruction would be written and given to the patient.