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Based on record review and interview the hospital failed to have in effect a discharge planning proces that applies to all patients and the hospital failed to have policies and procedure specified in writing, in that:

A. 4 of 4 patients that were admitted for surgical procedures did not have a discharge evaluation in their medical records.

B. The policy dated 03/01/05 titled Discharge/Transfer and Readmissions does not address the discharge planning process and procedures.

Cross refer A0806, A0810, A0812 and A0843

Based on record review and interview the hospital failed to insure that 1 of 1 (Patient#4) was provided with written notice of its resolution of a grievance. The hospital did not send a letter with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings included:

During a survey on 04/11/19 at 1145 the surveyor did not find a notation of a grievance received from patient #4's family entered into the Grievance Log.

During and interview on 04/11/19 at 1145 Personnel #2 stated she had received a letter from Patient #4's son. Personnel #2 stated she did not log this as a grievance nor send a response letter because the patient was happy with her discharge.

Based on record review and interview the hospital failed to provide a discharge planning evaluation to 4 of 4 (Patient #4, #7, #8, and #9) Patients in that, there was not a discharge evaluation in the patients record. There was no evaluation of the likelihood of the patients needing post-hospital service and of the availability of the services.

Findings included:

Patient #4 was admitted on 01/11/19 for Mechanical failure of orthopedic device, left hip and avascular necrosis, left hip. Patient #4 underwent a left total hip replacement on 01/11/19. Patient #4's medical record did not reflect a discharge evaluation.

Patient #7 was admitted on 01/23/19 for symptomatic intrasacral meningeal cyst. Patient #7 underwent cyst treatment and repair on 01/23/19. Patient #7's medical record did not reflect a discharge evaluation.

Patient #8 was admitted on 01/07/19 for left knee osteoarthritis. Patient #8 underwent a left total knee arthroplasty on 01/07/19. Patient #8's medical record did not reflect a discharge evaluation.

Patient #9 was admitted on 01/16/19 for adjacent disk and joint disease of lumbar spine. Patient #9 underwent surgery on 01/16/19. Patient #9's medical record did not reflect a discharge evaluation.


During an interview on 04/11/19 at 1245 Personnel #3 confirmed the above findings. Personnel #3 stated she did not chart a discharge evaluation on the patients in the hospital. Personnel #3 stated she pulled her information from other places in the chart.

During an interview on 04/11/19 at 1330 Personnel #2 stated the hospital did not have a policy regarding the discharge planning process.

Based on record review and interview the hospital failed to complete a discharge planning evaluation on a timely basis so that appropriate arrangements for post-hospital care were made before discharge to 4 of 4 (Patient #4, #7, #8, and #9) Patients in that, there was not a discharge evaluation in the patients record. There was no evaluation of the likelihood of the patients needing post-hospital service and of the availability of the services.

Findings included:

Patient #4 was admitted on 01/11/19 for Mechanical failure of orthopedic device, left hip and avascular necrosis, left hip. Patient #4 underwent a left total hip replacement on 01/11/19. Patient #4's medical record did not reflect a discharge evaluation.

Patient #7 was admitted on 01/23/19 for symptomatic intrasacral meningeal cyst. Patient #7 underwent cyst treatment and repair on 01/23/19. Patient #7's medical record did not reflect a discharge evaluation.

Patient #8 was admitted on 01/07/19 for left knee osteoarthritis. Patient #8 underwent a left total knee arthroplasty on 01/07/19. Patient #8's medical record did not reflect a discharge evaluation.

Patient #9 was admitted on 01/16/19 for adjacent disk and joint disease of lumbar spine. Patient #9 underwent surgery on 01/16/19. Patient #9's medical record did not reflect a discharge evaluation.

During an interview on 04/11/19 at 1245 Personnel #3 confirmed the above findings. Personnel #3 stated she did not chart a discharge evaluation on the patients in the hospital. Personnel #3 stated she pulled her information from other places in the chart.

During an interview on 04/11/19 at 1330 Personnel #2 stated the hospital did not have a policy regarding the discharge planning process.

Based on record review and interview the hospital failed to provide a discharge planning evaluation to 4 of 4 (Patient #4, #7, #8, and #9) Patients in that, there was not a discharge evaluation in the patients record.

Findings included:

Patient #4 was admitted on 01/11/19 for Mechanical failure of orthopedic device, left hip and avascular necrosis, left hip. Patient #4 underwent a left total hip replacement on 01/11/19. Patient #4's medical record did not reflect a discharge evaluation.

Patient #7 was admitted on 01/23/19 for symptomatic intrasacral meningeal cyst. Patient #7 underwent cyst treatment and repair on 01/23/19. Patient #7's medical record did not reflect a discharge evaluation.

Patient #8 was admitted on 01/07/19 for left knee osteoarthritis. Patient #8 underwent a left total knee arthroplasty on 01/07/19. Patient #8's medical record did not reflect a discharge evaluation.

Patient #9 was admitted on 01/16/19 for adjacent disk and joint disease of lumbar spine. Patient #9 underwent surgery on 01/16/19. Patient #9's medical record did not reflect a discharge evaluation.

During an interview on 04/11/19 at 1245 Personnel #3 confirmed the above findings. Personnel #3 stated she did not chart a discharge evaluation on the patients in the hospital. Personnel #3 stated she pulled her information from other places in the chart.

During an interview on 04/11/19 at 1330 Personnel #2 stated the hospital did not have a policy regarding the discharge planning process.

Based on interview the hospital failed to reassess its discharge planning process on an on-going bases in that, the hospital does not have a discharge planning process.

Findings included:

Patient #4 was admitted on 01/11/19 for Mechanical failure of orthopedic device, left hip and avascular necrosis, left hip. Patient #4 underwent a left total hip replacement on 01/11/19. Patient #4's medical record did not reflect a discharge evaluation.

Patient #7 was admitted on 01/23/19 for symptomatic intrasacral meningeal cyst. Patient #7 underwent cyst treatment and repair on 01/23/19. Patient #7's medical record did not reflect a discharge evaluation.

Patient #8 was admitted on 01/07/19 for left knee osteoarthritis. Patient #8 underwent a left total knee arthroplasty on 01/07/19. Patient #8's medical record did not reflect a discharge evaluation.

Patient #9 was admitted on 01/16/19 for adjacent disk and joint disease of lumbar spine. Patient #9 underwent surgery on 01/16/19. Patient #9's medical record did not reflect a discharge evaluation..

During an interview on 04/11/19 at 1330 Personnel #2 was asked if the hospital performed any quality review on the discharge planning process. Personnel #2 stated there was not any reporting of qaulity assessment and performance improvement of the discharge process. Personnel stated the hospital did not have a policy regarding the discharge planning process.