Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 08/21/2012
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0827 DISCHARGE PLANNING DOCUMENT
CFR(s): 482.43(c)(6)(iii)

The hospital must document in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf.


This STANDARD is not met as evidenced by:
Based on medical record review and staff interview, the facility failed to include documentation in the medical record that a list of available skilled nursing facilities (SNFs) was given to 1 of 3 sample patients (#2) who required SNF services. The findings were: Review of medical records showed patient #2 was admitted on 5/16/12. Further review showed the patient was discharged to the hospital's extended care facility (ECF), a SNF, on 5/18/12. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated that, although her staff was aware of the requirement to provide a list of SNFs, she did not have evidence to show it was provided for patient #2. Review of the medical record revealed no documentation about giving the patient a list of available SNFs prior to discharge.