HospitalInspections.org

Based on record reviews, interviews and review of hospital policies, it was determined the hospital failed to:

Assure discharge planning was complete.

Assure discharge assessment was complete.

Assure discharge plans were completed within the hospital policy timeframe.

Discuss discharge plans with the patient or caregiver.

Follow hospital policy for reassessment of needs.

Follow physician's orders for discharge instructions.

This affected 1 of 9 patients reviewed.

Refer to A 800, A 809, A 810, A 811, A 821, and A 822.

Based on review of medical records, hospital policies and interview with Employee Identifier (EI) # 1, the Discharge planner, it was determined the hospital failed to assure the discharge planning was complete on 1 of 9 patients including Medical record (MR) # 1.

Hospital Policy

Discharge Planning Assessment

Policy:

Discharge planning begins on admission and is designed to ensure a continum of care for each patient. The goal of discharge planning is to ensure a timely and smooth transition to the most appropriate type of post-hospital or rehabilitative care. This process is developed throughout hospitalization, is coordinated, confidential and is an interdisciplinary process. The process should be patient oriented, maintain patient advocacy, and ensure patient access to services during and after hospitalization...

Findings include:

1. MR # 1 was admitted to the hospital on 10/28/2009 with diagnoses including Recurrent Abdominal Incisional Hernia. The patient was admitted for surgical repair of the hernia.

After a review of documentation on the Patient Assessment Admission Data Base form, the area titled Anticipated Discharge Plans-' who will care for you', was left blank. The area titled Plan of Care, where the patient signs that they were informed and agree with the plan was left blank and had not been signed by the patient and/or significant other.

An interview on 6/17/2010 at 10:00 A.M. with EI # 1, the discharge planner verified the documentation was incomplete.

Based on record review and interview with Employee Identifier (EI) #1, the Discharge planner, it was determined the hospital failed to assure a complete discharge assessment was performed and documented for 1 of 9 patients, including Medical Record (MR) # 1.

Findings include:

1. MR # 1 was admitted to the hospital on 10/28/2009 with diagnoses including Recurrent Abdominal Incisional Hernia. The patient was admitted for surgical repair of the hernia.

On the form Patient Assessment Admission Data Base, section VI. Assessed needs for plan of care: educational needs area was left blank. This area included the following: Medication and IV (intravenous) Administration, coughing and deep breathing, basic health practices, pre-op/post-op care, disease/illness process, wound/ostomy care, procedure/tests, discharge care, pain management, psychosocial, equipment, fall precautions, safety practices and diet instruction.

The patient was discharged home with Jackson Pratt drains requiring care to the drains. The patient also had been on Lovenox injections from the first post op day until the hospital discharge day. He was not sent home on the Lovenox.

The hospital should have taught and documented the instructions of the drain care, post op care, breathing exercises and the signs to observe for pulmonary embolus/deep vein thrombus as this was relevant to the care of this patient.

Refer to hospital policy in A 800 and A 810.

An interview on 6/17/2010 at 10:00 A.M. with EI # 1, the discharge planner verified the documentation was incomplete.

An interview with the patient caregiver on 6/18/2010 at 9:45 A.M. revealed the caregiver had limited abilities due to personal illnesses and was unable to assist the patient with care. The caregiver also reported the illness of two grown children under her care, therefore causing a further limitation to her ability to assist the patient.

Based on review of medical records, hospital policy and interview with Employee Identifier (EI) # 1, the Discharge planner, it was determined the hospital failed to assure the discharge planning was completed within the policy time frame in 1 of 9 patients, including Medical record (MR) # 1.

Hospital Policy

Discharge Planning Assessment

Procedure:

...
A discharge assessment sheet completed by the case management department within 48 hours of patient's admission with the exception of weekends and holidays.


Findings include:

1. MR # 1 was admitted to the hospital on Wednesday 10/28/2009 with diagnoses including Recurrent Abdominal Incisional Hernia. The patient was admitted for surgical repair of the hernia.

A review of the Case Management Assessment revealed the assessment was done on 11/3/2009, which was 6 days after admission, and not within the 48 hours as per the hospital policy.

An interview on 6/17/2010 at 10:00 A.M. with EI # 1, the discharge planner, verified the assessment was not done within 48 hours.

Based on review of medical records, hospital policy and interview with Employee Identifier # 1, the Discharge planner, and interview with the complainant, it was determined the hospital failed to assure the discharge planning was discussed with the patient and/or significant other in 1 of 9 records, including Medical record (MR) # 1.

Hospital Policy

Discharge Planning Assessment

Policy:

...
Patients should be followed by Case Management and needs reassessed as often as necessary. An interdisciplinary plan of care should be initiated to assure patient needs are met. The discharge plan should be discussed with the patient and family/significant other as desired by the patient.

Findings include:

1. MR # 1 was admitted to the hospital on 10/28/2009 with diagnoses including Recurrent Abdominal Incisional Hernia. The patient was admitted for surgical repair of the hernia.

After a review of documentation on the Patient Assessment Admission Data Base form, the area titled Plan of Care, where the patient signs that they were informed and agree with the plan was left blank and had not been signed by the patient and/or significant other. No other documentation was present to show the patient/significant other had been instructed on the plan of care, nor the discharge plans.

An interview on 6/17/2010 at 10:00 A.M. with EI # 1, the discharge planner verified there was no signature of the patient or significant other.

A telephone interview on 6/18/2010 at 10:00 A.M. with the complainant revealed no one from the hospital had called to give any instructions on care the patient needed after discharge.

Based on record review, interview and hospital policy review, it was determined the hospital failed to assure the policy for reassessment for needs was followed as written in 1 of 9 patients, including medical record (MR) # 1.

Hospital Policy

Discharge Planning Assessment

Policy:
...
Patients should be followed by Case Management and needs reassessed as often as necessary. An interdisciplinary plan of care should be initiated to assure patient needs are met. The discharge plan should be discussed with the patient and family/significant other as desired by the patient.


Findings include:

1. MR # 1 was admitted to the hospital on 10/28/2009 with diagnoses including Recurrent Abdominal Incisional Hernia. The patient was admitted for surgical repair of the hernia.

The patient had multiple problems while in the hospital. On 10/29/2009, the patient began having tachycardia and became tachypenic with oxygen saturation (O2 sat) level of 91%. The patient was treated for post-op ileus, acute renal failure, infectious process with elevated white blood cell count and left pleural effusion. The primary physician consulted the Hospitalist and the Pulmonary Physicians to assist in the management of the patient's care.

The physician's progress note revealed the patient was placed on Lovenox (anticoagulant/aide in prevention of blood clots) 100 (milligrams) mg subcutaneous (sub-q) post operatively. On 10/30/09 at 2:20 PM the Lovenox was decreased to 40 mg every day as long as the patient was in the hospital. The case management notes did not reveal any re-assessment to determine the home needs of the patient in the event the patient was sent home on Lovenox injections, nor re-assess for the ability of a caregiver in the home to assist the patient with home needs when discharged.

On 11/1/2009 the patient became jaundiced. He was treated for gallbladder disease and gastroesophageal reflux.

On 11/3/2009, the patient vomited, aspirated and was transferred to the Intensive Care Unit. A nasogastric tube was placed with return of 1400 cc's (cubic centimeters) of green liquid. His temperature was elevated to 102 degrees, and his O2 sat dropped to 88%.

A review of the case management notes revealed the initial assessment was performed on 11/3/2009 and the next documentation was dated 11/9/2009, which did not show documentation of a needs assessment. The patient was discharged from the hospital on 11/11/2009. There was no documentation the caregiver was contacted to discuss the discharge plan of the patient. No further documentation could be located.

Based on review of medical recordand interview with Employee Identifier (EI) # 2 and a friend of patient, it was determined the hospital failed to assure the nurse followed the physician's order for discharge instructions for 1 of 9 patients, including Medical record (MR) # 1.

Findings include:

1. MR # 1 was admitted to the hospital on 10/28/2009 with diagnoses including Recurrent Abdominal Incisional Hernia. The patient was admitted for surgical repair of the hernia.

The physician's discharge order included: teach wound, drain care.

A review of the Discharge Summary Planning Checklist revealed under discharge instructions, only the words-drain care. There was no documentation as to what the patient was taught regarding drain care, and there was no documentation that wound care was instructed, as on page 2 under part II Interdisciplinary Instructions:Nursing, there is no documentation.

An interview on 6/17/2010 at 1:00 P.M. with the EI # 2, charge nurse revealed standardized instruction sheets are sent home with the patients according to their needs. There was no documentation or copies of instruction sheets to show what was sent home with patients.


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A telephone interview was conducted with a family friend who took the patient home from the hospital. The friend was asked by the surveyor: When you took him home, how difficult was it to assist him into the house? Reply: "Very difficult. He would walk maybe 3-4 feet and would have to stop and rest, because he was so short of breath. He had drains in the abdomen, and his feet and hands were extremely swollen."
The friend was asked if the discharge planner had questioned her about the home situation to find out if there was any assistance needed at home. The friend answered "no".

The patient was discharged home from the hospital on 11/11/2009 and expired on 11/13/2009.