HospitalInspections.org

Based on record review and interview, the hospital failed to establish an appropriate discharge plan for each patient. This deficient practice was evidenced by failing to ensure written discharge instructions were clear and concise for 2 (#1, #2) of 3 sampled patients.
Findings:

Review of hospital policy PC-301: Discharge Planning, Effective: July 10, 2012, with no revised date documented revealed, in part: Procedure: The case manager, along with other members of the treatment team, will discuss and document discharge plans with the patient and family prior to discharge. The purpose of the contact is to:
1. Finalize living arrangements and aftercare plans.
3. Review patient's medication regimen.

Review of Patient #1's Multi-Disciplinary Note dated 07/31/2024 revealed, in part: Patient discharged to hotel. Medications to be called in to pharmacy.

Review of Patient #1's Discharge Orders/Instructions/Transition Record dated 07/31/2024 revealed, in part:
Discharge Diagnosis: Major Depression recurrent severe with psychosis. Discharge Patient To: Grandparents home. Discharge Medications: Mobic 7.5 mg. Abilify 2 mg.
Continue the above medications until you are instructed by your physician to stop.
(No) Antipsychotic medications prescribed at discharge.
The following home medications were changed or discontinued during your hospital stay and should be discarded: Abilify, Mobic.
Additional Patient Instructions: Continue to take meds as prescribed.

In an interview on 09/09/2024 at 1:33 p.m., S2DON confirmed Patient #1 discharged to a hotel. S2DON confirmed Patient #1's discharged instructions were incorrect and should have stated patient discharged to hotel and not grandparents' home. S2DON confirmed Abilify was an antipsychotic medication. S2DON confirmed Patient #1's discharge instruction were incorrect and should have stated patient had 1 antipsychotic medication prescribed at discharge. S2DON confirmed Patient #1's discharge instructions pertaining to medications were not clear and concise. S2DON confirmed Patient #1's discharge medication instructions indicated to both continue and discontinue taking the same medications.

Review of Patient #2's Discharge Orders/Instructions/Transition Record dated 08/28/2024 revealed, in part:
Discharge Medications: Anafranil 50 mg. Zyprexa 7.5 mg. Vistaril 25.
Continue the above medications until you are instructed by your physician to stop.
The following home medications were changed or discontinued during your hospital stay and should be discarded: Anafranil, Zyprex, and Vistaril.
Additional Patient Instructions: Continue to take medications as prescribed.

In an interview on 09/09/2024 at 1:54 p.m., S2DON confirmed Patient #2's discharge instructions pertaining to medications were not clear and concise. S2DON confirmed Patient #2's discharge medication instructions indicated to both continue and discontinue taking the same medications.