HospitalInspections.org

Based on interview, record review, and review of facility policy, it was determined that the facility failed to ensure the transfer record for one (1) of ten (10) patients (Patient #1) included the patient's condition at the time of his/her transfer back to a skilled nursing facility on 11/14/19. Patient #1 sustained a fall on 10/14/19 while he/she was receiving services during an acute hospital stay for pancreatitis; however, hospital staff failed to communicate to the receiving skilled nursing facility that the patient had sustained a fall prior to his/her transfer. Furthermore, the discharging physician failed to address the fall that Patient #1 sustained on 11/14/19 in the patient's discharge summary that was sent to the skilled nursing facility.

The findings include:

Review of the Discharge Planning Guideline dated February 2019 revealed the nursing discharge assessment would include specific instructions for health maintenance and continued healing/recovery and general status information. The guideline further stated that a summary of care, treatment, and services provided and progress toward goals would be shared with the receiving facility.

Review of the Discharge Planning Process and Patient Dismissal policy, with a revision date of November 2017, revealed a discharge summary and/or continuation of care documents would be sent with the patient at time of discharge.

Review of Patient #1's medical record revealed the facility admitted the patient on 11/11/19 for treatment of acute pancreatitis. According to the medical record on 11/14/19 at approximately 12:45 PM, the patient was found lying on the floor of his/her room. The patient was assessed to be without injury or pain and was discharged to the skilled nursing facility at approximately 4:30 PM on 11/14/19.

Further review of the medical record revealed the discharge summary did not mention that the patient had sustained a fall prior to discharge from his/her acute hospital stay and the skilled nursing facility was not aware the patient had sustained a fall until 11/18/19, when the patient began experiencing pain and was transferred to the Emergency Department and diagnosed with an angulated trans-cervical femoral neck fracture.

Interview with Registered Nurse (RN) #1 on 11/25/19 at 4:04 PM revealed she was Patient #1's nurse on 11/14/19. She stated she was alerted to Patient #1 sitting on the floor of his/her room at approximately 12:45 PM on 11/14/19. She stated she assessed the patient along with two (2) other staff nurses and he/she did not have any signs of pain or injury. She stated the patient had not attempted to get out of bed unassisted prior to his/her fall. RN #1 stated when she called report to the receiving skilled nursing facility, she communicated to the nurse that Patient #1 had sustained a fall prior to his/her discharge; however, she stated she did not document it in her nursing notes.

Interview with Physician #1 on 11/27/19 at 4:40 PM revealed she was Patient #1's physician at the time of his/her discharge on 11/14/19. She stated she did not document about the patient's fall in his/her discharge summary that was sent to the skilled nursing facility. She stated she had already completed her documentation prior to the patient's fall. Physician #1 stated that she should have completed an addendum about the patient's fall and sent it to the receiving facility.

Interview with the Chief Nursing Officer (CNO) on 11/27/19 at 5:00 PM revealed RN #1 and Physician #1 should have documented the patient's fall in his/her discharge summary that was sent to the receiving facility.

Interview with the Administrator of the skilled nursing facility on 11/27/19 at 11:35 AM revealed facility staff were not aware that Patient #1 had sustained a fall on 11/14/19 hours before his/her discharge to their facility, until 11/18/19 when the patient began experiencing pain, at which time the patient was transferred to the Emergency Department and diagnosed with an angulated trans-cervical femoral neck fracture.