HospitalInspections.org

Based on review of the medical record, quality data, policy and procedure, and physician interview, it was determined that the facility lacked documented evidence that the patient and family was notified to prepare for post hospital care for 1 of 3 (#1) patients whose records were reviewed.

Findings were:

Review of the facility policy #PBR-6602 entitled, "Transfer of Clinical Information at Discharge", last revised May 2009 indicated that discharge information would be relayed to the patient and the clinical caregiver who would assume responsibility for care after discharge.

Review of the medical record for patient #1 revealed the physician had written an order for the patient to be discharged. The patient was discharged and was transferred to the facility's main campus for a psychiatric evaluation. The record lacked documented evidence of notification of the Power of Attorney for Healthcare on the day the patient was discharged and transferred. The medical record also lacked evidence that the patient and POA received post discharge instructions.

An interview with the physician (#2) at 11:45 a.m. on 01/4/12 in the conference room revealed he/she had talked to the POA about a possible discharge the day prior to the the patient being discharged. The physician explained that he/she felt the patient was capable of making his/her decisions concerning discharge plans. The patient wanted to return home. The physician explained the initial plan for the patient was to go home with home health and other necessary support. The physician stated the patient's neighbor; who was the POA for the patient, indicated that the patient was not able to take care of him/herself at home and needed to go to a nursing home for twenty four hour care. The physician explained that the POA stated the patient had episodes of forgetfulness and may have appeared to make sound decisions for him/herself but was not capable of caring for him/herself. After the discussion the physician needed to determine if the patient was capable of caring for him/herself and had written an order for the patient to have a psychiatric evaluation at the main hospital. The physician further explained this facility did not have psychiatric services available. The patient was transferred that day because the psychiatrist at the receiving facility was available to see the patient. The physician stated he/she, in an effort to expedite the patient's transfer, missed notifying the patient's POA of his/her decision to transfer the patient for a psychiatric evaluation.

Review of the facility's quality data with the Risk Manager revealed the patient's POA complained to the facility about not being notified of the transfer. The quality data revealed that the Risk Manager responded to the compliant according to the facility policy. The Risk Manager followed up, investigated the complaint, and confirmed that the POA was not notified of the patient's discharge/transfer to the main campus for the psychiatric evaluation.