HospitalInspections.org

Based on the observation, document review, and interview, it was determined that for 2 of 2 patients (Pt. #3 and #4), the hospital failed to label IV (intravenous) dressings when the dressings were applied/changed.

Findings include:

1. On 9/3/2024 at 9:50 AM, a tour of the Medical-Surgical Telemetry unit (7-South) was conducted, 2 of 2 patients (Pt. #3 and Pt. #4) were observed with peripheral IV's with dressings on their left/right forearms which were not labeled with insertion date, time, and initial.

2. The policy titled "Intravenous Therapy- (Patient Care Services)" (dated 1/2021) was reviewed and required "Post insertion guidelines:...label IV dressing with date, time, gauge of catheter, and initials..."

3. On 9/3/2024 at 10:10 AM, an interview was conducted with the Charge Nurse (E#9) on (7-South). E#9 stated that all patients' IV lines should be labeled with date, time, size of the gauge, and initials.

Based on document review and interview, it was determined that for 1 of 4 clinical records (Pt. #2) reviewed for discharge planning, the hospital failed to ensure that the patient's family was included included in discharge planning and notified regarding the patient's discharge, per policy.

Findings include:

1. The hospital's policy titled, "Discharge Planning Process" (Origination date: 06/2021) was reviewed on 9/3/2024 and required, "... The patient or representative and family/support person/caregiver are active participants in... post discharge care

2. On 9/3/2024, the hospital's policy titled, "Transfer of Emergency Department Patients to other Facilities" (Origination date - 6/2021) was reviewed and indicated that, "...V. Procedure...10. The patient's family will be given information regarding the receiving facility (name, address, contact information, directions.)"

2. On 9/3/2024, Pt. #2's clinical record (dated 3/15/2024 to 3/16/2024) was reviewed. Pt. #2 presented to the ED (Emergency Department) on 3/15/2024.
-The ED - H & P (History and Physical) by MD#1 included, "Patient ... with past medical history of dementia, psychosis, anxiety, adjustment disorder, MDD [Major depressive disorder], syncope presents from nursing home for psychiatric evaluation. On evaluation patient is hemodynamically stable, afebrile, nontoxic-appearing, is calm, concern for worsening dementia versus underlying mood disturbance, patient was aggressive at the nursing home he will need evaluation by psychiatric team and inpatient therapy. H & P indicated that Pt.#2 is verbal and alert x 1 (aware of self). "Addendum to the ED H & P by MD#2 indicated that there is no reason for medical admission. Patient is safe for inpatient psychiatric care. For agitation anxiety, patient given 2.5 mg of p.o. [by mouth] Zyprexa (antipsychotic). A psychiatric consult was ordered, and MD #3 was the consulting psychiatrist.
-The Behavioral Health Progress Note by Crisis Coordinator (E#7), dated 3/16/2024 at 8:38 AM, included, "Per [MD #3 - consulting psychiatrist] direction, [Pt #2] to be transferred out. [E #7] contacted [psychiatric referral service] ... referred to Neuropsych ... clinical [records] faxed. E #7's note, dated 3/16/2024 t 11:07 AM, included, "Received call from ... NeuroPsych reporting [Pt #2] was accepted under [accepting psychiatrist's name] in [City name] location in the 200 unit. [neuro-psychiatric hospital in a different state - approximately 45 minutes from the hospital]. ED charge [nurse] updated with information."
-The RN Discharge Note by (E#16) on 3/16/2024 at 1:25 PM, indicated that Pt.#2 was discharged to [psychiatric hospital] and was transferred by ambulance and medical records were sent with the patient.
The clinical record did not include any documentation indicating that Pt #2's family was notified by the Crisis Worker or Nurse of Pt #2's discharge/transfer.

3. On 9/4/2024 at approximately 9:50 AM, an interview was conducted with discharge planner (E#13). E#13 stated that discharge planning is initiated right after admission so as to give ample time to make arrangements for post-hospital discharge needs, services and care. E#13 stated that patients and family members are always involved in the discharge planning process and would be informed of the discharge plan. E#13 stated that if the patient is being discharged/transferred to a SNF (skilled nursing facility), the discharge planner will inform the patient's family. If the patient will be discharged/transferred to another hospital, the nurses will inform the patient's family. E #13 stated that E #13 did not recall Pt. #2 and did not know why the family was not notified.