HospitalInspections.org

Based on record review, it was determined that the facility failed to ensure that 1 of 1 patient's (patient #8) were able to make use of a representative [spouse] to participate in developing a care plan and discharge plan. The facility discharged the patient without notifying the representative of the date of discharge or location where the patient was sent. See tag A-0130.

Based on medical record review and interview the facility failed to ensure that the patient's caregiver [spouse] was given the opportunity to participate in the development and implementation of the plan of care and failed to communicate to the caregiver that the patient was to be discharged, when the discharge took place or the facility where the patient was discharged. Findings include:

The facility policy 1 CLN 001 - Patient Rights and Responsibilities includes the following:
Patients will be informed about their illness, the status of their condition, prospects for recovery, treatment plan, and any medical alternatives and choices. This information will be shared with the patient by the physician, his/her representative, or other staff. If patients are unable to communicate or make decisions, the information will be shared with the person acting on their behalf.

During record review on 5/29/12 at approximately 1130 it was found in medical record # 8 that the patient has dementia. Subsequently, the facility was unsure of the designated caregiver qualifications and failed to further investigate this so that a plan of care could be developed and implemented with the caregivers input. The patient's medical record showed that on 4/27/12, the patient was brought in by ambulance with his wife, who provided the facility with the patient's history and medical information and was accepted as the patient's representative. Over the following three days the patient's three daughters [who hadn't seen their father in over 30 years] began to participate in the plan of care and further stated that the woman that came in with the patient was not the patient's wife. The facility failed to investigate these claims and went forward with the daughters' decision to place patient in a nursing home selected by the daughters. The discharge took place on 5/1/12.

On 5/2/12 the wife called the facility to see how her husband was doing and was told that the patient had been discharged per his daughter's selection to a nursing home. The wife arrived at the facility on 5/2/12 and went to medical records to request a copy of the patient's medical record to determine what had happened and was denied until she was able to produce their marriage license.

During an interview on 5/29/12 at approximately 1500 it was confirmed by staff A, B, D, E and G that further evaluation should have been completed in regards to whom the patient's caregiver was before the plan of care was developed.

Based on medical record review and interview the facility failed to counsel and prepare the patient's family/caregiver in regards to post-hospital care. Findings include:

During medical record review on 5/29/12 at approximately 1130 it was found in medical record #8 that due to the facility failing to correctly identify the patient's caregiver, the discharge post-hospital care plan was not discussed with the appropriate person.

During an interview on 5/29/12 at approximately 1500 it was confirmed by staff A, B, D, E and G that further evaluation should have been completed in regards to whom the patient's caregiver was before the patient was discharged to a facility without the caregivers knowledge and against the caregivers wishes.