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MERCY HEALTH ST VINCENT MEDICAL CENTER
PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING
Tag No.: A0130
Based on medical record review and staff interview, the facility failed to implement an appropriate discharge plan which met all the medical needs of a resident when ordered medications were omitted from the discharge orders. This affected one patient (Patient #4) with the potential to affect all patients cared for at this facility. The facility census was 219.
Findings:
The medical record revealed Patient #4 was admitted on 1/27/24 at 12:58 AM to the medical surgery floor from the emergency room. The physician history listed positive for Covid-19 on 01/08/24, chronic obstructive pulmonary disease (COPD) and concerns for congestive heart failure (CHF) with swelling noted to bilateral legs.
Internal medicine physician notes on 02/02/24 at 2:18 PM stated potential discharge in one to two days.
Review of the nursing notes on 02/05/24 at 1:30 PM revealed a respiratory panel was ordered and a nasopharyngeal swab was obtained. This panel result was positive for Influenza A. The internal medicine physician was notified at 3:37 PM and orders received to start Tamiflu. A chest xray was completed at 6:50 PM which showed bilateral patchy lower lobe opacities, concerning for pneumonia. Tamiflu was given on 02/05/24 at 8:00 PM and again on 02/06/24 at 8:00 AM.
Notes from the internal medicine physician, Staff F on 02/06/24 at 12:08 PM revealed pulmonary medicine cleared this patient for discharge and orders were received to discharge home. Patient #4 was discharged home on 02/06/24 at 1:23 PM.
Review of the discharge summary revealed the Tamiflu was not ordered by either internal medicine physician (Staff E or Staff F) upon discharge.
Interview with Staff B on 02/29/24 at 10:55 AM stated the discharge orders were placed the day prior to Patient #4 starting on the Tamiflu and no physician caught it to add it on the discharge medications.
Interview with the pulmonologist (Staff G) on 02/29/24 at 9:30 AM verified the discharge instructions did not contain an order for the Tamiflu. Staff G stated it should have been given for five days.