HospitalInspections.org

Based on review of medical records and interviews, the facility failed to arrange for all the post-hospital services and the education of patient/family about post-hospital care for 1 (Patient #1) of 10 sampled patients.

The findings include:

1. During the review of sampled Patient #1's medical record, on 9/26/12 at 10:00 a.m., the following information was found: The patient was admitted to the facility through the Emergency Department (ED) on 6/9/12 with a diagnosis of aspiration pneumonia. He had undergone a partial laryngectomy (a partial laryngectomy is the surgical removal of a portion of the larynx, or the voice box) for cancer of the larynx on 6/5/12. The patient had a total wide-field laryngectomy on 6/14/12.

On 6/15/12 at 0730, the physician ordered "Arrange visiting nurse and suction supplies for possible weekend discharge."

The medical record contained no documentation that the patient had been suctioned during his hospitalization and no documentation that he, or his family, had received any instruction on how to perform the procedure.

The patient was discharged home on 6/16/12 at 16:19 (4:19 p.m.). The patient returned to the ED on 6/16/12 at 23:34 (11:34 p.m.) with respiratory failure and cardiac arrest. Suctioning found a firm fibrous plug of mucous and blood. The patient was admitted to the hospital from the ED on 6/17/12 in severe hypoxic encephalopathy. Life support was discontinued at the family's request and the patient expired.

Review of the facility's policy and procedure Discharge to Post- Acute Services on 9/26/12 found that the Care Management RN (Registered Nurse) is responsible to send referrals to appropriate providers and facilitate transfer and arrange for Durable Medical Equipment (DME) services and equipment, i.e. suction equipment.
Review of the facility policy and procedure Assessment-Discharge Planning on this date found that the role of nursing is to coordinate this function with direction and guidance from the physician and the medical social worker/ case manager. The nurse and physician are also responsible to provide the patient/family with discharge planning instructions and teaching.

During an interview with the hospital Risk Manager on 9/26/12 at 1:30 p.m., she confirmed that Care Management RN missed the suctioning supply order of the physician.
The unit nurse failed to coordinate the patient's discharge with the Care Management RN by checking if the suction supplies were in the home.