HospitalInspections.org

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Based on Medical Record review, document review and interview, in two (2) of six (6) Medical Records reviewed, the Nursing Staff failed to provide patients or their representatives discharge instruction education and medical supplies to continue post hospital care at home.

Failure to provide complete discharge instruction education and supplies could lead to inappropriate care and readmission.

Findings include:

Review of Medical Record for Patient #3 identified the following: This 73-year-old patient was sent to the Emergency Room on 03/22/18 by his Primary Physician with the inability to ambulate due to joint pain and weakness. The Discharge Note documented that the patient was alert, oriented to person, place, time and self-sufficient with his care. The patient was discharged home from the facility with a referral for home care. The written discharge instructions signed by the patient's wife documented that the patient had a history of chronic prostate enlargement and had a urinary catheter in place after failing three (3) voiding trails. The patient was to follow up with Urology in two (2) weeks.

The home care referral documented a request for a skilled nursing evaluation and instructions on catheter management which included cleaning, emptying, use of a leg bag and an overnight bedside drainage bag. The "medical equipment script" dated 03/29/18 documented a request for a rolling walker.

The "Patient Discharge Instructions" did not include instructions on care or maintenance of the catheter. There was no documented evidence that the staff educated and instructed the patient or his representatives regarding care of a urinary catheter and there was no documented evidence that the patient was provided with the equipment needed.

Patient #13's Medical Record identified the following: this 68-year-old patient was admitted with a worsening left lower extremity ulcer. The patient was referred for a wound care evaluation and was seen by the Advanced Practice Nurse (APN). The APN documented that the patient was alert and oriented times four (4) [oriented to person, place, time and situation]. The patient had two (2) chronic Diabetic wounds of the left lower leg and was at risk for moisture/incontinence-associated dermatitis. The patient was started on wound care with dressing changes every other day and skin care twice a day.

The home care referral documented a request for a skilled nursing evaluation and instructions on self-management of the stasis ulcer with dressing changes and skin care to prevent dermatitis.

The written discharge instructions signed by the patient documented that the patient was to follow-up with the Wound Care Clinic within two (2) weeks and continue the current skin and wound care. However, there was no documented evidence that the Nursing Staff educated or instructed the patient on the wound care and skin care, or that the patient was provided with the supplies needed.

On interview during the afternoon of 01/30/19, Staff E (Director) acknowledged these findings and confirmed there was no documentation to support that the patients or their representatives were given the opportunity to demonstrate their understanding of the patient's post hospital care needs.

The Policy and Procedure titled "Discharge Planning" last revised 03/16/17, stated: "... the objectives of the discharge planning process are ... to educate and provide training for the patient, caregiver, [and] family ... to manage self-care post discharge ... the patient and caregiver will be provided education on the post discharge plan of care ... [and] a care plan for the various conditions, problems or issues ... the plan must include at a minimum ... any instruction that the provider has given the patient."
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Based on Medical Record review, document review and interview, the staff failed to ensure that the residential facility received: (a) Discharge Instructions for post-hospital care in three (3) of six (6) Medical Records reviewed, and (b) A reconciled medication list with prescriptions for new medications in one (1) of three (3) Medical Records reviewed.

This failure may have placed patients at risk for inappropriate post-hospital care and/or readmission.

Findings related to (a) include:

The facility's Policy and Procedure titled, "Discharge Planning" last approved 03/16/17 stated, "Patient and caregiver will be provided education on post discharge plan of care prior to discharge and will be given the opportunity to ask questions."

Review of Patient #5's Medical Record identified the following information: This 54-year-old male, with a past medical history of Hypertension, Psychiatric diagnosis, Schizoaffective Disorder and Substance Abuse, presented to the Emergency Department (ED) on 02/10/18 after an unwitnessed fall / syncopal episode. Patient was discharged on 02/13/18 in the morning with a primary diagnosis of "Syncope and Collapse (resolved)." Cardiac and Neurology testing resulted "negative," and a secondary diagnosis of "Cardiomyopathy, stable heart function" was found. Patient was instructed to "continue medications as directed".

The patient was readmitted to the hospital on 02/14/18 for an Electrophysiology (EP) Evaluation and possible Implantable Cardioverter Defibrillator (ICD) placement. Patient was discharged on 02/22/18 with a principal diagnosis of Left Ventricular Dysfunction. The Patient Discharge Instructions dated 02/22/18 included instructions to follow a low salt diet, perform activity as tolerated and to monitor weights daily, with additional instructions to call the Physician for a 2-3lb. (two to three pound) weight gain in 24 (twenty-four) hours, or weight gain of 3lbs. (three pounds) or greater in one (1) week.

A Psychiatric Consult was called at Cardiology's request to determine the patient's capacity for decision making. A Behavioral Health Assessment Note dated 02/15/18 stated the patient, "is unable to verbalize understanding of current condition or treatment plan at this time ... cannot consent to medical procedures as he does not understand risk-benefit."

Review of Nursing's Daily Flowsheets from 02/14/18 to 02/22/18 documented the patient as "alert, arouses to voice or touch, disoriented to time, situation. The "Discharge Note Adult" dated 02/22/18, stated the patient has "difficulty concentrating; difficulty decision making; difficulty remembering."

Care Coordination Progress Note dated 02/22/18 stated, "SW [Social Worker] spoke with [Assistant Director] Hazel House ... advised patient will be discharged today, 2/22/18 at 2PM ... Senior Ride pick up 2PM, 2/22/18 ... No further SW needs." No documented evidence was found that discharge instructions were provided directly to Patient #5's group home or caregiver.

The Patient Discharge Instructions dated 02/22/18 documented that the patient was discharged back to Creedmoor Group Home. No signature from the caregiver, nor group home, was found for the receipt of the discharge instructions. There was no documented evidence that hospital staff communicated Patient #5's post hospital needs with the group home or that the group home received Patient #5's discharge instructions.

Interview with Staff G (Social Worker) on 01/29/19 at 2:52PM, revealed that the "nursing [staff] gives the discharge paper work to the patient or [transport] driver" for patients returning to group homes. Discharge instructions are not directly sent to every group home. Each home has different requirements.

Interview with Staff A (Director of Social Work) during the morning of 01/29/19 revealed there is no written process or procedure for ensuring discharge instructions are provided to the next level of care for patients returning to adult homes or group home settings.

Similar findings of the lack of discharge instructions provided to group homes were noted for Patients #6 and #7.

Findings related to (b) include:

The facility's Policy and Procedure titled, "Discharge Planning" last approved 03/16/17 stated, "... Upon discharge the patient and caregiver will receive a medication reconciliation record and discharge plan..."

Review of Patient #5's Medical Record identified the Patient's Discharge Instructions dated 02/22/18, included a list of ten (10) medications that were documented as "New Medication". However, upon review, only two (2) medications were newly prescribed. The other eight (8) medications were the same as in the previous admission.

Interview with Staff J (Registered Pharmacist) on 01/31/19 at 1:30PM, revealed Patient #5's new prescriptions had not been forwarded to their community Pharmacy upon patient's discharge.

There was no documented evidence that the hospital staff communicated the changes in the patient's medications to the group home.