HospitalInspections.org

Based on the medical record review,
interview with administration and staff,
the hospital failed to provide a complete
discharge assessment and evaluation
of patient's needs prior to discharge.
This was observed in 1 of 1 patient's
medical record and was observed
in P1's record.

Failure to provide patient with an adequate
discharge planning assessment and
evaluation plan will not assure that
patient's continuing care needs will be
met after leaving the hospital.



Findings:

1. During an interview on 02/08/2010
with the Chief Safety Officer and
Case Manager Team Leader.
They reported the patient was a 51
year old, who was Developmentally
Delayed, with many multiple medical
problems. The patient was discharged
on 09/07/2009 with a friend to the
friend's home. The patient was given
discharge instructions about drugs,
receive smoking cessation education
pamphlets and was educated about
monitoring his/her weight. The patient
was made an appointment on
09/24/2009 to a local clinic for
follow up care.

2. Review of the patient's medical record
determined the patient was admitted
through the emergency department on
09/03/2009 with complaints of nausea,
vomiting and abdominal pain.The physician's
plan documented the patient would be
NPO (nothing by mouth), IV fluids would
be started and a CT abdominal scan
would be obtained on 09/04/2009.
The patient would be discharged within 24 hours.

3. Review of the patient's abdomen x-rays
suggested the patient had an ileus versus
a small bowel obstruction. The patient also
had multiple medical problems to included
diabetes mellitus type 2 and was an
insulin-dependent. The patient's admit
glucose measured 223 ml the (normal
glucose labs measure from 70-105).
On 02/08/2010, I reviewed the patient's chemistry
glucose lab results. The results determined that
patient's glucose measured from 124-190.
During patient's hospitalization from
09/03/2009-09/07/2009.

4. Also, on 02/08/2010, I reviewed the patient's
Medication Reconciliation Discharge Form
dated 09/07/2009. The review determined the
discharge physician did not document 4
medications on the patient's discharge instruction
form. Documentation review determined the
physician wrote the patient's take home
medications orders on 09/06/2009 at 1720.
The patient's take home medications orders
read as follows:
1. Take Nitro 0.4 mg, take one tab sublingual
every 5 minutes, times 3 for chest pain.
2. Take Tylenol 650 mgs, take 2 tabs, by mouth,
every 4 hours for pain and fever.
3. Take Claritin 10 mg, one tab, by mouth,
for allegeries.
4. The physician wrote another order on the
patient's Medication Discharge Order List
dated 09/07/2009 at 0718. The order read:
Patient was to take Humulin 70/30 insulin,
33 units, twice a day (no route was documented
on the order). These 4 medication orders were
not found on the patient's Medication Discharge
Instruction dated 09/07/2009. These discharge
instructions were given to the patient at discharge.

5. Also, the review of the documentation on the
patient's discharge instructions documented the
patient was to do glucose blood checks before
meals and at bedtime. The review of a nursing
entry noted on in the Progress Notes or patient's
discharge instructions did not support that
trained was provided in to the patient or friend
to complete this task.

6. Further review of nursing documentation failed
to document that Humulin Insulin education was
provided to patient. Also, nursing failed to
document patient's response regarding the
instructions. Nursing diabetic education should
have included how to give the insulin, what side
effects one needed to know for hypoglycemia
or for comma conditions etc. The discharge
nurse made an entry in the Progress Notes
dated 09/07/2009. The nurse documented
the patient had no questions about discharged.
The hospital failed to effectively assess and
coordinate patient's discharge plans regarding
diabetic teaching according to the standards
of practice.

Based on medical record review,
the hospital failed to reassess
the patients condition noted in the
discharge plan in 1 of 1
medical records, as observed in
P1's medical record.

Failure to reassess the patient's initial care
plan regarding the patient's diabetic needs
does not assure the patient will have
an appropriate discharge plan.

Findings:

1. On 02/08/2010, I review the patient's
initial care plan dated 09/03/2009.
Review of care plan determined that
nursing identified the patient had diabetic
issues and noted this on the problem list.
The nursing entry read as follows:
The patient has "exiting problem or this is
a new onset or the patient had an altered
glucose problem." Also, review of the
case managers working notes determined
the patient's initial glucose measured 185
on 09/03/2009 on the admission day.

2. Review of a nursing entry made on the
Nursing Progress Notes dated 09/07/2009
at 08:04 AM determined the patient's glucose
blood sugar measured at 166. The patient was
given 3 units of Regular Insulin SubQ.

3. Further review of the medical record
documentation determined that nursing staff
or case managers were not attempting to
communicate with the patient about his/her
diabetic problem or determine if this was a new
onsite or ongoing problem or what kind of insulin
was the patient on when in the nursing home.

4. On 02/08/2010, review of patient's
discharge instruction dated 09/07/2009
did not address that patient or friend received
training about giving the prescribed Humulin
Insulin 70/30 to include the side effects,
the route or when to contact the physician.
with diabetic concerns.