HospitalInspections.org

Based on interview and record review, the hospital failed to ensure one sampled patient (Patient 1) was provided with the information regarding the care and health care requirements following the discharge from the hospital as evidenced by:

* Patient 1 was given the discharge instructions in a language that was not the patient's preferred spoken language.

* Patient 1 was presented with the incomplete discharge instructions upon discharge from the hospital when the physician's order for the post procedure pain medications was not included in the discharge instructions.

These failures posed the increased risk of unsafe care to the patient.

Findings:

Review of the hospital's P&P titled Discharging Outpatients from the Hospital dated September 2023 showed in part:

* Policy: Only a Registered Nurse (RN) who has been certified in standardized procedure of "Discharging Outpatients" may discharge patients from the hospital using established protocols following a physician order.

* Scope: A standardized procedure will be implemented for any outpatient who has undergone an invasive procedure and has a physician order to be discharged but is not evaluated by the physician at the time of discharge.

* Procedure: Outpatient department will provide verbal and written instructions to the hospital and/or responsible party regarding type of procedure, diagnosis (printed diagrams or brochures as applicable), follow up appointment with the physician, diet, medications, activities, complications to be aware of and who to contact should symptoms be demonstrated or for any questions.

* Documentation: Document assessment, interventions, patient outcome and the instructions given and patient/family understanding of the instructions on the unit specific form; document patient's condition and time of discharge on the unit specific form.

On 12/3/24 at 0920 hours, an interview with concurrent Patient 1's medical record review was conducted with the ICNO and CQO.

Patient 1's medical record review showed the patient was presented to the hospital outpatient area for a procedure.

Review of Patient 1's PreOp Assessment dated 11/8/24 at 0725 hours, showed the preferred patient's spoken language was Language 1.

Review of the Discharge Order dated 11/8/24 showed Percocet (a pain medication) as needed for pain. The Discharge Order was verified by a RN on 11/8/24 at 1035 hours.

However, review of the Discharge Instructions, Inpatient dated 11/8/24 at 0743 hours, showed the following:

* The discharge instructions form presented to the patient upon discharge from the hospital was in English.

* The discharge signatures were missing from the discharge instructions form.

* The discharge order for pain management was not included in the discharge instruction upon discharge from the hospital.

On 12/3/24, the above findings were verified by the CQO.