HospitalInspections.org

Based on record review and interview, the facility failed to implement the discharge planning policy for post hospital care by arranging follow up referrals and appointments for one (1) out of five (5) sampled discharged patients (SP#1).

The findings:

Review of sampled patient (SP) #1 medical record showed that the patient was admitted in the facility on 09/09/2015 and was discharged on 09/11/2015 with the diagnoses of a possible pancreatic mass. Review of the consultation report of the Gastroenterology of SP#1 dated 09/11/2015 includes but not limited to, patient presenting with obstructive jaundice, thought secondary to pancreatic head mass. The report further noted, the patient would most benefit from the endoscopic ultrasound. We will arrange for the patient to undergo outpatient workup within the next week. I have explained the findings to the patient's daughter who is at bedside. She has verbalized understanding and is agreeable to further management recommendations. Again unfortunately, we do not have endoscopic ultrasound at this institution, but we will arrange this as soon as possible on an outpatient basis. Contact information was provided to the patient and her daughter

Interview with the CMO (Chief Medical Officer) on 12/09/2015 at 02:44 PM confirmed above findings, she stated that, the ERCP (Endoscopic Retrograde Cholangio-pyelography) was cancelled due to patient's need to have endoscopic ultrasound for staging. The patient also had kidney injury and contrast study could not be performed. It was explained to the patient's family and agreed with further management recommendation.

Review of SP#1 " Discharge Instructions" for follow-up care dated 09/11/2015 did not show any scheduled future appointments, or any arrangements made for an out-patient ERCP/ endoscopic ultrasound within the next week as instructed by the gastroenterologist.

Review of the facility policy and procedure Code No. 210 - Section: 100-200 Administration; Subject - " Discharge Planning " documents that specific elements of the patient discharge plan should include patient/family discharge instruction, and appointments and/or referrals for follow up care. The policy also states that the day prior to discharge, the physician will write the discharge prescriptions and order follow up clinic appoints or physician appointments. The UBT (Unit Based Team) will provide discharge instructions and/or education to the patient, and/or family members, as appropriate and document this in the patient's chart. The UBT members (physicians, nursing, case management, social work, dietary, physical therapy, and admission/discharge/transfer nurses) will complete and sign the appropriate sections of the Discharge Education Summary Form (C229). The Procedure also shows under "Day of Discharge" (#3) the UBT (Unit Based Team) will review the documented instructions on the Discharge Education Summary Form, provide any additional information and make certain that the patient has a copy of documents and follow-up appointments.