HospitalInspections.org

Based on observation, record review, staff interview and review of the facility's policies and procedures, the facility did not ensure that the discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services for 5 of 15 patients (#4, 5, 10, 11 and 12) in the case sample.

Findings include:

1. Clinical record review on 10/20/10 at 4:45 P.M., revealed that patient #4 presented to the emergency room on 10/18/10 and subsequently was admitted to the telemetry unit for management/treatment of diagnoses that included atrial fibrillation with rapid ventricular response, paroxysmal supraventricular tachycardia, alcohol abuse, tobacco abuse, hypertension and diabetes mellitus type 2. Review of the Nursing Admission Assessment Database noted the patient's psychosocial assessment included depression and the substance abuse assessment indicated the patient used tobacco daily (3/4 pack per day) and drank 12 cans of beer a day. The social services (SS) and respiratory therapy (RT) referral triggers on the form however, were incomplete.

At the time the record review was conducted, the patient had been discharged on 10/20/10. It was found that although the patient was taught about his/her new cardiac medications and diabetes management in the Patient/Family Education Record, there was no documentation in the clinical records to indicate whether an evaluation or discharge plan for the patient's depression, smoking and alcohol use was done.

On 10/20/10 at 5:45 P.M., interview with the telemetry unit's nurse manager confirmed the lack of coordination in the discharge planning process for this patient. The nurse manager stated there should have been a SS referral for the triggered depression/alcohol use and an RT referral for the tobacco use. The nurse manager shared that patient #4 was enrolled in the hospital's alcohol withdrawal program and attended an "AA" (Alcoholics Anonymous) meeting while an in-patient. She verified there was no documentation to show that patient #4 attended this and/or was assessed or had treatment plans implemented prior to discharge by SS and RT, including the possibility of needing post-hospital services.

2. Clinical record review on 10/21/10 at 5:30 P.M., revealed that patient #5's diagnoses included the delivery of twins at 34 weeks gestation, gestational diabetes and a prior mid-term loss. The postpartum flowsheet indicated the twins were born on 10/19/10 and transferred to a children's hospital on Oahu. A 10/19/10 "0200 late entry" nursing note indicated the patient saw her twin boys before their transfer, received teaching and a direct phone number to call about their status from the Oahu hospital's transport team.

On 10/21/10 during a chart review with a unit staff nurse (OB RN #1), she stated this patient had daily, direct telephone contact with the Oahu hospital about the twins' condition. The section for family support services and a lactation consultant had been marked off on the OB Admission Database/Nursing Assessment. It was noted in a "10/20/10 0800" entry, that the patient reported being sad. The nursing plan was to "encourage questions," in addition to performing routine care and monitoring. Another staff nurse, OB RN #2, said one of their social workers was to have seen the patient on 10/20/10 regarding discharge assessment/needs.

At the end of the concurrent record review with OB RN #1, she confirmed there was no SS referral or entry in the record. She stated the known discharge plan was for the patient to fly to Oahu upon discharge to be with her twins. She said patient #5's arrangements were handled by the Oahu hospital for a place to stay. OB RN #1 verified however, there was no documentation for it in the clinical record. She also confirmed there was no documentation by SS to assess or identify whether any psychosocial concerns existed. OB RN #1 acknowledged that without a discharge evaluation/plan, they also could not assess whether the patient required post-hospital services related to her needs as a new mother currently separated from her newborn twins.

3. Patient #10 was a 50 year old admitted on 10/17/10 with diagnoses including chest pain syndrome, hypertension and had a history of tobacco abuse. Review of the 10/17/10 admission history and physical revealed the patient's father had died at the age of 45 from a heart attack and had a history of tobacco abuse. The patient then underwent a 10/18/10 cardiac stress test and the results found no restriction of blood flow in the heart study.

On 10/20/10 review of the clinical record revealed the Nursing Assessment Data Base triggered a SS referral for alcohol and drugs. There were no clinical entries by SS. An RT referral for tobacco use with documented RT teaching was noted on a 10/17/10 entry. Further review found that education/information was given to patient #10 about lifestyle changes to decrease the risk of recurrence and patient was counseled on diet, exercise and no alcohol. A 10/19/10 nursing entry documented the patient was also given web site addresses/phone numbers to the heart association and smoking cessation information.

However, there was no evidence of the coordination of discharge planning related to the actual or potential needs for patient #10 before and after discharge, except for the patient to return to his/her primary care physician in 1-2 weeks. Interview with a case manager (CM #1) on 10/19/10 at 9:15 A.M. revealed that case managers did the discharge planning for patients identified in high risk categories such as congestive heart failure, chronic obstructive pulmonary disease, cancer, fractures, falls, and for patients referred by nurses, physicians and other disciplines. CM #1 stated most case management notes were in the facility's MIDAS system and they would document their notes in the nursing progress notes if they needed to. CM #1 also stated the nurses could not access the MIDAS system. On 10/21/10, CM #2 accessed the MIDAS record for patient #10 and found the CM's notes were not included in the patient's record.

On 10/22/10, an interview with the charge nurse on the M/S unit confirmed she could not access the MIDAS system, although daily discharge planning meetings about each patient were held with the CMs present. Also on 10/22/10, during a concurrent record review with the M/S unit's charge nurse, she confirmed there was no documentation of an evaluation of the patient's post-hospital needs or availability of services. Cross reference to A 843 for additional details of findings.

4. Observation, review of the clinical record and staff interview on the evening of 10/21/10, revealed patient #11 was admitted on 10/18/10 and was a 21 year old first time mother. Concurrent record review and interview with a unit staff nurse (OB RN #3), revealed the patient had some problems with breastfeeding. The clinical record noted the patient's nipples were raw on one side and tender on both sides. OB RN #3 stated the mother could benefit from a referral to a lactation group. In addition, the nurse stated the patient's infant (patient #12) was identified with possible hearing loss and non-intact skin on his/her head (caput).

The record for patient #12 showed the infant was born on 10/19/10 and had an entry, "Potential pain r/t tissue trauma (with) vaginal birth aeb (as evidenced by) caput on head." Observation on 10/21/10 revealed the infant's caput was inflamed and swollen and had two areas of non-intact skin. OB RN #3 also stated the infant may have hearing loss on one side. She stated they would, "have the infant return in one week and try again, if no pass, would consider consult."

Review of the record on 10/21/10 found the section for discharge plan within the OB Admission Database/Nursing assessment had a lactation consultant checked off. However, there were no entries in the Interdisciplinary (IDT) care plan for "Normal Labor and Delivery and Postpartum." In addition, OB RN #3 confirmed there was no documentation of an evaluation for the availability of post-hospital services patient #11 might need as a first time mother with potential lactation problems and a newborn (patient #12) identified with potential hearing loss problem and swollen caput.

5. Review of the facility's policy and procedure, "Discharge Processes: Planning, Documentation, Patient Preparation, Instructions, Escort" (Policy No. TX 309-N; effective 3/15/06) stated: "Purpose: 1. To promote the interdisciplinary process in the effective planning for patient discharge. 2. To ensure...the continuity of care is maintained post-discharge. 3. To ensure patients receive adequate information prior to discharge that enables them to seek required follow-up...Policy:...2. The Interdisciplinary Team has the responsibility to plan the discharge process with involvement of all disciplines, including the patient, physician, family and community resources."

Based on record review, staff interview and review of the facility's policies and procedures, the facility did not ensure the patient and family members or interested persons must be counseled to prepare them for post-hospital care for 1 of 15 patients (#1) in the case sample.

Finding includes:

On 10/20/10, a closed record review of patient #1 revealed the patient was admitted on 10/23/09 to the M/S unit. Patient's diagnoses included jaundice, severe itching, chronic kidney disease and hypertension. The record review found the patient received supportive treatment and care and that on 10/27/09, a nursing entry documented a family member's concern of a plan to discharge the patient home. The family member asked for the initial attending physician as they felt that physician understood the health concerns they had. The nursing entry dated 10/27/09 at 9:30 P.M. noted the patient's discharge was canceled until the initial attending physician and the gastroenterologist were consulted.

Further record review noted a 10/29/09 nursing entry at 3:00 P.M. which documented that patient #1 was to be transferred to a hospital on Oahu. Although the Patient/Family Education Record documented a 10/26/09 entry indicating the patient's plan of care was discussed with the patient and the patient verbalized his/her understanding, there was no other clinical documentation to indicate what it included. There also was no other documentation whether other information/instructions were provided to either the patient or the family member in preparation for patient #1's post-hospital care.

Review of the facility's policy and procedure, "Discharge Processes: Planning, Documentation, Patient Preparation, Instructions, Escort" (Policy No. TX 309-N; effective 3/15/06) stated: "Purpose: 1. To promote the interdisciplinary process in the effective planning for patient discharge. 2. To ensure...the continuity of care is maintained post-discharge. 3. To ensure patients receive adequate information prior to discharge that enables them to seek required follow-up."

On 10/21/10 at 3:00 P.M., interview with the M/S unit's nurse manager confirmed she could not locate any additional documentation in the clinical record to indicate that patient #1 and/or the patient's family member was given information or counseled in preparation for the patient's transfer/discharge that occurred on 10/29/09.

Based on observation, record review and staff interview, the facility did not reassess its discharge planning process on an on-going basis and that the reassessment included a review of the discharge plans to ensure they were responsive to discharge needs for 5 of 15 patients (#4, 5, 10, 11 and 12) in the case sample.

Findings include:

Record review of patients #4, 5, 10, 11 and 12 revealed from each patient's admission, the facility's discharge planning process was not integrated to assure an evaluation and review of the discharge planning process was met. The facility's system did not ensure for the integration of information such that it was accessible to all staff involved in the discharge process and thus, failed to ensure the development of discharge plans which met the individual needs of the patients. Cross reference to A 808 for details of findings.

It was revealed through interviews with the CMs that documentation of discharge planning was not centralized as evidenced from interviews with CM #1 on 10/19/10 and CM #2 on 10/21/10. Both affirmed however, they did the discharge planning for patients transferred to long term care facilities, patients identified with home health agency referrals or durable medical equipment needs, and for patients referred for discharge planning by nurses, physicians and other disciplines.

During an interview on 10/20/10 at approximately 4:00 P.M., the M/S nurse manager said the IDT met every morning at 9:30 A.M. on Monday through Friday to discuss each patient's discharge planning needs. The IDT involved the charge nurse, case manager, social worker, rehabilitation therapists, respiratory therapists and others disciplines as needed. This was confirmed by the charge nurse on the M/S unit on 10/22/10. Despite the daily discharge planning meetings, the hospital failed to document the on-going assessment and reassessments related to the discharge planning process to ensure the discharge plans were adequate and responsive to meet the identified needs for patients #4, 5, 10, 11 and 12.