HospitalInspections.org

Based on medical record and policy review and interviews, the facility failed to assess continuing care needs and provide a Post Discharge Plan of Care designed to ensure the patients needs are met after discharge from the facility into the community for 1 (#3) of 3 discharged records reviewed. Failure to arrange appropriate care and services after discharge has the potential to lead to decline in the health of the patient.

Findings:

Review of patient #3 's medical record revealed that she/he presented to the Emergency Department on 04/13/2011 at 6:54 PM with a complaint of pain in his/her neck and chest, after a fall from standing on the bed trying to clean a ceiling fan. She/he had reported that she/he fell backward, hitting his/her head on the closet door. After a Computerized Axial Tomography (CAT) scan of of his/her head, spine and chest, it was determined that patient #3 had ribs fractured at #6, #7, and #8th of his/her left side.

Further review of patient #3 ' s medical record revealed that she/he was 81 years old and had a history of multiple falls in the past, hypertension, diabetes, an aortic valve replacement, and on anticoagulant therapy of Coumadin. Laboratory values revealed patient #3's Coumadin level as high, the Prothrombin Time (PT), which was 25.8 therapeutic, normal level is 9.0 -- 13.0 sec. White Blood Count (CBC) level was high, reading of this level was 11.5, normal levels are 5.0--10.0.

Interview on 06/15/2011 at 9:30 AM with the spouse of patient #3 revealed that he was in another hospital recovering from a surgical procedure on 04/13/2011 when his spouse was discharged from Shands Live Oak on 04/13/2011 at 3:30 AM to their home, to be alone, without a caregiver or family member present. The spouse further stated that the facility Emergency Room (ER) Physician was aware of the fact that there was no one at their home when patient #3 was discharged.

Review of patient #3's medical records revealed a Physician note dated 04/13/2011, listing the patient ' s diagnosis of fractures of the #6, #7, #8 ribs on the left side. Further review of the medical record for resident #3 reveals the patient was administered Dilaudid 0.5 mg intramuscularly (IM) at 2:15 AM on 04/14/2011, and was discharged at 2:54 AM with a prescription for Lortab 7.5 mg by mouth every 6 hours as needed for pain.

Review of patient #3's admission record dated 04/13/2011 reveals a discharge order for patient #3 written on 04/14/2011 at 2:54 AM stating that patient #3's pain level is 2 on a 1-10 scale in the left ribs. Patient #3 left the Emergency Department 3:06 AM. Pain is improved. Medication reconciliation documentation was completed and given to the patient and was provided along with discharge instructions. Belongings were taken by the patient.

Review of the nurse's discharge note dated 04/14/2011 at 03:25 AM did not reveal that the patient's spouse had been notified or that there would be family at home for patient #3 when she/he arrived via Emergency Services. Further review of the same nurses ' note reveals no arrangements for Home Health made by the nurse.

Review of the " Patient Acceptance, Admission, Transfer, and Discharge " Policy under III. Discharge A #2
States: " Physicians should instruct patients ( and families when appropriate) of their conditions, prognosis and required continued medical care. " And under III. Discharge B # 2 states " The patients RN is responsible for planning and coordination of discharge. "

Interview with the Director of the Emergency Room on 06/16/2011 at 12:40 PM revealed it was the Case Management who has the responsibility to contact family members and to set up Home Health for patients at discharge.

Interview with the facility's Director of Case Management on 06/16/2011 at 11:45 AM, after the review of the record by the Director, she confirmed that the record revealed no evidence could be found that a family member was contacted by Case Management. Further interview reveals that the Director of Case Management believed that this patient should have been admitted for observation with rib fractures. Also because of the abnormal laboratory values, Atrial fibrillation, history of falls, and for the patient's own safety.
Further interview with the facility's Director of Case Management on 06/16/2011 at 12:30 PM, she disclosed that the facility should not have sent an elderly patient home alone with fractures without family members present or available.

Review of the additional discharged records reviewed revealed that they had appropriate discharges.