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Based on record review, policy review and interview, it was determined the facility failed to ensure discharge planning was implemented for 4 of 8 sampled patients (Patient # 2, 4, 9 and 11) as evidenced by a failure to provide pertinent discharge instructions to meet the patient's needs and ensure continuity of care.


The findings included:


The Facility policy titled, " Discharge of Patient from Hospital " last revised 10/2015 documents, " To ensure that there are effective processes for the discharge of patients which meets the needs of the patient, ensures continuity of care and facilitates discharge in a timely manner.
Requirements for Discharge: Completed medication reconciliation and discharge instructions.
Discharge Process: After completing the discharge instructions in Meditech, the discharge instructions, prescriptions and medication reconciliation is reviewed verbally with the patient and or caregiver/family if appropriate. Patient is given the opportunity to ask questions, and to verbalize understanding of instructions.


The Facility policy titled, " Against Medical Advice Discharge " last revised 05/2015 documents, " To document patient electing to leave the hospital without a physician ' s discharge order.
1. Notify the attending physician immediately. Encourage patient to wait for physician visit or return call.
2. Notify the charge nurse and nursing supervisor.
3. Request patient signs discharge against medical advice form and place on chart.
4. If patient refuses to sign document refusal on discharge against medial advice form under- "patient signature."
5. Record specific details on chart.
6. Complete occurrence report.
7. Send computerized discharge.
8. Follow routine discharge procedures including completion of the discharge instruction sheet and appropriate follow up care. Escort patient out of hospital building when possible.



Clinical record review conducted on 01/14/16 revealed the following:

1) Patient # 2 was admitted to the facility on 11/07/15 with multiple medical conditions.
Physician progress notes dated 11/18/15 revealed the physician had spoken to the patient that has been here for 12 days and stated, cannot wait anymore. The physician located an orthopedic oncologist in another county and the patient should follow up with an oncologist's rapidly. The physician noted, the patient needs to remain non-weight bearing and placed a consult with case management about providing crutches.
A Document titled, "Discharged Against Medical Advice" revealed, Patient # 2 signed out of the facility on 11/18/15.
Further review of the record indicates Patient # 2 received multiple prescriptions for insulin and diabetic supplies. The record does not provide evidence of discharge instructions related to follow up care or obtaining crutches as specified in the physician' s progress notes.
Interview with the Risk Manager who was navigating the electronic record, on 01/14/16 at 11:09 AM revealed, after further review of the electronic record, there is no evidence written instructions, specifying follow up care and the requested durable medical equipment was provided to the patient prior or after discharge.


2) Patient # 4 was admitted to the facility on 11/21/15 with multiple medical conditions. Consulting physician progress notes dated 11/29/15 documents recommendations related to diet and medication management anticipating patient discharge.
A Document titled, "Discharge Against Medical Advice", revealed Patient # 4 signed out of the facility on 11/30/15.
Further review of the record failed to provide evidence of discharge instructions and follow up care. The clinical record does not contain documentation related to the discharge.


3) Patient # 9 was admitted to the facility on 11/24/15 with multiple medical conditions. The patient underwent a peripheral inserted central catheter (PICC) insertion on 12/27/15 due to a need of intravenous antibiotic therapy. The patient was discharged home on 12/29/15 with a caregiver. The written discharge instructions failed to address care of the recently inserted PICC line.


4) Patient # 11 was admitted to the facility on 05/13/15 due to multiple medical conditions. Nursing assessments dated 05/13/15 thru 05/15/15 documents the patient had a wound/skin tear to the right forearm. Patient # 11 was discharged to home on 05/15/15. Discharge instructions failed to address care for the wound/skin tear to the right forearm. Patient # 11 returned to the facility on 05/23/15 and was diagnosed with cellulitis to the right forearm.


Interview with the Risk Manager conducted on 01/14/16 at 2:36 PM while navigating the electronic record and subsequent interview with the Director of Patient Safety on 01/14/16 at 4:12 PM revealed, after researching the clinical records for the patients identified above, there is no evidence pertinent discharge instructions were given to Patients # 4, 9 and 11 and there is no evidence Patient # 2 received discharge instructions, follow up care instructions and durable medical equipment as recommended by the physician.