HospitalInspections.org

Based on interview and record review hospital staff failed to have an effective Discharge Planning process that facilitates the provision of follow-up care in 1 of 19 emergency room records reviewed. (Patient ID# 1)

Findings include:

Record review of the emergency room record for Patient ID# 1 revealed she presented to the emergency room on 6/7/14 complaining of hurting everywhere. The Physician diagnosed the patient with Backache / Chronic Pain. The patient was discharged from the emergency room. The Discharge Instructions stated " Discharge Instructions: None. Prescriptions: None. Follow Up Instructions: Dr. ID# 58(Emergency Medicine) When: As needed: Reason: Change in condition. Special Notes: None Diagnosis: Chronic Back Pain. The follow up instructions listed Dr. ID# 58 in Durham, North Carolina and listed a North Carolina phone number. The follow-up instructions failed to address the patient ' s Back Pain. The Discharge Instructions were not signed by the patient.

The Risk Manager (ID# 66) acknowledged 6/20/14 at 10 a.m. that the Discharge Instructions failed to address Patient ID# 1's Back Pain. The Risk Manager further stated that the hospital had a computer glitch as to why a North Carolina address and phone number for a physician was provided to Patient ID# 1 on the discharge instructions. (St. Joseph Hospital is located in Houston, Texas)

Record review of a policy titled " Discharge From the Emergency Department: Discharge and Follow-up Instructions " dated 6/2014 stated:

" Policy: Each patient discharged from the Emergency Department will receive written discharge and follow-up instructions, as applicable.
C. Prior to discharge from the Emergency Department, each patient or his / her representative will be given complete instructions regarding any follow-up care he / she may require.
4. The patient or his / her representative will sign that he /she has received and understands the written discharge instructions with a copy given to the patient and a copy affixed to the medical record.
D. The physician is responsible for documenting the follow-up care that will be required. Patients are referred to their primary physician for continuing care EXCEPT for those that are instructed to return to the Emergency Department for specific follow-up care - i.e. for worsening of symptoms ..."

In summary, Patient ID# 1 was given a Discharge Instruction sheet upon discharge 6/7/14 with no clear instructions for chronic back pain. The patient was instructed to call a North Carolina phone number and listed an address in North Carolina to follow-up with the Emergency Room Physician.