HospitalInspections.org

Based on policy review, medical record reviews, grievance file review and staff interviews, the hospital staff failed to ensure a safe discharge by not notifying the interdisciplinary team of a post-hospitalization concern for 1 of 5 discharged patients. (Patient #3).

The findings include:

Review on July 11, 2017 of the hospital's policy, "Discharge Planning", revised June 4, 2014 revealed, "I. SCOPE / PURPOSE...II. POLICY...1. Discharge planning is an interdisciplinary process in which the discharge and continuing care needs (i.e. physical, emotional, social) of patients are identified, evaluated and addressed by nurses and other health care providers (consistent with their professional scopes of practices) in collaboration with the patient/suport person(s)...III. QUALIFIED PERSONNEL...All employees are required to alert nursing, medical staff or case management of discharge concerns..."

Closed medical record review on July 11, 2017 revealed on January 10, 2017 at 1353, Patient #3, a 52 year-old presented to the emergency department with complaints of right-side upper and lower extremity numbness (stroke). Review revealed the patient received medical work-up for a stroke patient and at 1425, the patient had a stroke score of 1 (slightly impaired), was alert and oriented with complaints of right-sided numbness and tingling. As a result of the imaging study, the stroke diagnosis was confirmed and the patient was admitted to the hospital. On January 11, 2017 at 0050 and 0438, the patient experienced "tingling and numbness" in the right upper and lower extremities. At 0800, the physical assessment of the patient included a stroke score of 2 (slightly impaired), alert and oriented with "tingling and numbness" in the right upper and lower extremities. While receiving inpatient care, the patient orders included PT/OT (physical therapy/occupational therapy) evaluation and treat. At 0949, PT performed an initial evaluation of the patient; in which, the patient had decreased safety awareness with poor insight into limitation. PT recommendations included physical therapy and medical equipment. Review revealed the patient was not "receptive" to PT recommendations. At 1238, the patient continued to experience "tingling and numbness" in the right upper and lower extremities. At 1250, OT performed an initial evaluation of the patient; in which, the patient demonstrated a "lack of insight" and desired to continue life prior to hospitalization, including driving. Review revealed OT attempted to explain limitations; however, due to "lack of insight" demonstrated by the patient, OT recommendations included "...no driving, driver's rehab consult." At 1409, the patient had a discharge order. Review revealed the discharge order had no driving restrictions. At 1544, the patient received discharge education that failed to include driving restrictions. At 1549, a discharge transport order was entered and the discharge destination was the main lobby. At 1615, the request was in progress and at 1641(26 minutes later), the discharge request was completed. Review revealed the patient was discharge to home, with a stroke score of 2, with right lower extremity ambulation deficit and with no driving restrictions. Review failed to reveal the interdisciplinary team was notified of the "no driving, driver's rehab consult."

Review of the grievance on July 12, 2017 revealed on January 26, 2017, a family member of the patient filed a grievance related to the discharge process, in that, the patient was allowed to drive home and no family member(s) were notified of the patient's discharge. Review of the grievance revealed as an inpatient, the patient walked around the unit twice with "stand-by" assistance from staff. During the walk, the patient demonstrated a "catching of" the right leg. Prior to discharge, the patient was evaluated by PT and OT. PT detected no weakness; however, the "catching of" the right leg was observed. OT evaluated the patient and recommended assistive devices to which the patient agreed. Upon completion of discharge paperwork, the patient was discharged from the hospital [to home] with a follow-up [appointment] to the stroke clinic. The inpatient physician statement concluded with the acknowledgment of the driving restrictions, recommended by OT, were in the patient's electronic medical record. The physician realize 2-opportunities for improvement. The first opportunity, for a stroke score less than or equal to 1, the patient should not drive home until post follow-up visit at the stroke clinic. The second opportunity, PT/OT verbally discuss restrictions and provide written recommendation(s) to the medical team. Review failed to reveal the interdisciplinary team was notified of the "no driving, driver's rehab consult" and opportunities for improvement were identified.

Interview on July 11, 2017 at 1540 with RN (Registered Nurse) #1 in the presence of the Nurse Manager and a CUL (Clinical Unit Leader) revealed she worked as an admit/discharge nurse on the inpatient unit that the patient was admitted to and discharged from. Interview revealed the patient was discharge from the hospital, to home, with home health and medical equipment. Initially, the patient stated he would drive himself home. Later, the patient stated "someone would pick him up and about 30-minutes later, the patient stated driver was ready for patient pick-up." Interview revealed the discharge driver did not present to the inpatient unit but was located in the patient pick-up area [main lobby]. The Nurse Manager added the discharge transport process changed related to the patient's family member concern with the discharge process. Interview revealed during the discharge transport, the patient requested the "transporter to take him to the emergency department area because his car was located there." And as a result, the "transporter performed the duty as requested by the patient." Interview revealed the Nurse Manager was notified by the CUL of the patient complaint. Interview revealed "Guest Services" reviewed the complaint and determined there was no physician order indicating the patient could not drive. On March 1, 2017, due to the perception of an unsafe discharge, corrective action education was implemented for the staff on the patient's inpatient unit. Interview revealed on June 20, 2017, the education was available to all hospital staff including transporters, a contracted service. Interview revealed education was provided due to the perception of an unsafe discharge. Interview revealed the patient drove himself home after discharge from a hospital.

Interview on July 12, 2017 at 0915 with the OT in the presence of the OT Supervisor revealed the "no driving, drivers rehab consult" for Patient #3 was due the impulsive behaviors and falls precautions. During OT evaluation, the patient demonstrated impairments in cognition, problem-solving and safety/judgement. Interview revealed OT provide recommendations, not referrals, based upon the evaluation. Although OT does not enter orders, the recommendations were located in the patient's electronic record. Interview revealed since Patient #3 discharge incident, OT consult recommendations flow over into the flowsheet (neuro) for other disciplines to view. Interview revealed the OT no driving recommendation was based upon evaluation of the patient and was entered into the patient's medical record.

Interview on July 12, 2017 at 0925 with RN #2 and RN #3 revealed they were stroke educators and Patient #3 had no concerns related to stroke education. Interview revealed the patient lived with family and desired to return to the level of physical activity prior to hospitalization. Interview revealed the patient had a 2 of 6 social screening score which indicated the patient was "slightly impaired" but was able to perform activities of daily living independently. The social screening also revealed the patient drove prior to hospitalization. Interview revealed RN #2 did not feel driving was a concern for this patient; however, a patient driving home was dependent upon PT/OT evaluation of patient safety. Interview revealed the patient driving concerns were based upon PT/OT evaluations.

Interview on July 12, 2017 at 1000 with the Director of Patient Transportation in the presence of the Director of Emergency Department and the Manager of Accreditation/Regulation revealed Transporter #1 was unable to recall the patient-specific incident. Interview with review of discharge transport record revealed Patient #3 discharge transport request was re-assigned 3-times, no documented reason, prior to Transporter #1. The transportation director acknowledged the information and further stated the patient's family member alleged Transporter #1 assisted the patient into his car which would have been the correct action of not leaving a patient unattended. The new process was for all patient discharges to occur via the main lobby. Interview revealed the transporter should notify dispatch with changes in discharge location. Interview revealed as a result of Patient #3 discharge, transporters received safe discharge education.

Interview on July 12, 2017 at 1325 with Guest Services Representative #1 in the presence of the Corporate Director of Patient Partnership, Corporate Manager of Patient Services and the Manager of Accreditation/Regulation revealed we [Guest Services] obtained consent from the patient to continue communication with the patient's family. As communication continued, the family member was unhappy with the investigation outcome in that the patient drove home, with a right lower extremity limp, after discharge from the hospital. Interview revealed the progress note dictated by the Medical Director (MD) of Neuroscience indicated a stroke score of 1 should not restrict the patient's ability to drive. Interview revealed Guest Services Representative #1 did not interview RN #1, the nurse who discharged Patient #3, but interviewed the Director of Patient Transportation who did not recall the patient having restrictions at discharge and stated transporters rely on communication from the nurses. Interview revealed "OT recommendation was a recommendation at the discretion of the physician." Interview failed to reveal if the Nurse Practitioner, the discharge provider, reviewed OT recommendations prior to patient discharge.

Interview on July 12, 2017 at 1433 with MD of Neurosciences in the presence of the Vice President (VP) of Medical Affairs and the Manager of Accreditation/Regulation revealed the patient's family member voiced concerns due to the patient was allowed to drive home after discharge from the hospital. Interview revealed RN #1, a senior nurse on the inpatient unit, discharged the patient to the main lobby. Interview revealed upon knowledge of the patient going to the emergency department where his car was parked, the question was, "would the transporter have prior knowledge of the patient's vehicle location?" Interview revealed the OT recommendation was an allied note and was "requited" of the provider to open and read the allied note. Interview revealed there was not specific hard/soft-ware notification for real-time practice. The allied note should have been reviewed prior to the patient's discharge..."this [incident] is on us, not the patient." Interview revealed the multi-disciplinary team held conference on Monday through Friday and discussions included patients' discharge needs (i.e. placement, rehab or home health). The NP, who discharge Patient #3, was no longer at the hospital. Interview revealed the MD of Neurosciences verified the NP verbally told the patient not to drive but no documentation was available. The MD of Neuroscience further stated it was not "standard of practice" for a patient to drive post-discharge from the hospital. Interview revealed as a result of Patient #3 discharge, a corrective action was implemented in that the discharge summary should state no driving until follow-up at the stroke clinic or with PCP (Primary Care Physician).

Interview on July 12, 2017 at 1535 with Transporter #1 revealed the transporter did not remember the patient. As related to the discharge process, the transport would obtain equipment, travel to requested unit, notify nurse upon arrival to unit, pack up the patient's belongings, assist the patient into the wheelchair, and transport the patient to the discharge (main) lobby. Interview revealed the transporter has had a patient/driver to request an alternate discharge location; in which, the transporter notified dispatch. The current practice was for all patient discharges to occur via Lobby C (main lobby), remain with the patient until driver arrives and ensure the patient was in the vehicle. Transporter #1 stated an assigned discharge took 20-minutes to complete and a pending discharge took 30-minutes to complete. Any discharge greater than 30-minutes, the transporters were expected to call dispatch (standard of practice). Interview failed to reveal the transporter was aware of OT recommendation of "no driving, driver's rehab consult."

Interview on July 13, 2017 at 0930 with the Chief Nursing Officer (CNO) and the Manager of Accreditation/Regulation revealed safe discharge education was ongoing and starting this week, monitoring would continue for four months. The education was implemented due to Patient #3 discharge. Interview revealed the hospital staff had no desire for any patient to be at risk. Due to an increase of the population, the goal was to increase discharge communication between the hospital staff and patient/caregiver. Interview revealed the hospital was in the process of re-educating all staff on the patient discharge process.

Interview on July 14, 2017 at 0930 with the Director of Risk Management in the presence of the Manager of Accreditation/Regulation revealed a family member of Patient #3 filed a grievance with the Patient Partnership Department. The partnership department representative identified risk in the grievance information, developed an intake and then forward the intake information to the Risk Management department, which was later assigned to a risk manager to review and respond within 30-days per grievance policy. Review of the risk manager documentation revealed...concerns that the patient was allowed to drive home with a stroke score of 2. The MD of Neurosciences and the CUL verbalized the patient could not drive home with a stroke score of 2. The intent of the inpatient unit nursing staff was not for the patient to drive home and was unaware the patient had a car parked in the emergency department parking lot. The transporter did not specifically remember the patient. Interview revealed [the hospital staff] was unsure if the patient directed transporter to the emergency department location. The inpatient nursing staff did not deviate from standards of practice at discharge. Interview revealed since the incident with Patient#3 discharge, process changes had occurred in that a stroke score of greater than or equal 1 would have driving restrictions until follow-up at the stroke clinic and hospital staff education was currently ongoing.

Interview on July 14, 2017 at 1010 with the Corporate Senior Director of Accreditation and the Manager of Accreditation/Regulation revealed they acted as a "consultative" role by providing boundaries within the guidelines of policies and procedures. Interview revealed changes were not always made if action(s) were in accordance with policies and procedures; however, an opportunity was identified with the discharge process involving Patient #3. When a complaint was received, the issue should be addressed, which in this case, was the discharge of patient with a stroke score of 1. Interview revealed a patient with a stroke score of 1 could have been allowed to drive home. Interview revealed education deployment, hospital-wide, was in process and monitoring would occur for 4-months including patient transport. Interview failed to reveal the patient was discharged to home with a stroke score of 2.