HospitalInspections.org

Based on medical record review, hospital document and policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 2 of 5 patients (Patient #'s 1 and 2) in the sample. Findings included:

The hospital policy entitled "Personal Hygiene Assistance" stated, " ...nursing staff ...will assist patients as needed with personal hygiene, to include ...baths, showers ...to ensure patient cleanliness. Specifically, Children ...may need additional assistance to ensure patient cleanliness ...Assist Patient ...shower ...into clean clothing ...with oral hygiene ..."

A. Medical record review revealed no evidence or documentation to support that hygiene was completed, or assistance provided to the following two child patients, or a rationale for the patient to not have a shower, oral hygiene, and clean clothing, as follows:

1. Patient #1 (Age 6): 3 of 6 days between 2/24 through 3/1/20
2/28, 2/29, 3/1 and 3/2/20
This finding was confirmed on 10/30/20 at 11:15 AM by Director of Clinical Services A.

2. Patient #2 (Age 5): 3 of 7 days between 2/27 through 3/7/20
2/27, 3/2 and 3/4/2020
This finding was confirmed on 10/30/20 at 1:02 PM by Director of Clinical Services A.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to reevaluate the discharge plan for 1 of 5 discharged patients in the sample (Patient #3). Findings include:

The hospital policy entitled "Discharge/Aftercare Planning" stated, " The Discharge Plan should ...Identify problems to be addressed in the next level of care ...Include timely and direct communication with and transfer of information to ...individuals that will be providing continuing of care."
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The hospital policy entitled " Documentation of Lay Caregiver" stated, " ...the social worker will contact the support person to review the patient's aftercare needs ...the social worker will document this information in the patient's medical record."

The hospital job description for social worker stated, "Essential Job Duties ...Develop and coordinate an individualized discharge plan for the patient ...to determine aftercare needs ...Identify and assess family ...to meet patient's aftercare needs."

A. Review of the medical record revealed:

1. Patient admitted 3/25/20
2. Social Worker A notes contained the following information:
a. 4/1/20 patient consented for social worker to contact brother.
b. 4/2/20 social worker contacted patient's brother, brother requesting to speak with psychiatrist, social worker relayed message.
c. 4/6/20 social worker concerned about patients discharge. Brother notified and in agreement. Discharge cancelled.
d. 4/8/20 brother expressed concerns regarding sister's treatment and has not spoken with psychiatrist.
e. 4/14/20 brother notified of patients discharge plan. Brother expressed psychiatrist has not called him regarding patient's aftercare planning and he will not accept patient without psychiatrist calling and verifying treatment plan. Brother feels sister is not ready for discharge. Social worker notified psychiatrist.

3. "Psychiatrist Treatment Planning Progress Note" dated 4/15/20 at 10:30 AM documented:
- " ...Patient stable for discharge today ...spoke to patient's brother and he is agreeable to d/c (discharge) plan.

4. Social Worker notes documented on 4/16/20 at 9:30 AM and 9:40 AM revealed:
- Patients brother unhappy with patient discharge. Brother stated "I have a lawyer and you can tell Dr. Begum that she cannot dump my sister on me after she was possibly exposed to Covid-19"
- Dr. was notified of brothers concerns by social worker, Dr. Begum continued to discharge patient home.

During an interview on 10/29/20 between 2:27 PM and 2:43 PM Director of Social Services A reported:
-patient was stable and ready for discharge on 4/16/20
-patient was not exposed to Covid-19 during admission
-patient lived with brother prior to admission and wanted to return
-spoke with brother on phone after brother expressed his concerns to Social Worker A
-after phone conversation , brother was in agreeance with discharge plan but was reluctant
-gem ambulance picked up patient to take home
-brother did not accept patient into home and told gem ambulance to take to Hospital A to get tested for Covid-19
-hospital A did not test due to patient not meeting criteria for testing.
-hospital A sent patient back to Rockford due to patient being at risk if stay in Emergency Department
-while patient was in transport from hospital A back to Rockford, Director of Social Services A was able to educate brother on Covid-19 concerns, referred brother to Department of Public Health who also educated brother.
-brother then accepted sister to return home in his care
-gem ambulance arrived to Rockford and asked gem ambulance to take patient back home
-gem ambulance wanted to speak with brother prior to transporting patient home to confirm brother would accept patient into home
-facility called brother and brother confirmed that he will accept patient into his home
-patient was transported back home by gem ambulance

Review of the medical record failed to provide evidence that discharge plan was re-evaluated after brother expressed concerns regarding patient being discharged into his care.

During an interview with Director of Clinical Service on 10/29/20 at 3:18 PM confirmed that the medical record failed to reflect re-evaluation of the discharge plan.