HospitalInspections.org

Based on record review and interview, the facility failed to implement an effective discharge plan for one (#2) of 3 patients whose records were reviewed for discharge planning, resulting in the potential for less than optimal outcomes for patient #2.
Findings include:

Review of the medical record for patient #2 was conducted on 6/28/2021 at 1300 and revealed the following:
The patient of concern (#2) was an 82-year-old male who presented to the facility (A) via ambulance for an elective surgical procedure on 11/13/2020 at 1353.

Review of the Procedure Note dated 11/13/2020 at 1514, revealed the patient had a clinical history of Bile Obstruction and underwent a CT Guided Needle biopsy with the insertion of an Internal/external biliary drainage catheter. The provider noted the patient tolerated the procedure well, vitals remained stable throughout, the patient denied any complaints and was sent to the recovery area in stable condition.

The patient was transferred back to a subacute facility (B) via ambulance following the procedure on 11/13/2020 at 1730. However, there were no documentation in the medical record that documented discharge instructions were provided to the patient or the facility (B) at discharge.

An interview was conducted with Clinical Coordinator Staff J who was queried regarding the patient (#2's) discharge and documentation that addressed aftercare following the placement of the biliary catheter. Staff J said, a copy of the discharge instructions would have been given to the ambulance drivers who transported the patient back to the rehab facility (B) after the procedure and a copy should have been in his chart here (facility A). Staff J said, "We've looked, and we have not been able to locate the discharge instructions." At that time, Staff J was asked to provide the surveyor with a sample copy of the form that would be given to patients at discharge.

Review of a sample copy of the facility's "Interventional Radiology Discharge Instructions" form 49294410 (5/09) revealed the following:

"Sedation: The medicine you received for your test will be acting in your body for the next 24 hours. You may feel a little sleepy or drowsy, so for the next 24 hours you MUST NOT
Drive or operate machines or power tools
Drink alcohol
Make important decisions or sign important papers
STAY WITH AN ADULT (18 years of older) THE FIRST NIGHT AFTER THE PROCEDURE
Fluids and Diets: ....
Incision Care: ...
Complications: ...
Medications: ...
Drainage Catheter care: ...
Activity: ...
Follow-up Care: ...

I have received the post-procedure instructions:
Signature of Patient or responsible person ... ... ...Date: ...
Relationship to patient: ...
RN Signature (Witness) ... .... Date/Time ...
Physician Signature ... .... Date/Time:.."

However, there was no evidence that this was done.

An interview was conducted with Medical Doctor Staff N on 6.29.2021 at 1430. He explained he was familiar with the patient (#2) and had been consulted to place the catheter for biliary drainage. He explained the patient was alert and talking before and after the procedure. He explained the patient's baseline blood pressure ran on the low side. He said we gave the patient additional fluids at one point during the procedure and the patient's blood pressure improved. Staff N said the patient was stable at discharge. Staff N was queried regarding a lack of documentation for discharge instructions. He replied he did not recall if that was done.

A request for the facility's "discharge planning" policy was requested, but was not provided prior to exit.