HospitalInspections.org

Based on interview and record review the hospital failed to ensure a current nursing plan of care was was completed for 1 of 4 patients [Patient #1]. [Patient #1's] nursing care plan did not address the use of coumadin therapy and a seizure disorder.

Findings Included:

The history and physical dated 12/10/10 reflected, "Assessed on 12/08/10, for suicidal ideation...she continued to make statements that she was going to harm herself, stated she was going to jump out of a window and kill herself. She says she is tired of being sick...with health problems. She told the nurse "I want to jump out the window." Cardiovascular positive for two valve replacements of the heart...history of atrial fibrillation...and history of seizure disorder..."

The physician's orders dated 12/10/10 reflected, "Coumadin 5 mg [Milligrams] by mouth every day...Depakote500 mg two by mouth in the AM..."

The Interdisciplinary treatment plan dated 12/09/10 reflected, "Problem #1 alteration in mood-depressed potential for self-harm..." No further nursing plan of care was found in the medical record.

On 03/10/11 at 1:45 PM [Staff #3] was interviewed. [Staff #3] was asked to review Patient #1's medical record. [Staff #3] stated the nursing plan of care was incomplete and did not address Patient #1's seizure disorder and anticoagulant therapy.

The Policy and Procedure entitled, "Charting in the Medical Record" with a review date of 05/2010 reflected, "Entries in the chart should be relevant and consistent with the goals outlined in the individual master treatment plan..."

Based on interview and record review the hospital failed to ensure the discharge planning evaluation provided post-hospital services and/or follow-up for 1 of 4 patient's [Patient #1].

Findings Included:

The history and physical dated 12/10/10 reflected, " Assessed on 12/08/10, for suicidal ideation...she continued to make statements that she was going to harm herself, stated she was going to jump out of a window and kill herself. She says she is tired of being sick...with health problems. She told the nurse " I want to jump out the window. " Cardiovascular positive for two valve replacements of the heart ...history of atrial fibrillation ...history of seizure disorder..."

The physician's orders dated 12/12/10 timed at 10:45 AM reflected, "Patient to be discharged today at her request..."

The aftercare Plan Instructions dated 12/12/10 reflected, "Patient request...social service will follow-up on Monday with referrals...signed by patient, social worker and nurse..." The case management notes reflected no follow-up entries or the patient's need for post-hospital services.

On 03/10/11 at 12:55 PM, [Staff #5] was interviewed. [Staff #5] was asked to review Patient #1's aftercare discharge plan. [Staff #5] reviewed the aftercare plan and stated she did not follow-up with Patient #1. She stated she usually does a progress note. She stated she overlooked it.

The policy entitled, "Discharge Aftercare Planning" with a review date of 05/2010 reflected, "The discharge plan should 1) Prepare the patient and family for the transition to the next level of care. 2) Address the patient's and family's need for instructions about continued treatment. 3) Delineate how progress made in the current level of care will continue after discharge. 4) Identify problems to be addressed in the next level of care. 5) Identify the responsibility for ensuring that the prescribed follow-up is accomplished. 6) Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care..."

+Based on interview and record review the hospital failed to ensure a comprehensive treatment plan was completed for 1 of 4 patients [Patient #1]. Patient #1's treatment plan did not address the use of coumadin therapy, Hypertension and a seizure disorder.

Findings Included:

The history and physical dated 12/10/10 reflected, "Assessed on 12/08/10, for suicidal ideation...she continued to make statements that she was going to harm herself, stated she was going to jump out of a window and kill herself. She says she is tired of being sick...with health problems. She told the nurse "I want to jump out the window." Cardiovascular positive for two valve replacements of the heart...history of atrial fibrillation...and history of seizure disorder..."

The physician's orders dated 12/10/10 reflected, "Coumadin 5 mg [Milligrams] by mouth every day...Depakote 500 mg two by mouth in the AM..."

The Interdisciplinary treatment plan dated 12/09/10 reflected, "Problem #1 alteration in mood-depressed potential for self-harm..." No further interdisciplinary treatment plan problems were found in the medical record.

On 03/10/11 at 1:45 PM [Staff #3] was interviewed. [Staff #3] was asked to review Patient #1's medical record. [Staff #3] stated the treatment plan was incomplete and did not address Patient #1's seizure disorder and anticoagulant therapy.

The Policy and Procedure entitled, "Charting in the Medical Record" with a review date of 05/2010 reflected, "Entries in the chart should be relevant and consistent with the goals outlined in the individual master treatment plan..."

Based on interview and record review the hospital failed to ensure the social worker provided aftercare, follow-up care for 1 of 4 patient's [Patient #1].

Findings Included:

The history and physical dated 12/10/10 reflected, " Assessed on 12/08/10, for suicidal ideation...she continued to make statements that she was going to harm herself, stated she was going to jump out of a window and kill herself. She says she is tired of being sick...with health problems. She told the nurse " I want to jump out the window. " Cardiovascular positive for two valve replacements of the heart ...history of atrial fibrillation ...history of seizure disorder..."

The physician's orders dated 12/12/10 timed at 10:45 AM reflected, "Patient to be discharged today at her request..."

The aftercare Plan Instructions dated 12/12/10 reflected, "Patient request...social service will follow-up on Monday with referrals...signed by patient, social worker and nurse..." The case management notes reflected no follow-up entries.

On 03/10/11 at 12:55 PM, [Staff #5] was interviewed. [Staff #5] was asked to review Patient #1's aftercare discharge plan. [Staff #5] reviewed the aftercare plan and stated she did not follow-up with Patient #1. She stated she usually does a progress note. She stated she overlooked it.

The policy entitled, "Discharge Aftercare Planning" with a review date of 05/2010 reflected, "The discharge plan should 1) Prepare the patient and family for the transition to the next level of care. 2) Address the patient's and family's need for instructions about continued treatment. 3) Delineate how progress made in the current level of care will continue after discharge. 4) Identify problems to be addressed in the next level of care. 5) Identify the responsibility for ensuring that the prescribed follow-up is accomplished. 6) Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care..."