HospitalInspections.org

Based on interview, clinical record review, and facility procedure review, the facility failed to implement discharge planning for one (Patient #1) of three sampled patients.

The findings include:

Patient #1 was admitted to the hospital on 12/28/09 with abdominal pain. At the time of admission the patient was assessed as being a smoker. The patient was prescribed a Nicotine Patch which was refused.

An interview with Patient #1 revealed the patient was told that there was no smoking on the hospital property so the patient left the hospital property to smoke. The patient was observed by security staff and upon return to the hospital floor was discharged.

Clinical record review on 1/21/10 shows the nursing staff documented the patient had left, the supervisor was called, and the patient was told she/he was being discharged. The AMA (Against Medical Advice) form shows the patient refused to sign the form. Further clinical record review shows nursing staff had documented the patient refused to wear a Nicotine Patch as ordered; however there is no documentation to show the patient's physician was notified of this refusal so alternate treatment could be offered.

The clinical record for "Discharge Planning" shows the following was documented by nursing staff: Date 12/31/09; Topic: AMA (Against Medical Advice) discharge; Taught: Patient; Method: Verbal; Response: Understands; Teaching Summary: Asked pt. to sign AMA form and explained to the patient due to LMHS no smoking policy she/he must be discharged. Pt. refuses to sign AMA Form. Stated, "You guys are kicking me out; I'm not going to sign anything." The clinical record shows the physician was notified after the patient was presented with the AMA form and the record does not show the patient was provided with discharge instructions.

On 1/26/10 at approximately 11:35 a.m., an interview was conducted with the nurse on the unit that day. The nurse stated the patient was outside and security notified the nursing staff. The nurse said the supervisor was called, they were told to discharge the patient because of the no smoking policy. Nursing staff was asked if counseling occurred with the patient or did the patient say she/he was going to continue to smoke while at the hospital. The nurse stated the patient was not given counseling or stated she/he would continue to smoke. The nurses stated, "It's a new policy and we're not sure how to handle it." The nurse said the patient refused the Nicotine Patch and she/he never thought to offer Nicotine Gum as the nurse did not know that was an option; "I hope that she/he's ok; I did see that she/he didn't need to come back to the hospital so she/he must be ok."

On 1/27/10 at approximately 11:05 a.m., an interview was conducted with the nurse who documented the discharge planning on 12/31/09. The nurse stated the patient asked if she/he could go outside and get some fresh air. She/he was told there was no smoking on the hospital property. The patient came back in and did not smell like smoke. The patient went out again and that's when security called to say that the patient was on the street with her/his IV and antibiotics smoking. The patient left the property with hospital equipment.

An interview with the Unit Director was conducted on 1/21/10 at 3:45 p.m. The Unit Director stated a Security Guard came up to the 4th floor and said he saw the patient on 6th Street smoking in a gown and with an I.V. The Charge Nurse that day called and asked what to do. The nurse was told patients are not allowed to leave to smoke. Patients have to be discharged. The Director was asked if anything other than Nicotine Patch was offered to the patient and was the physician notified. The Director couldn't say because she was not on the floor.

Interview with hospital administrative staff on 1/21/10 at 4:30 p.m. reveals patients who smoke are discharged because smoking is not part of the treatment plan, and it is against medical advice. "They are refusing to adhere to their treatment plan."

The facility Policy and Procedure for a Tobacco Free Environment (#876), dated 10/8/09, was reviewed. Section B for Patients/Visitors shows the following: Section B.2.e "If after all education attempts have been made and a patient still wishes to leave their room to utilize tobacco products they will be informed that they are choosing to do so against medical advice at their own risk and they will not be able to remain as a hospitalized patient."; B.2.f. "The nurse must inform the patient about the implications of such a choice and document that education."; B.2.g. "The patient is to sign the Statement of Patient Leaving Against Medical Advice (AMA)." Section B.2.h. shows "The attending physician is to be notified of the patient's decision to leave AMA."

The facility did not follow its policy to educate and document prior to discharging Patient #1. The patient was not provided with adequate discharge planning to receive follow up care for a medical condition.