HospitalInspections.org

Based on review two weeks staffing, policy and procedure and staff interview, it was determined that the facility failed to have immediate availability of a registered nurse on ten (10) out of 84 shifts for care of patients.
Findings include:
A review of documentation of staffing for 10/30/16 through 11/12/16 revealed that, ten (10) of 84 shifts lacked registered nurse coverage for patient care needs.
During an interview on 1/11/17 at approximately 2:00 p.m. in a conference room, the Director of Nursing Services acknowledged the finding.

Based on review of the patient's medical record, facility policy and procedures and staff interview, it was determined that the facility failed to ensure the patient's safety during discharge.
Findings include:
Review of the medical record of patient #1 revealed that the 62-year-old patient had a history of dementia and suicidal ideations (SI - thinking about planning suicide). The patient resided in a nursing home and had become agitated and combative. The patient was transferred to the current facility for medical evaluation and psychiatric management. Patient #1 was seen by a physician who ordered the patient to be monitored on special observation (an assigned mental health personnel records the patient's location and behavior every fifteen minutes.)

Further review of the medical record revealed that patient #1 showed signs of confusion with poor concentration and memory impairment secondary to an assessment performed on 11/3/16.

The patient had a treatment plan that addressed the patient's diagnoses of major depressive disorder and dementia. The initial discharge plan was for the patient to return to the nursing home.

On 11/9/16, physician #1's progress note revealed that 11/9/16 the patient reported feeling better and was oriented to person, place, time and date. The patient's speech was appropriate, thoughts were organized, mood anxious, insight was moderately impaired and judgment was described as fair.

Review of LPN #5's discharge note on 11/10/16 at 2:30 p.m. revealed that the patient was alert with the ability to make his/her needs known and that the patient had been transferred via Uber. The LPN's documentation failed to mention the patient's destination upon transfer. LPN #5 wrote that patient #1 received follow-up information and that it was also explained to the patient.

In an interview conducted in a conference room at 9:20 a.m. on 1/10/2017, physician #1 stated that case managers do discharge planning and that he/she provides input regarding the patient's clinical needs and level of care. Physician #1 stated that the patient was stable and no longer depressed before discharge. He/she further stated that the hospital uses an ambulance service and a new system of transport which are taxis.

Physician #1 stated that the ambulance transport service is often overwhelmed and thus shows up late or sometimes not at all. The physician also stated that if a patient can use a taxi, that would be the method of transport. Physician #1 further stated that he/she did not decide patient's mode of transport, but would prefer that patients were not transported via taxis.

During an interview conducted in a conference room at 10:10 a.m. on 1/10/2017, therapist #2 stated that he/she was patient #1's therapist and recalled that the patient was "pleasantly" confused. Therapist #2 stated that he/she had completed the patient's discharge and faxed the reconciliation (list of types of medication) sheet, discharge care plan and a copy of the patient's prescription to the nursing home. Therapist #2 stated that on 11/9/16, he/she called the nursing home and spoke to the admissions director regarding the patient's bed hold and scheduled discharge back to the nursing home. Therapist #2 explained that he/she checked off "hospital transport" on the patient's discharge plan papers. Although he/she is responsible for completing the discharge care plan, he/she is not the person who actually sets up the patient's transportation. Therapist #2 confirmed that there was no documented evidence of phone contact to the NH on 11/10/16 to inform the NH staff of the patient's pending arrival.

On 1/10/17 at 10:50 a.m. in a conference room, the Director of Clinical Services, (DCS) employee #3 stated that he/she gets a daily list of patients who are projected to be discharged. The DCS explained that he/she calls either and ambulance service or a non-profit organization which contracts with Uber to transport patients. He/she stated that staff take patients to the hospital lobby when the taxi arrives, but do not accompany patients in the taxi.

The DCS stated that "in hindsight," he/she realizes that the use of Uber was not the most appropriate form of transportation for patient #1. The DCS acknowledged that there was no call made to the NH to inform staff that the patient was on the way. He/she recalled that there is a computer dashboard that he/she can refer to and it displays that the patient's transport was completed.

Employee #3 confirmed that Patient #1's discharge documentation was written by a Licensed Practical Nurse and that the note lacked a Registered Nurse's co-signature as required by hospital policy.

During an interview at 12:30 on 1/10/17, in a conference room, LPN #5 stated that when he/she works on the Crystal unit (unit that houses geriatrics, patients with dementia and other mental and medical problems) he/she confirms with social workers and therapist as to the mode of transportation the patient would leave in. LPN # 5 stated that depending on the patient's condition, he/she would have mental health staff escort the patient to the lobby to wait with the patient until Uber arrives. LPN #5 further stated that he/she gives the patient an explanation of the discharge paperwork and has the patient sign the bottom of the page.

Review of policy # PC.110 entitled "Patient Transfer to Another Facility" issued 10/08 and policy # PC.115 entitled "Discharge and Aftercare Planning", issued 10/08 respectively lacked a process for the safe transport of patient with dementia.