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Based on interview and record review, the hospital's failed to ensure a safe and complete discharge process for one of four sampled patients (Patient 1). This had the potential to compromise the patient's safety, and to result in inadequate continuity of care.

Findings:

Review of the hospital's P&P titled Assessment/Re-assessment of Patients dated February 2025 showed its purpose is to comprehensively screen and document the initial assessment and reassessment of all patients admitted to the hospital. The reassessment provides ongoing data about the patient's biophysical, psychological, spiritual and social needs. The section of Discharge Assessment showed prior to discharge identify any needs related to psychosocial, physical care, treatment and/or services needed after discharge in order to meet the patient's needs for care services; a registered nurse is responsible for all discharge processes.

Review of the hospital's Registered Nurse Clinical Skills Checklist-Core showed the initial checklist is completed upon hire and as needed. The section of Discharge showed to provide education to the patient and family members prior to discharge using the teach-back method; validate patient understanding of discharge medications, including side effects and how to obtain medications upon discharge; and document patient personal belongings, including medications that are to be discharged with the patient.

On 7/16/25, a review of Patient 1's closed medical record was initiated. Patient 1's medical record showed the patient was admitted to the hospital on 9/28/24 and discharged on 10/10/24.

Review of the H&P examination dated 9/28/24 at 0506 hours, showed Patient 1 was admitted to the hospital for diverticulitis with contained perforation to receive IV antibiotics.

Review of the Hospitalist Discharge Summary dated 10/10/24 at 1104 hours, showed Patient 1 was diagnosed with acute diverticulitis with contained perforation, and pericolonic abscess to the caecum. Patient 1 was discharged home. The patient's discharge condition was stable. The diet was full liquid, advance diet gradually to soft. The Discharge Follow Up section showed to follow up with home infusion pharmacy.

Review of the physician's discharge order dated 10/10/24, showed to discharge Patient 1 after one dose of IV medication Invanz (antibiotic used to treat a variety of bacterial infections). The Discharge Disposition section showed home with home health.

Review of Patient 1 Flowsheet dated 10/10/24, showed the last set of vitals were taken at 1635 hours.

Review of Patient 1's medical record did not show any documentation of the RN's discharge note indicating the date or time the patient was safely discharged from the facility. There was no RN discharge note documenting that discharge education was provided to the patient regarding their medications, diet, follow-up medical appointments, or home health/home infusion pharmacy. There was no validation that the patient understood the discharge medication instructions, including side effects and how to obtain medications upon discharge. Additionally, there was no documentation showing that the patient had taken their personal belongings.

On 7/17/25 at 0930 hours, an interview and concurrent record review was conducted with the Nurse Manager of 3 West MST/Oncology. The Nurse Manager of 3 West MST/Oncology verified the assessment and reassessment policy applied to Patient 1's care and to the 3 West MST/Oncology. The Nurse Manager of 3 West MST/Oncology reviewed the Registered Nurse Clinical Skills Checklist-Core and stated it was the orientation training provided to the RNs including registry/agency RN's (travel nurses). The Nurse Manager of 3 West MST/Oncology verified it applied to the RN providing care to the patients on 3 West MST/Oncology.

The Nurse Manager of 3 West MST/Oncology reviewed Patient 1's medical record and confirmed there was no RN discharge note indicating the date, time, or any discharge instructions regarding medication, diet, or follow-up care. The Nurse Manager of 3 West MST/Oncology verified that the nurse had received training on how to discharge patients and stated that it was the responsibility of the Registered Nurse to ensure a safe discharge by providing education on discharge medication, diet, and follow-up appointments.

The Nurse Manager of 3 West MST/Oncology stated for a safe discharge, the RN was expected to provide education on discharge medication, diet, and follow-up appointments. Additionally, the RN was expected to take the patient's vital signs before discharge to ensure the patient was stable for discharge.

The Nurse Manager of 3 West MST/Oncology verified that Patient 1's vital signs were taken at 1634 hours, but no additional vital signs were recorded closer to the discharge time from the system. The Nurse Manager 3 West MST/Oncology could not determine based on Patient 1's medical record when or with whom the patient left the hospital but confirmed that Patient 1 was discharged from the hospital computer system on 10/10/24 at 1844 hours. The Nurse Manager 3 West MST/Oncology verified that neither the hospital's assessment/reassessment policy nor the RN Clinical Skills Checklist Core training was followed by the discharging RN based on the documentation reviewed in Patient 1's medical record.

On 7/17/25, the Director of Risk Management, Regulatory & Patient Safety was made aware of these findings.

Based on observation, interview, and record review, the hospital failed to ensure the use of restraint for the management of non-violent or non-self-destructive behaviors was ordered by the physician for one of four sampled patients (Patient 2). This failure posed a risk of unnecessary restraint use and substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraint for Non-Violent Non-Self-Destructive Behavior dated April 2025 showed restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely. An episode of restraint is the period of time beginning with the application of restraint and ending with its release. Each episode requires the order of a physician/LIP/APC. Restrains may be used only when less restrictive interventions are ineffective and must be utilized, per the order of a physician/ LIP/APC.

On 7/17/25 at 0950 hours, a tour of the 3 West unit was conducted with the Charge Nurse. Patient 2 was observed lying in bed, in a chest restraint. The Charge Nurse stated Patient 2 was confused, had tried to get out of bed, and pulled out an IV.

Review of Patient 2's medical record review was conducted with the Nurse Manager of 3 West MST/Oncology. Patient 2's medical record showed Patient 2 was admitted to the hospital on 7/14/25 at 1705 hours.

Review of the Restraint Flowsheets showed the chest restraint was applied to Patient 2 on 7/15/25 at 0130 hours.

Review of the medical record showed the initial physician's order for chest restraint to manage non-violent behavior was issued on 7/15/25 at 1713 hours.

The Nurse Manager of 3 West MST/Oncology verified the findings and confirmed the physician's order for restraint should be issued when the restraint was initiated for Patient 2.