HospitalInspections.org

Based on record review and interview, the facility failed to reassess the discharge plan and coordinate services with the Skilled Nursing Facility to ensure the continuity of patient care needs related to pain management in one (#2) of 12 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#2 conducted from 10-31-11 to 11-3-11 revealed an admitting diagnosis of Lumbar Spinal Stenosis. Documentation showed that on the same day, 3-28-11, she had "extensive thoraco-lumbo-sacral spine repair." Documentation on the Discharge Summary showed that "the patient's condition improved and was transferred to a Skilled Nursing Facility (SNF) on 4-5-2011 in fair condition. The patient is to follow regular diet. No medications prescribed."

Physician documentation on the Medical Certification for Nursing Facility/Home Based Services Form conducted on 10-31-11 revealed a form with no date but signed by the discharging physician and showed no medication and treatment orders.

Documentation on the Medication Administration Record dated 4-5-11 showed that the last dose of Oxycodone/Apap 5/325 mg [milligrams] was given to SP#2 at 1745 for "Pain Level/ Intensity:10" .

The 9th Floor Staff RN II's documentation on 4-5-11 at 1806 showed that SP#2's pain level was "0". Documentation on the Discharge Instructions showed discharge instructions for the general patient population but no documented evidence that SP#2 was educated on "special instructions" after her back surgery and "special discharge education" on pain relief anticipating SP#2's need for pain medication.

The 9th Floor Charge Nurse's documentation dated 4-5-11 at 1905 showed that SP#2's intravenous access "was removed per physician's order". Further documentation showed: "Medication Education: No."

Case Manager I's documentation on 4-5-11 at 1932 showed that SP#2 was transferred to the Skilled Nursing Facility via ambulance. Further documentation showed: "Additional Discharge Disposition Notes: No."

Review of the facility Policy on Discharge Planning Process conducted on 11-2-11 included but not limited to:

"Evaluation of patient considering post-hospital needs" ;
"The evaluation will include, but not limited to, information related to ... - medication needs" ;
"The interdisciplinary team will consider the patient needs and abilities when developing the discharge plan and integrate medical, psychological, age-specific needs ...and available resources to ensure essential needs are planned for." ;
"The case manager/social worker will concurrently evaluate the patient for discharge readiness throughout the hospital stay. Discharge criteria will be applied and ongoing discussions with the attending physician and patient/family should occur."

Interview with the Director of Case Management conducted on 11-1-11 at 1115am revealed that an onsite reviewer does the patient discharge assessment. She explained that prior to July 27, 2011, electronic documentation was sent through the Extended Integrated Network. She stated that on the day of discharge, a packet including the Continuity of Care forms completed by the physician and the nurse/social worker are sent with the patient. She added that nurses do not give verbal report to Skilled Nursing Facility staff.

Interview with 9th Floor Staff RN II conducted on 11-1-11 at 1120am confirmed that she discharged SP#2 on 4-5-11 as documented in her notes. She stated that she could not recall SP#2. She confirmed that the Discharge Instructions listed were for the general patient population. She confirmed that there were no specific instructions for SP#2 on medications and no special instructions after the type of surgery SP#2 had.

Telephone interview with 9th Floor Staff RN III conducted on 11-1-11 at 1125am revealed that he does not remember SP#2. He explained that the transfer forms are prepared by the Case Manager. He stated that the Medication Administration Record, medication reconciliation form and prescriptions, if any, are included in the transfer packet sent with the patient to the other facility.

Interview with Case Manager I conducted on 11-1-11 at 2pm revealed that she is the Case Manager for SP#2. She enumerated the documents included in the discharge packet sent with the patient to the Skilled Nursing Facility (SNF). She explained that a prescription for narcotics is needed when patients are transferred to the SNF.

Interview with Case Manager II conducted on 11-1-11 at 215pm revealed that she helped out in SP#2's case. She explained that the medication reconciliation form and prescriptions, if any, are considered "the responsibility of Nursing."

Interview with the Chief Executive Officer conducted on 11-1-11 at 330pm after discussion of SP#2's case concurred that the facility staff "could have done better in discharging this patient."

Interview with the Director of Case Management conducted on 11-1-11 at 4pm revealed that the medication reconciliation form is not used as a physician order. She stated that a prescription from the physician is needed for pain medications.

Interview with the Physician who discharged SP#2 conducted on 11-2-11 at 1110am revealed that he is a critical care medicine physician who evaluated SP#2 after her surgery and who ordered SP#2's discharge. He stated that he intentionally "did not order narcotics because of complications with narcotics" considering SP#2's age. He added that he should have written "to follow MAR" [Medication Administration Record]. After reviewing the MAR, he continued to say that he "preferred that when the patient reached the SNF, the physician would prescribe what is appropriate." He ended by stating that he "will not take responsibility over a patient not under my care."

Interview with the Orthopedic & Spine Nurse Navigator conducted on 11-2-11 at 220pm revealed that he does the follow-up of orthopedic and spine patients on the 9th floor. He stated that he keeps a log of patients he contacted after discharge. He recalls SP#2 well. He stated that he spoke with the Director of Nursing (DON) at the SNF where SP#2 was admitted regarding pain management. He concurred he didn't have the date written and could not recall exactly when the follow-up with the DON was. He calculated the conversation could have been a week after SP#2's discharge when he was told that "the SNF physician will help with pain management."

Interview with Case Manager I and Case Manager II conducted on 11-4-11 at 1035am confirmed that there was lack of continuity of care for SP#2 when it came to pain management. They both concurred that the hospital team should have properly coordinated with the SNF staff regarding SP#2's needs for pain relief.