HospitalInspections.org

Based on review of Medical Staff Rules and Regulations, Medical Record Review, and Interviews, the facility failed to provide an ordered consultation for one (#3) patient of ten patients reviewed.

The findings included:

Review of the facility's Medical Staff Rules and Regulations dated June 2014, revealed "...Consultations shall be completed within a time frame appropriate for the condition of the patient but not to exceed 24 hours..."

Review of the medical record revealed patient #3 was admitted to the facility on 6/15/16 with diagnoses that included "...Rt Knee Effusion, Suspect Knee Injury, Unable to Ambulate..."

Medical record review of Physician #1's orders for an orthopedic consult dated 6/15/16 at 8:37 PM revealed "...Consult Physician...Reason for Consult: Knee Pain...routine in AM...Consult with recommendations and interventions knee pain...had appt with you today, got moved to Friday...plan admit tonight, pain control, consult Dr...in AM..." Further review of the medical record revealed no documentation of the orthopedic consult being completed.

Medical record review of a discharge summary written 6/17/16 at 6:34 PM, revealed "...We placed a consult with Orthopedics, however they advised to follow as an outpatient, so the patient will make an outpatient appointment...Patient can be discharged in the morning..."

Interview with Patient #3 by telephone on 7/14/16, at 10:00 AM confirmed she had been admitted to the facility on 6/15/16 and was told the orthopedic doctor would see her in the morning. Continued interveiw revealed "...I was there three days waiting to see Dr...and he never came..."

Interview with Director of Quality on 7/28/16, at 10:00 AM, in the administration conference room, confirmed an orthopedic consult had been ordered for Patient #3 on 6/15/16 and had not been provided to Patient #3 during the 6/15/16 to 6/18/16 admission.

Based on policy review, medical record review, and interview, the facility failed to implement the discharge plan for one (#1) patient of ten patients reviewed.

The findings included:

Review of the facility's policy titled Discharge Planning, effective date 3/3/15, revealed "...The discharge planning process...provides for the...implementation of the discharge plan prior to the discharge of the inpatient..."

Review of the medical record revealed Patient #1 was admitted to the facility on 7/17/16, with diagnoses that included: Cerebrovascular Disease and Congestive Heart Failure. Continued review revealed the patient was discharged home on 7/23/16.

Medical record review of a case manager's (CM) discharge planning note dated 7/22/16 at 4:05 PM revealed "...No HH [home health] needed at this time...Home with DME only ..." Continued medical record review of a physician's discharge order dated 7/23/16 revealed "...home with home health services..." Further review of a case manager's note dated 7/27/16 at 12:35 PM revealed "...Late entry from 7/23/16...Received call that pt [patient] needed to go home with HH services...faxed info to [named HH agency]...Received call from CM that HH didn't receive referral. Resent everything today..."

Interview with the Case Manager on 7/27/16 at 2:00 PM, in the administrative conference room, confirmed Patient #1 had a discharge order for home health service and there was no documentation of a referral being made to home health services prior to the patient's discharge on 7/23/16. Further interview with the case manager confirmed she had contacted the home health agency and the home health agency did not receive a referral for Patient #1 until 7/27/16.