HospitalInspections.org

Based on document review and interview, the hospital failed to transfer necessary medical information to a receiving facility for 1 of 10 patient (P1) medical records (MR) reviewed.

Findings:

1. Review of the policy titled Transfer of Patient, inter-facility and intra-facility indicated the following:
a. Transfer of the patient will be ordered by the physician based on assessed need of treatment and/or services.
b. Guidelines for Transfer of Patient to Nursing Home: 5. A completed transfer form, summary of care record, and medication reconciliation sheet...must be sent with the patient. 7. The following must accompany the patient: c. H&P (history and physical); e. Other pertinent information.
c. The policy was reviewed 3/2015.

2. Review of P1's MR indicated the following:
a. The patient was admitted to the hospital's BHU (behavioral health unit) on 2/2/16. On 2/10/16, the patient experienced a fall resulting in hip fracture, was transferred to a medical/surgical unit and underwent hip surgery on 2/11/16.
b. On 2/16/16 a PEG (percutaneous endoscopic gastrostomy) tube was surgically placed for nutritional enteral feedings.
c. The Discharge Assessment/Summary Report indicated on 2/22/16 at 15:47hrs, the patient was transferred to a SNF, the CDA (clinical documentation architecture) was sent and report was called to the receiving nurse at the SNF.
d. The MR lacked documentation of an H&P or feeding tube orders/instructions being sent/provided to the SNF.

3. On 4/12/16 at 10:15am, A5, RN (registered nurse)/Quality PI (performance improvement), indicated it could not be determined from the MR for P1 that the H&P or feeding tube instructions were sent or provided to the SNF.

4. On 4/12/16 at 12:00pm, A2, Quality/Infection Prevention Manager, indicated the CDA is pulled from a Quick Links selection list within the MR. He/she indicated the list to include the following: Hospital Admission Diagnosis, Social History, Problems, Medications, Allergies, Results, Vital Signs, Plan of Care, Procedures, Encounters, Immunizations, Functional Status and Hospital Discharge Instructions.

5. Review of the printed CDA document of P1 lacked documentation of an H&P and lacked documentation of feeding type or feeding tube instructions.