HospitalInspections.org

Based on observation and record review the facility failed to initiate a safe discharge plan for 1 of 6 discharged patients (#1) increasing the likelihood of all patients being discharged without safe plans. Findings include:

Record Review:
On 11/5/14 from 1200-1430 patient #1's clinical record was reviewed with staff O. Patient #1 was admitted on 8/6/14 after sustaining a fall while walking outside on a sidewalk. The History & Physical (H & P), dated 8/6/14, states patient #1: "has lived in a group home for the past 11 years." The H & P states: "Neurosurgery came to evaluate patient and recommended Aspen collar for 1-2 weeks." A Social Work Assessment dated 8/6/14 states that patient #1 required "moderate assistance" with activities of daily living prior to admission. The note states that patient #1 is to be transported home by EMS at the time of discharge. The Discharge Summary, dated 8/12/14 states that the patient was discharged with a walker.

Patient #1 was discharged on 8/13/14. No documentation of how patient #1 got home or whether the walker was with the patient at the time of discharge was provided. No documentation of facility staff informing the patient's Adult Foster Care (AFC) home of the 8/13/14 discharge date and time was found. These findings were confirmed by staff O during record review.

Interviews:
1. On 11/5/14 at 1440 Adult Foster Care (AFC) home staff Z stated that patient #1 was discharged from this hospital on 8/13/14. Staff Z stated that staff on duty at the home at the time of discharge were not notified in advance of the patient's discharge. Staff Z stated that AFC staff on duty on 8/13/14 became aware of patient #1's discharge when another patient found patient #1 at the base of the home's driveway.
2. On 11/6/14 from 0910-1000 staff I and J confirmed that there was no documentation stating that patient #1''s group home was informed of the anticipated date and time of discharge and that documentation of how the patient was transported home could not be found.
3. On 11/6/14 at approximately 0930 facility policies pertaining to discharge planning were reviewed. Staff I confirmed that discharge policies do not assign responsibility for arranging and documenting specifics of patient discharge plans to specific (identifiable) staff members.