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Based on review of Policy and Procedure, clinical records and interview with hospital staff, the hospital failed to provide discharge instructions to the patient's primary care giver in 1 of 5 sampled cases (P3).

Findings include:

The hospital Policy and Procedure titled: LHS.900.3224.Patient Care, Last Review Date March 2010; Section: Fundamental Procedures; Title: Patient Screening, Assessment and Reassessment stated: "Text:
1. The patient receives care based on initial and ongoing assessments; developmentally appropriate assessment of his or her immediate problems and transition (discharge and/or referral to other community services) planning needs, when needs are identified through the screening process. Data is gathered from the patient, patient's family, significant other(s), and/or caregivers whenever appropriate."
Discipline/Department; Scope of Assessment/Reassessment (page 7 of 16) stated: "Clinical Resource Coordinators, Clinical Care Managers Resource Specialists: Complex discharge/transition planning; Upon initial assessment: patient's living situation, identification of support persons including availability to serve as caregivers.....anticipated changes in function at discharge, anticipated level of care; patient/family responses to illness/disability."

Documentation in the medical record for P3 revealed he/she had been an inpatient from 05/26/2010 to 05/29/2010, with discharge at 1430 on 05/29/2010 to an Assisted Living Facility (ALF). P3 returned to the Emergency Department (ED) via ambulance at 2116 on 05/29/2010 with uncontrolled pain.

The medical records for P3 revealed the following: a 75 year old with lung carcinoma, stage IV, status post palliative radiation and chemotherapy and total brain irradiation for brain metastases. He/she was admitted to inpatient care through the ED on 05/26/2010. P3 resided in his/her own apartment at an ALF. P3 and spouse resided at the same ALF but in separate apartments. ALF staff had been responsible for dispensing P3's pain medication and arranged transportation for P3 to the hospital via ambulance on 05/26/2010 at 2030. Based on information above, ALF staff are pt's primary caregiver.

P3 was admitted to inpatient care from the ED on 05/26/2010 with primary complaint of abdominal pain, possible bowel obstruction, thought to be secondary to chronic opioid use for pain control. He/she was found to have a bowel ileus. Cardiology was consulted because EKG (electrocardiogram) findings were concerning for lateral wall MI (myocardial infarction). Due to his/her medical comorbidities, he/she was treated medically for cardiac issues. His/her bowel obstruction was treated.

During his/her inpatient admit, P3 and his/her spouse were counseled by P3's primary care physician on his/her prognosis and a decision was made to return P3 to his/her ALF (Assisted Living Facility) apartment with Hospice Care.

Documentation on an ED report dated 05/29/2010 reflected that P3 presented back to the hospital ED at 2116, less than seven hours after discharge, via ambulance with chief complaint of agitation secondary to pain. According to the documentation the ALF did not have the pain medication ordered during the hospitalization. The physician who treated the patient in the ED documented that the case was discussed with another physician involved with this patient who reported that he/she had received a call from the ALF earlier. ALF staff had concerns about the patient ' s declining condition. As that physician was unable to clarify treatment goals for the patient with ALF staff the physician had directed the ALF to send the patient to the ED.

Documentation in P3's medical record revealed that P3's primary care physician had hand written a discharge instruction sheet. The discharge instruction sheet was signed by P3's spouse on 05/29/2010. Written prescriptions for pain medications (Morphine Sulfate and Vicodin) were given to the spouse of P3, which was noted in the hand written discharge note by P3's attending physician. P3 was discharged on 05/29/2010 at 1430 with medical transport (wheelchair van) with spouse in attendance. P3's medical record lacked documentation to support that P3's discharge plan was communicated to ALF staff.

The hospital staff failed to adhere to internal Policy/Procedure in patient screening, assessment and reassessment.

An ED dictated report documented P3 returned to the ED on 05/29/2010 at 2116 via ambulance with chief complaint of agitation secondary to pain. Spouse reported to ED physician that P3 was in pain earlier and the ALF did not have his/her morphine. "Spouse stated that P3 was not really SOB (short of breath), just seemed to be in pain. And he/she wants to make sure pt is comfortable."

At 2226 on 05/29/2010 the ED physician documented: "Case discussed with Dr. [name]. He/she was called from the care facility about pt and he/she (pt) had BP (blood pressure) of 81/52 and HR (heart rate) of 154. He/she was unable to clarify the tx (treatment) goals for pt with the ALF staff and suggested ED evaluation for the pt. He/she is in agreement with plan to discharge home and for pt and spouse to meet with hospice tomorrow."

An interview with the hospital's RN Manager of Case Management was conducted on 07/29/2010 at 1000. He/she stated that there was no other documentation to reflect that the discharge plan for Patient #3 had been communicated to ALF staff. He/she stated that since the written discharge instructions and prescriptions had been given to the patient ' s spouse, they would expect that the spouse would provide that information to ALF staff.