HospitalInspections.org

Based on staff interview and clinical record review, the facility failed to ensure that the discharge planning evaluation includes an assessment of the patient's home environment and available support systems for 1 of 1 active patients (#4) whose clinical record was reviewed, as evidenced by: failure to identify patient anxiety related to returning to an alcohol laden environment with a diagnosis of alcohol dependency.

The findings include:

Record review for patient #4 reveal the patient was admitted to the facility on 3/19/11 with complaints of abdominal pain. The physician History and Physical indicates that the patient has a history of seizures, Hepatitis C, Bipolar disorder, depression and alcohol dependency. The nursing admission assessment notes that no discharge needs are anticipated and the patient will be discharged home.

A case management note dated 3/21/11 documents that the plan is to discharge the patient home; the patient is uninsured so prescriptions will be filled at the hospital prior to the patient's discharge and the patient is to follow up at a Clinic.

During an interview with the patient's nurse on 3/23/11 between 11:45 AM and 12:00 PM, she stated that the patient was to be discharged home today but "we're having to rearrange things because he's complaining of nausea and I just gave him some medication and his ride is coming from 70 miles away."

During an interview with the patient on 3/23/11 at 12:00 PM, he was asked what his discharge plans were. He responded that he was going back home but didn't want to go there because everyone there drinks (alcohol) constantly which will make it hard for him to stay away from it. When asked if he had spoken with anyone in the hospital about his concerns with discharge, he replied that he had not, but would be willing to speak with someone. When asked why he had not voiced his concerns with discharge to hospital staff, he replied, "No one asked."

During an interview with the case manager on 3/23/11 at 12:15 PM, she stated that discharge planning includes an assessment of the patient, review of the medical record and talking with the patient, staff and physician, as needed. When asked if she was aware of patient #4's concerns about returning to an alcohol laden environment, she responded that she was not aware that he had a problem with alcohol (patient has a diagnosis of alcohol dependency) and "he didn't say anything when I stuck my head in the door."

During an interview with the Director of Case Management on 3/23/11 at 12:45 PM, she stated utilization review is done on every patient on admission then every 1-3 days. She states that utilization review consists of reviewing the chart and diagnosis and speaking with the nurses and/or physician. When asked if she would expect the case management assessment to include a review of the patient's home environment and available support systems, she stated that she would.

Based on clinical record review and staff interview, the facility failed to ensure the discharge planning evaluation was completed on a timely basis to avoid unnecessary delays in transfer for 1 of 3 patients whose closed clincial records were reviewed (#3) as evidenced by: the patient was under a 72 hour hold for an involuntary psychiatric examination (service not provided by facility) and was cleared by the physician for discharge or transfer on 3/04/11. The patient was not evaluated by case management or transferred to a psychiatric facility until 3/06/11.

The findings include:

Record review for patient #3 reveal the patient was brought into the facility's Emergency Department by ambulance on 3/04/11 at 12:22 PM and was under an involuntary examination hold for psychiatric examination that was initiated by a police officer and dated 3/04/11 (the facility does not provide psychiatric services and is not a receiving facility for involuntary psychiatric evaluations.)

The patient was found to have an Oxygen saturation level of 88% on room air and was admitted to the hospital for medical care and treatment. Admitting diagnoses are listed as alcohol intoxication, leukocytosis and altered mental status. Emergency Department notes indicate no bed was available for the patient until 3/05/11 at 12:41 AM, and also no sitter was available for the patient, so the patient remained in the Emergency Department. During an interview with the Risk Manager on 3/23/11 at approximately 3:00 PM, she stated that the patient was admitted to a nursing unit on 3/05/11 at 7:51 AM. There is a nursing admission assessment documented on 3/05/11 at 7:51 AM though no documentation of a transfer from the Emergency Department to a nursing unit or a room number was found.

There is a physician's note on 3/04/11 (no time noted) that states,"The patient is sober now and ok to discharge home once cleared by psych."
There is a physician's order on 3/05/11 at 7:57 AM to discharge the patient home when cleared by psych.
There is a physician's order on 30/05/11 at 12:41 PM to transfer the patient to a psychiatric facility if not seen by psych.
There is a 3/05/11 physician's discharge note that states discharge in stable condition.

The discharge planning notes show the patient's admission date and time as 3/04/11 at 11:47 AM. Facility policy is for case management to assess a high risk patient for discharge planning needs within 24 hours (a patient under a hold for involuntary psychiatric evaluation is listed as high risk on the facility's anticipated discharge needs form.) Facility policy also meets State guidelines to transfer a patient, who is under an involuntary psychiatric hold, within 12 hours of being medically cleared. Case management documented meeting with the patient on 3/06/11 at 2:27 PM to discuss the patient's hold for involuntary psychiatric evaluation and transfer to a psychiatric facility. The case management note documents that transfer is anticipated tonight upon medical clearance (physician wrote that the patient was ok for discharge on 3/04/11.)

The patient was seen for a psychological consult on 3/06/11 (time not indicated on the written note; the dictated note is dated 3/06/11 at 11:16 PM) and was deemed appropriate for involuntary hold for psychiatric evaluation. The patient was transferred to a psychiatric facility on 3/06/11 at 5:23 PM, greater than 24 hours after the physician determined that the patient no longer required acute medical care. This was confirmed during an interview with the 2 Risk Managers, the Chief Nursing Officer and the Director of Case Management on 3/23/11 at approximately 3:00 PM. The Director of Case Management stated that, even though the physician wrote that the patient was ok for discharge on 3/04/11, he did not write the "magical words, medically cleared" until 3/06/11 and that the psychiatric facilities would not accept patients without those "magic words." She agreed that there is no evidence that the receiving psychiatric facility was even contacted regarding transfer of this patient until 3/06/11.

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