HospitalInspections.org

Based on record review and interview, the facility failed to document a nursing discharge note per facility policy in 1 of 3 patients discharged to home (Patient #1) out of a total sample of 11 medical records reviewed.

Findings include:

Review of the facility policy titled, "Discharge of the Inpatient," revised 7/22/16 revealed, " ...Discharged Patient documentation to include the following: A. Date, time, and method of discharge in the computer system within 15 minutes of actual discharge. In the case of a minor or dependent adult, indicate to whose care the patient was discharged. B. The present status of the patient, including the patient plan of care outcomes and evidence of the patient's, significant other's and/or caregiver's understanding of the discharge instructions, using the computer system charting pathway entitled 'Discharge Notes.' C. Document any additional teaching/patient education ..."

Patient #1's electronic medical record was reviewed on 12/4/19 at 8:49 AM and revealed the following:

Patient #1 was admitted to the facility on 10/23/19 at 3:01 PM with a diagnosis of a liver abscess. #1 underwent a surgical removal of the gallbladder on 10/23/19, and was treated with intravenous antibiotics.

On 10/30/19 at 12:47 PM, "Clinical Notes" revealed, "Patient's home tube feedings and home IV antibiotics have been arranged ...for discharge home today. [Home Health agency] has been arranged to provide home teaching for assistance with patient's home IV antibiotics. Writer has contacted patient's legal guardian [Complainant A] who agrees to the above plan for discharge home today. [Caregiver E], patient's foster [parent], notified ...updated and agrees; patient's foster [parent], [Caregiver F] will provide discharge transport this afternoon at 2:30 ...Patient's RN ...has been notified of patient's discharge plan for today at 2:30."

Discharge instructions titled, "After Visit Summary," printed 10/30/19 at 1:27 PM revealed instructions for new and continuing home medications, follow up appointment dates and times, lab draw appointment dates and times, and dressing change instructions. "Other instructions" revealed, "Change dressing weekly and PRN (as needed) if loose or soiled, use antimicrobial dressing at insertion site. "Instructions" revealed, "[Home Health agency] has been arranged to provide support for your home IV antibiotics. [Home Health agency] will plan to see you at home on Thursday (10/31/19; the day after discharge) at noon. They will call [Caregiver E] prior to their arrival. Their contact number is ..."

Patient #1 was discharged to home at 4:00 PM.

There was no nursing discharge note found in the medical record per facility policy indicating who Patient #1 was discharged with or evidence of the caregiver's understanding of the discharge instructions.

On 12/5/19 at 8:15 AM, Manager I was asked about the expectations for nursing staff during discharge. Manager I stated, "The nurses are expected to go through medication changes, dressing changes, changes in diet. It is an expectation that a nursing note is entered upon discharge. I see there is a note documented by case management."