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WELLSTAR COBB MEDICAL CENTER
IMPLEMENTATION OF A DISCHARGE PLAN
Tag No.: A0820
Based on review of medical records, facility policy and procedure, staff interviews and written statements, it was determined that the facility failed to document implementation of the discharge plan for 1 (#1) of 5 patients whose records were reviewed.
Review of the physician's discharge summary, for patient #1 revealed that the patient was discharged home from the facility on 01/01/2010.
A review of facility policy SPP#: CC-15 Subject, "Disposition Planning" effective date 12/ 1998, last reviewed/revised 10/07, revealed that documentation of all disposition activities will be a permanent part of the patient's medical record. Nursing documentation will reflect the nurse's ongoing assessment and involvement in preparing patients for discharge.
Patient #1's medical record lacked documented evidence of discharge nursing assessment, medication review, discharge instructions, coordination of discharge transportation, family notification of discharge, time of discharge from the facility or mode of transportation for discharge.
Interview with and written statement provide by the facility's Executive Director for Behavioral Health, at 3:00 p.m., revealed that on the day of discharge the registered nurse was required to complete a final patient assessment for condition/behavior, check medications and resolve medication issues, provide discharge instructions, coordinate discharge transportation, and escort the patient from the unit when transportation arrived. All information was to be documented in the patient record, dated, timed and signed by the nurse. The interviewee confirmed that the required information related to the patient #1's discharge was not documented in the patient's record.
Interview at 12:55 p.m. with and a written statement provided by the unit Charge Nurse, on the day of the patient's discharged, revealed that the nurse could not remember the patient and was unable to provide an explanation for the missing documentation or additional information related to discharge of the patient.