HospitalInspections.org

Based on record review and interview the facility failed to identify at an early stage of hospitalization patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning for 1 (P#1) of 12 sampled patients. This deficient practice can cause patient harm when transferred patients are not accepted at the receiving facility due to inadequate discharge planning. The findings are:

A. Record review of P#1 Discharge Summary undated revealed, patient was admitted with "severe sepsis, bilateral hospital-acquired pneumonia present on admission, previous diagnosis of cholangiocarcinoma and urinary tract infection present on admission".

B. Record review of P#1's "Discharge Planning Summary" dated 04/03/19 revealed, "Patient resides at [name of facility] group home. He is dependent in all cares (sic) bathing, feeding, and clothing. Case conference is requested prior to discharge and they (group home) will require all of his medical records for this stay. Case management will follow and assist as needed as POC (Plan of Care) evolves."

C. Record review of hospital case management fax dated 04/08/19 at 9:32 am revealed, P#1's demographics, progress note, history and physical, patient discharge summary report, orders, and pulmonary note were faxed to the receiving facility (nursing home). Fax cover sheet did not identify the recipient, however, the attached documents to the fax were for specific to P#1. S#4 verified the fax was intended for receiving facility for P#1.

D. Record review of email sent from the receiving facility (nursing home) dated 04/08/19 at 2:50 pm revealed "received". There was no confirmation of facility accepting patient included in the email.

E. Record review of email sent from the hospital to the receiving facility dated 04/08/19 at 2:54 pm revealed "Thank you let me know when ready for me to set up ambulance." No confirmation of the nursing home verifying acceptance of patient or setting up a time for ambulance transfer was included in email correspondence or case management notes.

F. Record review of P#1's hospital nursing notes dated 04/08/19 at 10:53 am revealed "given report to [name of person receiving report] in [name of facility] center". On 04/08/19 at 7:18 pm nursing note by same nurse revealed, "Pt (patient) cannot be transferred to [name of facility] nursing home until tomorrow per case manager." There was no documentation clarifying the reason for the delay in transfer.

G. Record review of Nursing notes dated 04/09/19 at 11:56 am revealed, "Discharged patient to [name of facility] ambulance, gave report to [name of facility] group home nurse, night nurse saying report was already given to the hospice facility yesterday."

H. Record review of P#1's "Discharge Planning Summary" dated 04/09/19 at 11:55 am revealed "Pt arranged to go to [name of facility] SNF (skilled nursing facility) with hospice @ 8:00 am. [name of ambulance] did not show up at 0800 (8:00 am) and finally came around 0930 (9:30 am). DNR (do not resuscitate) signature was not avail until guardian comes over. [Name of Guardian] notified by [name of hospital case management manager] and she came over signed DNR form. [Name of ambulance] left around 1030 (10:30 am) and notified to [name of facility] nursing home."

I. Record review of hospital documentation dated 04/08/19 at 7:18 pm and on 04/09/19 11:56 am by case management and nursing revealed, P#1 was being transferred to hospice.

J. On 09/17/19 at 3:00 pm during interview, S#1 confirmed no arrangements were made for hospice. S#1 stated hospital #1 uses the term hospice and comfort care interchangeably.

K. On 09/17/19 at 3:15 pm during interview, S#2 Manager of Case Management confirmed not finding any documentation in patient's chart which confirmed acceptance of P#1 at the nursing home.

L. Record review of ambulance transfer record dated 04/09/19 10:04 am revealed, when patient was transferred to the nursing home, P#1 was not accepted and staff at the nursing home told the medics they did not receive the necessary paperwork and the patient was too critical. P#1 was transported to hospital #2. En route to hospital #2 patient went into asystole (heart stopped beating) and became apneic (breathing stopped).