HospitalInspections.org

Based on policy, medical record review and interview, the hospital failed to ensure fall assessments were completed timely and/or accurately to ensure patient safety for 2 of 3 (Patient #1 and 2) sampled patients.

The findings included:
1. Review of the hospital's Fall Potential policy revealed, "The Fall Potential Risk Assessment will be completed on all patients at the time of admission...the Edmonson Fall Scale will be completed on all non- geriatric adult patients upon admission...All applicable fall potential is re-evaluated on a daily basis and indicated on the Edmonson assessment..."

2. Medical record review for Patient #1 revealed a 48 year old male with diagnoses of Bipolar Disorder, Traumatic Brain Injury, and Aphasia. Patient #1 had an emergency involuntary admission to the hospital on 10/11/19 for agitation, combativeness and unprovoked physical aggression. Patient #1 had a fall from a wheelchair on 10/13/19. Review of the Edmonson Fall Risk scores for Patient #1 revealed the staff had answered the history of falls section incorrectly and documented the patient had not fallen in the past three months on 10/20/19,10/21/19, 10/22/19, 10/24/19, 10/25/19, 10/26/19 and 10/27/19. There was no fall assessment completed on 10/23/19. The nursing staff failed to accurately assess Patient #1's fall potential for 8 days.

During an interview on 12/16/19 at 2:25 PM, the Chief Nursing officer verified his staff had incorrectly completed the fall assessment for Patient #1 based on his fall history.

3. Medical record review for Patient #2 revealed a 54 year old male with diagnoses of Paranoid Schizophrenia and alcohol use. Patient #2 had an emergency involuntary admission to the hospital on 10/10/19 for paranoid delusions. The initial nursing assessment dated 10/11/19 did not included the Edmonson fall Risk assessment. The Edmonson Fall risk assessment was not completed until 10/14/19, three days after admission.

During an interview 12/17/19 at 10:05 AM, the Chief Nursing Officer verified the fall risk assessments were not implemented upon admission for Patient #2 and should have been documented each day.

Based on policy, medical record review and interview, the hospital failed to ensure the discharge plan documented the mode of transportation utilized at discharge for 2 of 3 (Patient #1 and 3) sampled patients and failed to ensure hospital staff communicated changes in the discharge plan to patient families for 1 of 3 (Patient #1) sampled patients.

The findings included:
1. Review of the hospital's discharge policy revealed, "...Aftercare plans are communicated to the patient and family, as appropriate, and documented in the medical record...Discharge transportation arrangements have been identified to include the ability of the patient to navigate the chosen transportation method. Senior leadership will verify that the discharge plan and transportation method is comprehensive, appropriate for the patient and complete..."

2. Medical record review for Patient #1 revealed a 48 year old male with diagnoses of Bipolar Disorder, Traumatic Brain Injury, and Aphasia. Patient #1 had an emergency involuntary admission to the hospital on 10/11/19 for agitation, combativeness and unprovoked physical aggression. The patient's wife was identified as his responsible party. The Social Worker documented contact with Patient #1's wife during his hospitalization about discharge plans. On 10/28/19 arrangements were finalized for Patient #1 to discharge to a skilled nursing facility in Jackson, Tennessee. The Social Worker contacted the insurance company to arrange for Patient #1's transportation. On 10/28/19 at 4:35 PM, the Social Worker was informed that insurance would not cover the cost of discharge transportation. On 10/28/19 at 4:50 PM, Patient #1's wife informed the Social Worker that she wanted use a friends transportation company (Transportation Company #1) to move Patient #1 from the hospital to the skilled nursing facility. The Social Worker, Patient #1's wife and Transportation Company #1 owner were on a conference call at 4:50 to discuss the transportation plan. The Social Worker documented the patient would be picked up by Transportation Company #1 around 6:30 PM.

Review of the Continuing Care/ Discharge Summary form for Patient #1, documented a "routine" discharge on 10/28/19 at 4:09 PM. (The Social Worker was still making arrangements for his discharge at 4:59 PM) The form was not fully completed to include the type of transportation, who the patient was accompanied by and their relationship to the patient. The medical record did not document how Patient #1 left the facility at discharge.

During an interview on 12/16/19 at 11:55 AM, the Social Worker verified she assisted with transportation arrangements for Patient #1 on 10/28/19. She stated insurance refused to pay and Patient #1's wife arranged for Transportation Company #1 transport the patient. She stated when she returned to work the following day, she was informed another company transported Patient #1. She verified the Continuing Care/ Discharge Summary form did not clearly document how the patient left the facility on 10/28/19. She verified she did not inform Patient #1's wife of the change in transportation arrangements on 10/28/19 because they occurred after she left the hospital.

During an interview on 12/16/19 at 12:14 PM, the Geriatric unit Director Of Nursing verified he was working when Patient #1 discharged from the facility on 10/28/19. He verified his initials were on Continuing Care/ Discharge Summary form. He stated when Transportation Company #2 (ambulance) arrived to pick up Patient #1, he was not aware Transportation Company #1 had been arranged by the wife and Social Worker. He stated Patient #1 left the facility with Transportation Company #2 and about 15 minutes later Transportation Company #1 arrived to pick up Patient #1.

During a telephone interview on 12/17/19 at 9:10 AM, Patient #1's wife stated when she talked with the hospital Social Worker on 10/28/19, she was told insurance would not cover the transportation to the skilled nursing facility. Patient #1's wife stated she contacted a friend who owned Transportation Company #1, and he agreed to provide her husband transportation. She stated the hospital discharged her husband on 10/28/19 with another transportation company and did not inform her. She stated when Transportation Company #1 arrived at the hospital, Patient #1 was already gone. She stated she immediately called the hospital to ask what company was transporting her husband and the facility staff were unable to provide her the name of the company.

The hospital staff failed to communicate with each other and the patient's family regarding the change in transportation upon discharge.

3. Medical record review for Patient #3 revealed a 40 year old female with diagnoses of Paranoid Schizophrenia, Bipolar Disorder, and Mild Intellectual Disability. Patient #3 had an emergency involuntary admission to the hospital on 10/26/19 for aggression, confusion and disorientation. The patient's mother was identified as her responsible party. The Social Worker documented contact with Patient #3's mother during her hospitalization regarding discharge plans. On 11/5/19 at 9:09 AM, the Social Worker documented, "...left a message that [named Patient #3] will be discharged today..." At 3:21 PM, the Social Worker spoke with Patient #3's mother who stated she would pick Patient #3 up from the hospital by 5:00 PM.

Review of the Continuing Care/ Discharge Summary form for Patient #3, documented a "routine" discharge on 11/5/19 at 4:40 PM. The form was not fully completed to include the type of transportation, who the patient was accompanied by and their relationship to the patient. There was no signature by the mother in the family/guardian section of the form. The medical record did not document how Patient #1 left the facility at discharge

During an interview on 12/17/19 at 11:45 AM, the Geriatric unit Director of Nursing verified the Continuing Care/ Discharge Summary form for Patient #3 had not been completed as he expected and he was unable to tell who the patient left with to what type of transportation was utilized.