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Based on medical record review and staff interview, the facility failed to ensure that 1 patient (#1) of 20 sampled patients had a nursing care plan that was revised to reflect her current medical conditions and needs for post acute care resulting in an unsafe discharge.

The findings include:

Interview with the complainant on 12/31/13 at 3:10PM revealed Patient #1 returned to the Assistant Living Facility (ALF) on 11/26/13 wearing only a hospital gown and she had a central intravenous line (CIV) and a peripheral IV still intact.

Review of the policy and procedure for patient history and assessment dated May 2007 revealed the following procedures:
C. The patient's history is completed within 24 hours of admission. Patient assessments and reassessments are performed and documented based on the patient's condition, standard of care, when there is a change in the patient's condition, change in the patient's caregiver, hand off from another department, response to nursing interventions, or new problems are identified or others have been resolved.
T. Reassessment is completed at discharge and should include evaluation of pain and pain management effectiveness. The plan of care is reviewed at this time for recognition of continuing care needs after discharge.
U. The patient status and continuing care needs are reviewed with the patient and family and documented in the medical record at discharge.

Review of the policy and procedure for discharge planning dated August 2012 revealed the following steps:

B. Assessment
Each member of the interdisciplinary team assesses needs for post acute care as part of their ongoing assessment process. Social Service staff members gather information that will be necessary to meet patient's post hospital care needs. This includes identifying current and future physical and psychosocial needs of the patient, the support system available and the financial needs of the patient upon discharge. It is an interdisciplinary approach which requires constant collaboration with health care professionals and community resources.

D. Reassessment
As the patient's hospitalization progresses, continuous monitoring is necessary to identify changes, new problems, and potential complications affecting the discharge plan. The evolving discharge plan will be communicated to physicians and other hospital staff through timely and effective documentation in the patient's medical record. Documentation will include problems to be addressed and proposed actions or interventions.

Review of the medical record for Patient #1 revealed she was admitted to Tower 5A on 11/24/13 after coming to the emergency department (ED) from an Assisted Living Facility (ALF). Patient #1 suffered a couple episodes of syncope (fainting) and had a laceration from a fall. The cardiologist recommended a cardiac loop monitor be inserted to follow the patient for a period of time to see if any arrhythmias could be identified to account for her syncope episodes.

Patient #1 was taken to the Electrophysiology (EP) lab on 11/26/13 at 10:55AM and report was given to the EP staff by Nurse #7. The EP lab event log dated 11/26/13 at 12:03PM revealed Patient #1 had a peripheral IV line that was not functioning and 3 attempts had been made by the nurse to re-start a peripheral IV line without success. The cardiologist attempted an internal jugular IV twice without success and it was noted that a central line would be placed in the lab. The EP event log revealed the cardiologist inserted a right internal jugular central line at 12:21PM.

Patient #1 returned to Tower 5A floor at 1:05PM and documentation revealed Nurse #7 was given report. Further review of the medical record revealed the internal medicine hospitalist wrote an order for patient discharge at 1:27PM on 11/26/13. Review of Nurse #7's note dated 11/26/13 at 3:34PM revealed the patient was discharged to return to the ALF by the internal medicine hospitalist.

Patient #1 was sent to the ALF via a cab with a voucher and arrangements to have a rolling walker delivered. The medical record revealed a call was received by the Social Services Supervisor on 11/26/13 at 5:47PM from the ALF stating Patient #1 was returned to the facility wearing only a hospital gown and she had an IV in her neck.

Review of the medical record for Patient #1 revealed Nurse #7 documented a complete physical assessment on 11/26/13 at 8:03AM. There was no evidence of a physical assessment being completed after the patient returned from the EP lab where she had a central line placed in her right internal jugular. There was nothing noted in the patient's care plan for having a central venous line and how to provide care.

Interview with Nurse #7 on 1/2/14 at 3:05PM revealed she was taking care of Patient #1 on the day of discharge. She stated it wasn't a normal discharge. The patient was downstairs in a procedure having a loop recorder placed when the hospitalist came on the floor about 2:20PM and demanded to know why this patient was here and that she needed to go home. The physician was ranting and raving and said to get her out of here. At first the Assistant Nurse Manager (ANM) was dealing with the physician and he said whatever needs to be done just get her out of here.

The ANM got the form and he signed it but did not fill it out. She stated this is not the normal procedure. She revealed Social Services (SS) usually coordinates all the information and gets it on the floor. Nothing had been done in the departure plan because the patient was not on the floor. She revealed the SS came up and said the patient had to go back to her facility. I tried to fill out this part of the form but I don't usually deal with that. She stated she had 6 other patients to deal with. The SS does the paper work but the nurse does the physical part of discharging the patient. The SS said if the patient doesn't leave by three something she can't go because the ALF won't accept her back. The loop went fine and the patient was going to come back to the floor. SS filled out her part of the form. I asked if I needed to call anybody and SS said I didn't have to call anybody. I was told that she was given all the instructions for caring for the loop. I filled out the cab voucher and the physician kept yelling at me. He wanted orthostatic vitals taken and the nurse aide did that and I told him the patient was orthostatic and could not be discharged. The physician said to give her a 200 cc bolus and then she can go. He then said make it happen. When I went in to give her the bolus she already had fluids hanging but I did not check for a different IV line. I gave her the bolus but I did not disconnect her or take her down to the cab. The ACP rolled her out into the hallway and I assumed that everything was done. I take responsibility for that. She was in a gown and I said she has to have clothes. The ANM said they checked everything and there wasn't anything in her room. The SS was new and she didn't know. Someone, the SS or the ANM handed the patient the packet of paperwork. I felt like I had no control to stop anything. I didn't do her physical discharge. The ANM must have disconnected the fluids and she should have discontinued the line. I didn't know the patient had a central line. The ACP took the patient downstairs. I should have documented all this in the nurse notes but I didn't feel like I could document the physician's behavior.

Based on medical record review, patient and staff interview, the facility failed to ensure that 1 patient (#19) of 20 sampled patients received a discharge planning assessment or evaluation prior to discharge from the hospital.

The findings include:

1. Interview with Patient #19 on 1/2/14 at 12:05PM revealed she was admitted to the hospital on 12/29/13 through the Emergency Department(ED) with shortness of breath and weakness. She stated she has been discharged today and the nurse has talked to her about oxygen at home but she is concerned because she doesn't have any clothes to wear. She stated her clothing was soiled in the ED and she does not have any family. She stated she lives by herself in a trailer.

2. Review of the medical record for Patient #19 revealed she was admitted on 12/29/13 with exacerbation of chronic obstructive pulmonary disease (COPD). There was no documentation of a discharge assessment or evaluation being completed since admission.

3. Interview with the Assistant Nurse Manager (ANM) of Heart 3 North on 1/2/14 at 12:25PM revealed the admitting nurse is the one to fill out the discharge planning assessment within 24 hours of the admission. The ANM confirmed that Patient #19 did not have a completed discharge planning evaluation in her medical record.

Based on medical record review and staff interview, the facility failed to ensure a safe discharge for 1 patient (#1) of 20 sampled patients when they failed to reassess the patient's medical condition and revise her discharge plan after a procedure and prior to her discharge.

The findings include:

Interview with the complainant on 12/31/13 at 3:10PM revealed Patient #1 returned to the Assistive Living Facility (ALF) on 11/26/13 wearing only a hospital gown and she had a central intravenous line (CIV) and a peripheral IV still intact.

Review of the policy and procedure for patient history and assessment dated May 2007 revealed the following procedures:
C. The patient's history is completed within 24 hours of admission. Patient assessments and reassessments are performed and documented based on the patient's condition, standard of care, when there is a change in the patient's condition, change in the patient's caregiver, hand off from another department, response to nursing interventions, or new problems are identified or others have been resolved.
T. Reassessment is completed at discharge and should include evaluation of pain and pain management effectiveness. The plan of care is reviewed at this time for recognition of continuing care needs after discharge.
U. The patient status and continuing care needs are reviewed with the patient and family and documented in the medical record at discharge.

Review of the policy and procedure for discharge planning dated August 2012 revealed the following steps:

B. Assessment
Each member of the interdisciplinary team assesses needs for post acute care as part of their ongoing assessment process. Social Service staff members gather information that will be necessary to meet patient's post hospital care needs. This includes identifying current and future physical and psychosocial needs of the patient, the support system available and the financial needs of the patient upon discharge. It is an interdisciplinary approach which requires constant collaboration with health care professionals and community resources.

D. Reassessment
As the patient's hospitalization progresses, continuous monitoring is necessary to identify changes, new problems, and potential complications affecting the discharge plan. The evolving discharge plan will be communicated to physicians and other hospital staff through timely and effective documentation in the patient's medical record. Documentation will include problems to be addressed and proposed actions or interventions.

Review of the medical record for Patient #1 revealed she was admitted to Tower 5A on 11/24/13 after coming to the emergency department (ED) from an Assisted Living Facility (ALF). She suffered a couple episodes of syncope (fainting) and had a laceration from a fall. The cardiologist recommended a cardiac loop monitor be inserted to follow the patient for a period of time to see if any arrhythmias could be identified to account for her syncope episodes.

Patient #1 was taken to the electrophysiology (EP) lab on 11/26/13 at 10:55AM and report was given to the EP staff by Nurse #7. The EP lab event log dated 11/26/13 at 12:03PM revealed Patient #1 had a peripheral IV line that was not functioning and 3 attempts had been made by the nurse to re-start a peripheral IV line without success. The cardiologist attempted an internal jugular IV twice without success and it was noted that a central line would be placed in the lab. The EP event log revealed the cardiologist inserted a right internal jugular central line at 12:21PM.

Patient #1 was returned to Tower 5A floor at 1:05PM and documentation revealed Nurse #7 was given report. Further review of the medical record revealed the internal medicine hospitalist wrote an order for patient discharge at 1:27PM on 11/26/13.

Review of Nurse #7's note dated 11/26/13 at 3:34PM revealed the patient was discharged to return to the ALF by the internal medicine hospitalist. Patient #1 was sent to the ALF via a cab with a voucher and arrangements to have a rolling walker delivered. The medical record revealed a call was received by the Social Services Supervisor on 11/26/13 at 5:47PM from the ALF stating Patient #1 was returned to the facility wearing only a hospital gown and she had an IV in her neck.

Review of the medical record for Patient #1 revealed Nurse #7 documented a complete physical assessment on 11/26/13 at 8:03AM. There was no evidence of a physical assessment being completed after the patient returned from the EP lab where she had a central line placed in her right internal jugular. There was nothing noted in the patient's care plan for having a central venous line and how to provide care.

Interview with Nurse #7 on 1/2/14 at 3:05PM revealed she was taking care of Patient #1 on the day of discharge. She stated it wasn't a normal discharge. The patient was downstairs in a procedure having a loop recorder placed when the hospitalist came on the floor about 2:20PM and demanded to know why this patient was here and that she needed to go home. The physician was ranting and raving and said to get her out of here. At first the Assistant Nurse Manager (ANM) was dealing with the physician and he said whatever needs to be done just get her out of here. The ANM got the form and he signed it but did not fill it out. She stated this is not the normal procedure. She revealed Social Services ( SS) usually coordinates all the information and gets it on the floor. Nothing had been done in the departure plan because the patient was not on the floor. She revealed the SS came up and said the patient had to go back to her facility. I tried to fill out this part of the form but I don't usually deal with that. She stated she had 6 other patients to deal with. The SS does the paper work but the nurse does the physical part of discharging the patient. The SS said if the patient doesn't leave by three something she can't go because the ALF won't accept her back. The loop went fine and the patient was going to come back to the floor. SS filled out her part of the form. I asked if I needed to call anybody and SS said I didn't have to call anybody. I was told that she was given all the instructions for caring for the loop. I filled out the cab voucher and the physician kept yelling at me. He wanted orthostatic vitals taken and the nurse aide did that and I told him the patient was orthostatic and could not be discharged. The physician said to give her a 200 cc bolus and then she can go. He then said make it happen. When I went in to give her the bolus she already had fluids hanging but I did not check for a different IV line. I gave her the bolus but I did not disconnect her or take her down to the cab. The ACP rolled her out into the hallway and I assumed that everything was done. I take responsibility for that. She was in a gown and I said she has to have clothes. The ANM said they checked everything and there wasn't anything in her room. The SS was new and she didn't know. Someone, the SS or the ANM handed the patient the packet of paperwork. I felt like I had no control to stop anything. I didn't do her physical discharge. The ANM must have disconnected the fluids and she should have discontinued the IV. I didn't know the patient had a central line. The nurse aide (ACP) took the patient downstairs. I should have documented all this in the nurse notes but I didn't feel like I could document the physician's behavior.

Interview with Social Worker #9 on 1/2/14 at 3:49PM revealed she has been working at the facility for about 5 months. Patient #1 was from an ALF. I got a referral and I sent them a referral about her admission. I put the 1823 ALF form in the chart for her discharge. The next day in rounds they said possible discharge and I asked if they had done the ALF form and asked them to complete it. I explained to them they don't accept people after 4PM. Social Worker #9 stated she was informed at around 3:00PM that the patient was ready and needed to be discharged. She stated she did not put anything on the discharge form except for a loop recorder because she was not aware that the patient had any IV 's that she would be returning with. The nurse filled out the rest of the form and she could not verify what happened to it other than it was supposed to go with the patient. There shouldn't have been anything the ALF needed to do with it. That was all I was aware of. I was told the patient was not going home on any IV' s. She did not remember who told her that. She stated she called the ALF and asked what services they could provide. The ALF staff member stated it was an Assisted Living Facility and the patient needed to be able to do everything themselves. She did not need home health care to see her for the loop monitor. She stated she did not have an order for IV therapy. Social Worker #9 stated she is not usually present when the patient is actually discharged but she would expect them to return to their facility dressed in the clothes they came with. She stated she did not know what happens if a patient doesn't have any clothes to go home in because she hadn't experienced that yet but she would probably call someone to help. Social Worker #9 revealed she received a call later that same day informing her that Patient #1 was returned to her facility in only a hospital gown and with IV's intact. She stated it was a rush discharge job because the order came in very late. She stated she did not know what the problem would have been in waiting until the next day. She confirmed it was not appropriate for a patient to be discharged in that physical condition.