HospitalInspections.org

Based on clinical record review, facility record review, and family and staff interview, the facility failed to ensure 1 (Patient #1) of 5 sampled patient were provided with instructions for post-hospital care related to pain management.

The findings include:

Patient #1 was admitted to the hospital on 2/14 /11 for observation and was discharged on 2/16/11. The patient was examined in the Emergency Department and diagnosed with retractable right knee pain. The patient had been hospitalized previously for a laminectomy (back surgery) on 1/27/11. The patient was discharged home and was to return to the hospital at a later date for knee surgery.

Review of the clinical record for Patient #1 shows that upon discharge the information provided for the patient's discharge instructions was for smoking cessation, stroke, and congestive heart failure. The discharge instructions failed to contain any mention of pain.

An interview with the Administrative Representative was conducted on 3/16/11 at approximately 10:05 a.m. It was stated the physician provides orders and discharge teaching. However, interview with the Chief Nursing Officer revealed nursing staff also have information available to be printed off the computer and provide to the patient. Providing the information at the time of discharge is part of the nursing process.

Based on record review and interview, the facility failed to provide an appropriate transfer for 1 (Patient #4) of 5 patients transfered to another hospital.
The findings include:
A review of Patient #4's closed medical record indicated he was discharged on 1/23/11. A review of the nursing notes showed the last entry was made on 1/23/11 at 0600 (6:00 a.m.) for routine medications "given as ordered." There was a doctor's order stating the patient can be transferred to another hospital and then discharged home from there. There was no documentation in the patient's record showing an actual discharge/transfer.

An interview was conducted with the Risk Manager and Director of Resource Managers on 3/16/11 at 12:50 p.m. They both described the process for the hospital to transfer a patient to another hospital. The nurse from this hospital is to talk to the nurse from the hospital where the patient is being transferred to and make copies of any pertinent information in the patient's chart to give to the receiving hospital. This is to be documented in the patient's chart.

At 2:00 p.m. the Director of Resource Manager revealed a policy titled "Transfer of Patients To Acute Care Facilities - Intrafacility Transfer." A review of page 3, #14 shows the "Patient Transfer Checklist" is to be used to identify documents sent to the receiving facility." Documentation of what information is sent to the facility and who receives the information packet to deliver to the facility is documented in the medical record."

Interview with the Director of Resource Managers at 2:10 p.m. confirmed the patient transfer form and documentation of what was sent to the hospital with the patient is not in Patient #4's chart. The hospital did not show a discharge plan documented in Patient #4's medical record. The medical record failed to show the patient was transferred to another hospital, and did not show that any pertinent information was sent with the patient. There is no documentation of any conversations with hospital staff between both hospitals pertaining to Patient #4's medical information.