HospitalInspections.org

Based on medical record review, policy review and staff interview, the facility failed to ensure a supply of tube feeding formula and supplies were available to a patient upon discharge. This affected one patient (Patient #2) with the potential to affect all patients needing supplies at discharge.

Findings include:

The medical record revealed Patient #2 was admitted on 03/28/24. Primary diagnoses included failure to thrive, severe malnutrition with history of not eating or drinking for the past three days, Type II diabetes with altered mental status, and dementia. The patient had an infected percutaneous endoscopic gastrostomy (PEG) tube which was removed.

A swallow test was attempted on 03/29/24 under fluoroscopy, which was unsuccessful due to this patient unable to cooperate. A new PEG tube was placed on 04/01/24 with tube feeds initiated on 04/02/24.

Review of the enteral nutrition notes revealed on 04/05/24 Patient #2 was to receive Osmolite 1.5 formula, 250 milliliters (ml) bolus feeds four times a day. The patient was also to receive 60 ml water flush before and after each feeding.

Review of the Careport notes for Patient #2 on 04/03/24 at 11:01 AM asked the Medical Service Company (MSC) if they could provide Osmolite 1.5 for bolus feedings at home upon discarge. The MSC's response was they can provide the formula they just need the prescription. Careport notes on 04/04/23 at 12:21 PM stated the hospital anticipated a weekend discharge. Notes from the MSC on 04/05/24 at 11:00 AM stated they are waiting for the prescription and will drop ship to the patient's home as long as the hospital can provide the patient with a three day supply at discharge. On 04/06/24 at 10:31 AM the MSC asked when the patient will they be discharged and was informed discharge was scheduled for that day. The next note was on 04/08/24 from the MSC stating they still need the physician to sign off on the order to deliver the formula.

Review of a progress note dated 04/06/24 at 10:05 AM revealed the social worker informed the nurse the patient was awaiting tube feeding supplies to be delivered to the patient's home.

Review of a discharge planning note by a licensed social worker (LSW), Staff R, on 04/06/24 at 1:31 PM stated after discussion with this patient's nurse the family will be coming in for tube feed education.

The medical record documented the family completed education related to tube feedings and care of the gastrostomy tube site prior to discharge on 04/06/24.

Review of the discharge instructions dated 04/06/24 revealed Patient #2 was to have no food or liquid orally due to a high risk of aspiration. The patient was to receive Osmolite 1.5, one carton four times a day.

The medical record contained no evidence any tube feeding formula or supplies were sent home with Patient #2 upon discharge on 04/06/24 at 9:30 PM.

Interview with the registered dietician (RD), Staff O, on 07/02/24 at 10:00 AM revealed upon discharge the dieticians will work with the Care Navigators, who work with the infusion company to get everything set up.

Interview with an available care coordinator, Staff P, on 07/02/24 at 11:38 AM revealed upon discharge the process is they work with the RD, physician, and supply company to have everything ready at discharge. They will then confirm the date and time supplies will be delivered and let the family know. Staff P further stated all these communication notes get written in Careport.

Interview with the Manager for the Care Navigators, Staff Q, on 07/02/24 at 12:10 PM revealed Careport is where the navigators document communications with other providers such as home health and equipment companies. Staff Q reviewed Patient #2's Careport notes and stated she hoped the nurse sent the patient home with a three day supply of tube feeding formula. Staff Q stated nursing staff do not see these communication notes in Careport, only the Care Navigators can see this information.

Interview with Staff S, who was one of the discharge nurses, on 07/03/24 at 8:22 at AM revealed they gave discharged instructions to who they believed was Patient #2's daughter. Staff S stated she wasn't sure she sent the patient home with a three day supply of tube feeding formula, but she would have sent her home with whatever she had left in the room. Staff S stated she had double checked with the social worker to make sure everything was in place for discharge and te social worker stated it was. Staff S stated she received a call a couple days later from the patient's daughter who said they were trying to get in touch with the home health agency because they still have not received the tube feedings or supplies. Staff S went to the care navigator who informed her to call MSC. MSC was asking questions Staff S could not answer so she gave the phone to the care navigator. Staff S stated if there were no supplies or formula available for home use at discharge they nurses would call the physician and hold the discharge. But in this case the care navigator told Staff S the discharge was all set. Staff S stated she wasn't aware of any Careport notes to send the patient home with three days worth of Osmolite.

Review of the facility policy titled "Multidisciplinary Discharge Planning," dated 09/06/23, identifies the policy purpose was to ensure smooth and safe transition for post-hospital care. This policy states discharge planning starts at the time of admission. Staff are to document in the medical record the patient's needs, goals for care, treatment preferences, and the selected agencies have the capability to provided the care needed. The staff should verify the patient, or guardian, understand the discharge instructions as well as medications and referrals.

Interview with Staff B on 07/03/24 at 3:00 PM verified the medical record did not identify if a three day supply of tube feeding formula and supplies was sent home with Patient #2.