HospitalInspections.org

Based on record review and interview, the facility failed to:

a. document assessment of patient's condition at discharge;

b. provide necessary medical information to the post-acute care facility upon patient's discharge [citing Patient # 1] .

Findings included:

TX00478176

Record review of facility policy titled "Discharge Planning," dated 07/2020, showed:

"...Procedure: A. Nursing/Medical Staff & other patient care disciplines: f. Upon discharge, the patient's condition and status of current patient problems are assessed and documented in the medical record.

Discharge Education / Instruction: All disciplines are responsible for documenting all discharge instructions provided to the patient/family. The hospital transfers or refers patients, along with necessary medical information to appropriate facilities, agencies, or outpatient services as needed for follow-up care..."

a. Patient's condition at discharge not assessed / documented :

Review of Patient ID # 1's clinical record showed he was 80 year old male with past history of hypertension, diabetes, multiple falls, dementia, and pulmonary edema. Patient # 1 was transferred to facility on 10/19/2023 from another acute care hospital. He permanently resides in a long term care nursing facility. He was discharged on 10/31/2023.

The last nursing assessment of Patient # 1 was documented on 10/31/2023 at 1455. Review of the Discharge instructions showed Patient ID # 1 signed "Patient Signature Page" on 10/31/2023 at 1 PM. Review of the nursing progress notes on 10/31/2023 failed to documentation of when Patient # 1 was actually transported off the unit.

b. Patient information was not provided to post-acute care facility prior to discharge:

Interviews were conducted on 11/08/2023 between 10 and 10:30 AM with three (3) staff RNs on Patient Unit 1-South (Staff ID #s F,G, H). All three RNs said that when a patient is discharged and returning to a long-term care facility/ nursing home: a nurse -to- nurse report is given via telephone. The patient's current condition, hospital course, and medications are reviewed. All 3 RN's said this report should be documented in the medical record by the nurse who conducted the report telephone call.

Review of Patient #1's case management progress notes showed "clinicals" were faxed to nursing home on 10/20/2023 and "Savanna had been notified." Case management note dated 10/31/2023 at 1220 PM showed transport arranged with Texan EMS; DC (discharge) packet at nurses' station.

Review of the nursing notes on the day of Patient ID # 1's discharge, 10/31/2023, failed to show documentation that a nurse-to-nurse report telephone call had been conducted. There was no documentation that the "Discharge Packet" of patient information had been given to EMS prior to patient transport.

During an interview on 11/08/2023 at 3:10 PM with Staff- F, Director of Nurses (DON), she said the expectation is that nursing would assess the patient's condition prior to discharge. Staff-F went on to say the nurse caring for the patient was responsible for calling report to the nursing home. The date, time, and name of staff spoken with should be documented in the medical record. Staff-F was unable to locate documentation of report being called to the nursing home prior to Patient ID# 1's discharge.