HospitalInspections.org

Based on document review and interview, the director of the nursing service failed to ensure that the nursing staff gave the correct discharge instructions to discharged patients for 1 of 9 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of policy / procedure D-013, Discharge of Patient From Inpatient Unit, indicated the following:
"Discharge Instruction Sheet (For patient going home)
1. May be completed all or in part by physician. RN is responsible for completing sections not completed by physician."
This policy / procedure was last reviewed / revised on 12-08-09.

2. Review of patient #1's MR indicated the patient was admitted to the facility on 06-18-13 for an abdominal hysterectomy with bilateral salpingo oophorectomy. The patient was discharged to home on 06-20-13. Patient #1's MR indicated the patient was given Cesarean Section Postpartum Discharge Instructions on 06-20-13 at 1321 hours. The patient's MR lacked documentation that the patient had a cesarean section.

3. On 10-28-13 at 1105 hours, staff #42 confirmed that patient #1's MR indicated the patient received Cesarean Section Postpartum Discharge Instructions. Staff #42 confirmed that when a patient is discharged, nursing staff are suppose to print out the discharge instructions that relate to why the patient was admitted to the facility and the facility has discharge instructions for patients who have had an abdominal hysterectomy.

Based on document review and interview, the facility failed to ensure a list of Home Health Agencies (HHA) was made available to the patient and documented in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf for 2 of 4 medical records (MR) reviewed (Patient #1 & 7).

Findings include:

1. Review of policy/procedure Discharge to Home Health Care Services indicated the following:
"Statement of Purpose: To define the process of referring a patient to home health care companies for continued post acute care. This process applies to all patients new to home health care and all patients currently receiving home health care.
3. The case manager will supply the patient with the official Community Health Network home care list.
4. The case manager will inform patient that the choice of which company to use is strictly the patient's choice.
8. The patient will write their company of choice and sign the official homecare list.
9. These lists will then become a part of the patient's permanent chart."
This policy/procedure was last reviewed/revised on 11/2010.

2. Review of patient #1's MR indicated the patient was admitted to the facility on 07-04-13 for a post operative wound abscess and was discharged to home on 07-07-13. The physician ordered home wound care. Review of patient #1's MR lacked documentation that the patient was supplied with the official Community Health Network home care list and that the patient wrote their company of choice and signed the official homecare list.

3. Review of patient #7's MR indicated the patient was admitted to the facility on 09-28-13 for deep vein thrombosis and was discharged to home on 09-30-13. The physician ordered home health care. Review of patient #7's MR lacked documentation that the patient was supplied with the official Community Health Network home care list and that the patient wrote their company of choice and signed the official homecare list.

4. On 10-28-13 at 1108 and at 1350 hours, staff #43 confirmed that patient #1 and 7's MR lacked documentation of the official Community Health Network home care list being given to the patients.