HospitalInspections.org

Based on review of the medical record, staff interview and review of facility policy and procedures it was determined the facility failed to ensure staff arranged for the implementation of the patient's discharge plan for one (#2) of ten patients sampled.

Findings included:

Review of the facility policy, "Discharge Planning", last reviewed 1/2017, states 5.0 the discharge/aftercare plan defines the following: all professionals who will follow-up with the patient, including medical follow-up to monitor medications documented on page 2 of the "Comprehensive Discharge Plan"; referrals to self-help groups, support groups, or community resources documented on page 2; follow-up appointments based on the patient's clinical needs, including medical follow-up if indicated documented on page 2; and 7.0 each discipline shall communicate aftercare plans related to their discipline to the patient and family, as appropriate, and documented in the medical record.

Review of the medical record for Patient #2 revealed the patient was admitted to the facility on 5/5/2018 for psychiatric evaluation and treatment. Review of the intake assessment and nursing assessment revealed the patient was homeless and was living in a shelter. Review of the psychiatric evaluation, dated 5/6/2018, stated the patient felt helpless and hopeless due to his living situation and health concerns. Review of the record revealed the patient was started on medication for depression, was provided milieu therapy, and psychiatric treatment. Documentation revealed the patient improved.

Review of the Social Service progress note, dated 5/9/2018, stated the therapist met with the patient to discuss his discharge plans, follow-up care and to review his treatment plan. The discharge safety plan was completed by the patient and reviewed with the patient by the therapist. Review of the discharge plan revealed the patient would be discharged to a shelter in the city the patient had come from and follow-up care would be at a local care center near the shelter and the local health department. Review of the physician orders revealed on 5/11/2018 at 8:45 am an order which stated to discharge the patient today.

Review of the Social Service progress note, dated 5/11/2018, stated the therapist met with the patient to review his discharge plans and follow-up care appointments. Documentation stated the patient would be discharged to a shelter in the city in which the patient came from. Review of the nursing progress note, dated 5/11/2018 at 11:45 am, stated discharge paperwork was completed, copied and signed by the patient. At 11:50 am the patient was escorted to the intake area, a cab was called and the patient was provided a cab voucher.

Review of the three page discharge care plan revealed page one was completed and signed by the physician. The documentation revealed the reason for the patient's admission, the discharge diagnosis, medical follow-up care required, a regular diet and no activity restrictions. Page one of the discharge plan was signed by the physician on 5/11/2018 at 8:50 am and the same physician signed page one again on 5/14/2018 at 1:50 pm.

Review of page two of the patient's discharge care plan revealed the following information: discharge disposition, mode of transportation, follow-up appointment location, date and time, education provided and statement the patient received a copy of the plan and patient understanding. Review of page two revealed the patient and therapist signed the page on 5/14/2018 at 2:00 pm.

Review of page three of the patient's discharge care plan revealed a list of the patient's medication and instructions. Review of the page revealed the patient signed on 5/11/2018 at 12:03 pm, the nurse signed on 5/11/2018 at 11:49 am and the physician signed on 5/11/2018 at 8:50 am. The physician signed the page again on 5/14/2018 at 1:50 pm.

Review of the nursing progress notes, dated 5/11/2018 at 4:45 pm, stated a call was received from the patient's daughter who stated she received a call from her father that he was dropped off in the wrong city. Review of the record revealed documentation of attempts to rectify the situation over the span of approximately three hours. The final documentation in the medical record regarding the situation was at 8:05 pm on 5/11/2018 which stated the AOC (Administrator on Call) returned the staff's call and asked to speak with the Charge Nurse.

Review of the record revealed no evidence how the incorrect location of the patient's discharge was rectified. Review of facility documentation for the address listed on the cab voucher and documentation of the shelter the patient was to be discharged to revealed the same name of the shelter, same street address but different cities. The city listed on the cab voucher was incorrect.

Review of the medical record revealed on 5/12/2018 at 3:30 pm a telephone order from the physician stated discontinue the discharge. Review of nursing documentation revealed the patient was discharged from the facility on 5/11/2018 at 12:03 pm and transported via taxi cab service to a shelter approximately 2 hours away. It was determined the patient was transported to the city listed on the cab voucher which was filled out incorrectly by the facility staff. Review of the patient's three page discharge care plan revealed page two which contained the patient's discharge disposition, mode of transportation, follow-up appointment location, date and time, education provided and statement that confirmed the patient received a copy of the plan was not in the patient's medical record and could not be provided at the time of survey. Review of the record revealed the patient was discharged again on 5/14/2018. Page two of the discharge plan, dated 5/14/2018, was present in the medical record.

An interview and review of the record was conducted with the CEO on 8/7/2018 at 10:45 am. The CEO confirmed the above findings.