HospitalInspections.org

Based on observation, staff interview and medical record review the facility failed to ensure that there was a discharge planning evaluation for one of ten sampled patients, Patient #4, that included an evaluation of the likelihood of the patient's capacity for self-care or the possibility of the patient being cared for in the Assisted Living Facility (ALF) from which the patient entered the hospital.

The findings include:

1. A review of case management/discharge planning documentation on the facility form titled Psychosocial, Interventions and Discharge Plan of Care, for sampled Patient #4, revealed documentation on 5/16/11 at 12:55 AM that the patient was admitted as Patient Type, 24-Hour Observation, with the primary diagnosis as altered mental status and questionable seizure. Past medical history was documented as seizure disorder, hypertension, bipolar disorder, dyslipidemia, hypothyroidism, history of gout, history of hepatitis C, and osteoarthritis.

On 5/18/11 the Social Worker (SW) documented at 11:08 AM that social services screened the patient's chart for possible needs at discharge. The SW documented that the patient (#4) was a resident at an assisted living facility (ALF) that served residents with limited mental health needs and that the ALF form was on the chart. The SW stated the patient had recently been to the Emergency Department (ED) for frequent falls and did go home last admission with a request for PT (physical therapy) sessions as well as with a 4 pronged cane. The SW documented that social services would follow for possible needs at discharge; most likely returning to the ALF.

There were no other discharge planning notes except for nursing documentation stating that the patient would be discharged via ambulance back to the ALF. Nursing documented on 5/18/11 at 5:14 PM that the patient continued to have tremors, was alert and oriented x 3 (person, place, and time), but at 4:00 PM nursing documented that the patient was confused.

A review of the paperwork titled Medical/ Surgical Patient Discharge Summary, which was sent via ambulance drivers with Patient #4 and which nursing documented at time of discharge that the patient was unable to sign, revealed no information related to the patient's ability to care for self or the patient's confusion or risk of falls. There was no documentation that discharge instructions were given or understood by the patient at the time of discharge.

An interview on 6/29/11 at 1:45 PM with the Social Worker (SW), who was responsible for case management on the unit and had documented on patient #4 on 5/18/11, revealed she stated that she starts discharge planning within 24 hours of patient admission unless it's the weekend when the covering SW does orders on an only as needed basis. She stated that if a patient was confused or actively mentally ill "I make sure I know who the person is who is appointed according to Florida law." She stated that if the patient was not deemed incompetent and the facility was waiting on a psychiatrist's determination , she would still work to see who may be the POA (power of attorney) and must ensure there was a medical clause in the POA paperwork, or Health Care Surrgogate, et cetera for the patient. She stated that typically at a place like the ALF, where Patient #4 resided, which had limited mental health needs residents, she would talk with the Administrator or one of the staff members. She stated they also have community mental health case managers who she might call or they might call her. The SW stated, "I would have to speak with someone and provide a filled out DOE 1823 form to ensure they can provide the care needed." She stated this particular ALF had a nurse who administers medications, but knows they would not typically accept a patient back who required intravenous (IV) medications or needed constant observation. She stated they would not send someone back in a nightgown. She stated that they have had the situation occur here that a patient arrived from an ALF with no clothing (for example, fell in the shower and rescue was called) and the hospital had arranged to get some clothes for them.

An interview with the same SW on 6/29/11 at approximately 5:00 PM revealed that Patient #4 was discharged before she could revisit the patient. She stated that knowing the patient was from that particular ALF she knew she probably needed some interventions to assist with discharge, but the patient was discharged before she could do a return visit.

A review of the written and video documentation by staff at the ALF on 5/18/11 revealed that the patient was confused and disoriented and required assistance to walk upon arrival via ambulance at the ALF at 6:30 PM. The facility staff found the patient lethargic and dressed only in a hospital gown. There was no documentation that the hospital attempted to contact the patient's case manager and arrange for clothes to be taken to the hospital for the anticipated discharge or that there was any discussion with medical staff, nursing, or hospital case management regarding the patient's capacity for self-care upon return to the ALF.