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Based on observation, review of documentation, and interviews with facility staff, the facility failed to ensure that specific discharge plan requirements are met as there was no physician's order for discharge of the patient in the medical record of 1 of 1 patient records reviewed.

The findings were:
The Rules and Regulations of the Medical Staff of Texas Health Heart & Vascular Hospital dated 9/10 were reviewed on the afternoon of 2/27/12 and reflected "10. Patient Discharge: a. Patients shall be discharged only on written order from the physician or another individual with privileges to write orders."

The medical record of patient #1 was reviewed on 2/27/12, and revealed that there was no physician order in the record for the patient's discharge. In an interview with staff #2 on 2/27/12 at 4:50 pm, the physician orders in the record of patient #1 were reviewed with her and she stated that there was no physician order in the record for the patient's discharge. She further stated that the usual procedure would be for the physician or physician's assistant to enter the discharge order into the electronic record system, or a nurse could enter a verbal order into the system.

The facility "Safety Action Learning Tool Form" dated 8/1/11 was reviewed on the afternoon of 2/27/12. The form was regarding patient #1; the date and time of the incident was 4/20/11 at 7:49 pm; the general location was the Telemetry Unit; and the reporting department was Cardiac Telemetry. The incident description reflected "Discharge planning was done by social worker, case manager, and physician's assistant. DC (discharge) summary written by PA (physician's assistant) and cosigned by physician. No discharge orders written. Husband called and wanted to know how we can discharge a patient without an order or notifying him. He feels we did something illegal. All paperwork is in order, third party transfer and MOT (Memorandum of Transfer) done, report called to rehab center. Discussion of transfer to rehab center held by CM (case manager)/SW (social worker)/PA/NP (nurse practitioner) and all documentation showed patient was to be transferred. Order for discharge never written."