HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 6 clinical records (Pt. #1) reviewed for discharge planning, the Hospital failed to ensure that the patient's family and accepting facility were notified regarding the patient's discharge.

Findings include:

1. On 5/1/2024, the Hospital's policy titled, "Discharge from Inpatient to a Skilled Nursing Facility, Extended Care Facility, or with Home Health Services" (dated 8/3/2023) was reviewed and indicated, "The unit nurse will communicate the hand off report to the receiving institution and complete discharge documentation in the EMR (electronic medical record). Patient or surrogate and family when appropriate will be informed of the reasons for transfer including risks and benefits. Other information about transfer should be shared as appropriate: names of accepting facility or Home Health, location, contact information and directions."

2. -Pt. #1's face sheet dated 1/16/2024 noted, "Reason for visit - cerebral infarction (stroke). Hospital problem -aphasia (loss of ability to understand or express speech, caused by brain damage). Arrival date/time - 1/16/2024 at 10:12 PM. Discharge date/time - 1/18/2024 at 6:25 PM. Final diagnosis - aphasia, facial weakness, unspecified intellectual disabilities, other cerebral infarction due to occlusion of small artery. Pt. #1's face sheet and clinical record lacked documentation of a POA (Power of Attorney) or guardian. Pt. #1's brother is listed as a contact."

-Pt. #1's admission history & physical written by MD #1 dated 1/16/2024 at 10:45 PM noted, "Pt. #1 significant for bipolar (mental disorder characterized by periods of depression and periods of abnormally elevated moods) spastic dysphoria (voice disorder), intellectual disability admitted for acute CVA (cerebrovascular accident - stroke). Brother is present who relays information from group home. Pt. #1 has been acting bizarrely today ...Assessment and plan - possible acute CVA with facial drooping and ataxia (neurological sign consisting of lack of voluntary coordination of muscle movement) resolved, plan for MRI to further workup, could be related to underlying psych disease."

-Neurology consult note dated 1/17/2024 written by MD #3 (Neurologist) noted, "Yesterday Pt. #1 had difficulty getting... dressed and was also confused. Stat CT head was negative. MRI is negative - no acute intracranial abnormality. From neurology perspective, ok to discharge."

-Case Management daily rounding note dated 1/18/2024 at 1:54 PM indicated, "Rounding discharge checklist - Barriers to discharge - none, planned discharge disposition/goals - group home. Communication of goals - goals discussed with patient/family ...Case management summary - case manager spoke with group home over the phone ... Pt. #1 will need transport arranged on discharge. Case manager called Pt. #1's brother for update, no response, left voicemail ...Addendum ... Medicar on will-call."

3. On 5/1/2024, the Hospital's incident report written by E #5 (ED Registered Nurse) dated 1/18/2024 noted, "Pt. #1 arrived via medicar for incorrect address when discharged from 3rd floor at about 7:00 PM. Pt. #1 arrives soiled. Called [name of group home's] CM (case manager) and she states that no one told her or the facility about Pt. #1's discharge and also that the address on the face sheet was the administrative office building. She was told that last time she spoke with E #1 (Case Manager) was this AM and was told discharge plan was either today or tomorrow. She would have provided an updated address that she had she been informed of discharge today. Facility was not called to update that Pt. #1 was being discharged, neither was the brother."

4. On 5/1/2024 at 11:00 AM, an interview was conducted with the Case Manager (E #1). E #1 stated that Pt. #1's discharge plan was to return to the group home. E #1 stated that E #1 was not aware that Pt. #1 had a discharge order on 1/18/2024. E #1 stated that E #1 left a voice message for Pt. #1's brother that Pt. #1 could possibly be discharged on 1/18/2024 or 1/19/2024. E #1 stated that E #1 found out that Pt. #1 had been discharged when E #1 came back to work on 1/19/2024. E #1 stated that since E #1 was not at work when Pt. #1 was discharged, it was the nurse's responsibility to notify the group home and Pt. #1's brother of Pt. #1's discharge. E #1 stated that there is no documentation that Pt. #1's brother or group home had been notified of Pt. #1's discharge. E #1 stated that E #1 found out the next day from E #3 (Director of Care Coordinator) that Pt. #1 had been brought to the wrong address upon discharge. E #1 stated that the medicar brought Pt. #1 to the administrative office instead of the group home. E #1 stated that the normal discharge process is to notify the patient's family and receiving facility regarding discharge date and time. E #1 stated that this did not happen because E #1 was not aware of the discharge order when arrangements were made. E #1 stated that E #1 had already sent discharge paperwork to group home. E #1 stated that E #1 arranged transportation for a will-call when Pt #1 was ready for discharge/discharge orders received. E #1 stated that the Registered Nurse (E #6) called the will-call transportation that had been arranged and discharged Pt. #1.

5. On 5/1/2024 at 2:30 PM, an interview was conducted with the ED Registered Nurse (E #5). E #5 stated that E #5 worked in the ED on the evening of 1/18/2024. E #5 stated that the ambulance brought Pt. #1 back from a discharge attempt at Pt. #1's group home. The paramedics stated that they had the wrong address and it was after hours so they brought Pt. #1 back to the ED. E #5 stated that E #5 put a new diaper on Pt. #1 and kept Pt. #1 in the waiting room in the ED. E #5 stated that E #5 contacted the group home case manager who told E #5 that she did not know about Pt. #1's discharge. E #5 stated that the case manager at the group home then contacted Pt. #1's brother (Z1). Z1 came to the ED and took Pt. #1 back to the group home. E #5 stated that Z1 was upset because Z1 told E #5 that Z1 did not know about Pt. #1's discharge.