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Based on record review and interview the facility failed to reassess the appropriateness of the discharge plan in 5 out 5 of sampled patients (SP) #1, #2, #3, #4 & #5 who were discharged home with an infusion ports.

The findings include:
Review of SP#1 closed medical record on 06/30/14 and 07/01/14 show that the patient presented to the facility on 12/29/13 with complaints of pain with urination, pregnancy, chills, and abdominal pain. According to the physician consultation dated 01/02/2014, the patient underwent 2 bone marrow biopsies which showed acute leukemia. Review of the discharge summary revealed that the patient is advised to follow up at Hospital #2 for her high risk pregnancy as well as hematology outpatient for further (chemo) chemotherapy. The patient ' s medical record then showed that the patient was transferred home with a Groshong catheter port for chemotherapy.
Review of the SP # 1 record revealed that there that the reassessment discharge plan was inappropriate. Review of the follow up instructions provided to sampled patient #1 also revealed that there was no documented education to the patient on how to care for the Groshong catheter ' s incision site upon discharge and there were no outpatient hematology/oncology/obstetrician physician referrals or numbers given to the patient.


In an interview with Social Worker #B on 07/01/14 on 11:21am, she stated, " the list of Hospital #2 clinics was provided (to SP#1). She needed to choose the clinic and make appointment for herself. We could not make the appointment for her because she has to get into the Hospital #2 system. There is no appointment; it ' s on a first come first serve basis.

In an interview with the Nurse Director of 3 Main on 07/17/14 at 12:05 pm, she stated, the high risk clinic at hospital #2 provides OB (obstetrician) and oncology. Hospital #2 won ' t take appointments from us. She (SP#1) needed to call. We can ' t get appointments.

In an interview with the Quality Management Officer on 07/17/14 at 12:13pm, she stated, only with acute transfer will Hospital #2 take information from us. With outpatient appointments, Hospital #2 doesn ' t take information.

Review of SP#2 closed medical records on 06/30/14 and 07/01/14 show that the patient was admitted to the facility on 02/05/14 for lung mass. Social Services/ Case Management Adult Transition Evaluation dated 02/06/14 show that the patient lives at home and the anticipated transition plan was home with home health. Review of the discharge summary also showed that a chest tube was inserted on 02/10/14 during a lobectomy (lung surgery). On 02/13/14, the chest tube was removed and Physician Ordered daily dressing change to right chest tube insertion site, and to apply Vaseline gauze, 4x4 dry gauze, and tape. The signed Discharge Instructions dated 02/14/14 has that SP #2 was discharged home on 02/14/14. Review of SP #2 record revealed that the reassessment of the discharge plan was inappropriate. There was no documentation of any discharge education regarding the care of the chest tube wound or care of the port-a-catheter surgical site provided to SP#2.

Review of SP#3 closed medical record on 06/30/14 and 07/01/14 show that the patient was admitted to the facility on 03/20/14 for respiratory failure. Review of the Operative report shows that on 03/22/14, the patient underwent surgical placement of an infuse-a-port. Review of the SP #3 record also revealed that the reassessment of the discharge plan was inappropriate. Review of the signed Discharge Instructions dated 03/22/2014 has that SP #3 was discharged home on 03/22/2014. There was no documentation of any discharge education regarding the care of the infuse-a-port surgical site provided to SP#3.

Review of SP#4 closed medical record on 06/30/14 and 07/01/14 shows that the patient was admitted to the facility on 01/18/14 for lymphadenopathy (abnormal lymph nodes).Operative Report shows that the patient underwent a PICC (peripherally inserted central catheter) port insertion on 01/28/14. Discharge Order on 01/30/14 then state that it is ok to d/c home, and to f/u (follow-up) with heme-onc (hematology/oncology) outpt (outpatient). The Discharge Summary showed that the patient was discharged home on 01/30/14. Review of the SP # 4 record further revealed that the reassessment of the discharge plan was inappropriate. There was no documentation of any discharge education regarding the care of the port surgical site provided to SP#4.

Review of SP#5 medical record on 06/30/14 and 07/01/14 show that the patient was admitted to the facility on 05/31/14 for neck swelling. The Operative Note dated 06/04/14 show that the patient underwent insertion of a venous port. Discharge Order on 06/04/14 states, to discharge patient home. Review of the SP #5 record then revealed that the reassessment of the discharge plan was inappropriate. The Discharge Summary on 06/04/14 show that the patient was discharged home with family care. There were no documentation of any discharge education regarding the care of the venous port surgical site provided to SP#5.


In an interview with the Discharge Planner on 06/30/14 at 11:58 am, she states, " the doctor lets us know if patients need rehabilitation, or it is based on assessment of needs. Transition Assessments are completed in 24 to 48 hours of admission and identify discharge needs which are discussed with the doctor. Discharge needs are updated and reassessments are based on patient ' s needs. If a patient needs care at home for ports, this is discussed with the doctor who determines if it is needed. If I see patients who needs or request assistance at home, I tell the doctor that the patient needs assistance and they place the order. With chemo patients, we don ' t make arrangements for the patients for outside care. Sometimes, the patients leave with the appointment with the oncologist.
In an interview with the Quality Management Officer on 06/30/14 at 12:05pm, she stated, that Infusion ports are for possible chemo up to one year. Most of the time the patients leave with HHA (home health agency) services who receives instructions from the doctor. If they follow up with an oncologist, they will receive instructions there. The Nurse (at this facility) would provide education on signs and symptoms.
In an interview with Registered Nurse (RN) #D on 06/30/14 at 12:11pm, the RN stated the discharge plans are explained to the patients along with signs and symptoms of medications and infections. We work with the Social Workers to do arrangements for transfer and explain the progress to the patient. Patient who have lines are explained the symptoms to address, usually with catheters, what to report to the nurse. Usually the patient usually goes home with home health.

In an interview with RN#F on 06/30/14 at 3:23pm, she states, " RNs provide discharge instructions to patient and the teachings are documented in the patients ' medical records. HHA (Home Health Agency) services are arranged for PICC (Peripheral inserted central catheter).

Review of the facility ' s policy : Discharge Instructions/ Food and Drug Interaction, Form states that patient/ significant other (Patient Representative) will receive individualized discharge instructions before leaving the unit. The Special Instructions and Comments are to be documented on Cerner any additional information that will be beneficial to the patient after discharge.

Review of the facility ' s Care and Maintenance of the Groshong Catheter Policy show that sterile dressing changes shall be performed routinely once per week or as needed if the dressing becomes soiled, wet, or loose using a clear dressing. Also, the catheter should be flushed with 5cc (cubic centimeters) of normal saline every seven days when not in use.

Based on interview and record review the facility failed to provide an appropriate referral/ transfer to an outpatient hematology/oncology physician and obstetrician physician in 1 out of 12 sampled patients (SP)#1.

The findings include:
Review of SP#1 closed medical record on 06/30/14 and 07/01/14 show that the patient presented to the facility on 12/29/13 with complaints of pain with urination, pregnancy, chills, and abdominal pain. According to the physician consultation dated 01/02/2014 , the patient underwent 2 bone marrow biopsies which showed acute leukemia. Review of the discharge summary revealed that the patient is advised to follow up at Hospital #2 for her high risk pregnancy as well as hematology outpatient for further (chemo) chemotherapy. The patient ' s medical record then show that the patient was transferred home with a Groshong catheter port for chemotherapy. There were no further specific written instructions of a transfer/referrals regarding which outpatient hematology/oncology physician to contact, or which obstetrician physician to follow up with along with any necessary medical information provided to SP#1.

In an interview with the Social Worker #A on 07/01/14 at 10:30 am she stated, I did the initial assessment (for SP#1) and identified that she was from home. There was an order to transfer to hospital #2 . As per Hospital #2 review, she was deferred for admission. I don't know why she was deferred.

In an interview with Social Worker #B on 07/01/14 on 11:21am, she stated, the list of Hospital #2 clinics was provided (to SP#1). She needed to choose the clinic and make appointment for herself. We could not make the appointment for her because she has to get into hospital #2. There is no appointment it ' s on a first come first serve basis. There is no appointment. This was explained to the patient.


Review of the facility ' s Hospital Case Management Transition Planning policy states, " HCM (Hospital Case Management) will provide post-acute options and available resources. Documentation of the transition planning evaluation(s) and plan (s), patient choice and referrals, if needed, will be made, in the case management documentation system.

Based on record review and interview the facility failed to reassess the appropriateness of the discharge plan in 5 out 5 of sampled patients (SP) #1, #2, #3, #4 & #5 who were discharged home with an infusion ports.

The findings include:
Review of SP#1 closed medical record on 06/30/14 and 07/01/14 show that the patient presented to the facility on 12/29/13 with complaints of pain with urination, pregnancy, chills, and abdominal pain. According to the physician consultation dated 01/02/2014, the patient underwent 2 bone marrow biopsies which showed acute leukemia. Review of the discharge summary revealed that the patient is advised to follow up at Hospital #2 for her high risk pregnancy as well as hematology outpatient for further (chemo) chemotherapy. The patient ' s medical record then showed that the patient was transferred home with a Groshong catheter port for chemotherapy.
Review of the SP # 1 record revealed that there that the reassessment discharge plan was inappropriate. Review of the follow up instructions provided to sampled patient #1 also revealed that there was no documented education to the patient on how to care for the Groshong catheter ' s incision site upon discharge and there were no outpatient hematology/oncology/obstetrician physician referrals or numbers given to the patient.


In an interview with Social Worker #B on 07/01/14 on 11:21am, she stated, " the list of Hospital #2 clinics was provided (to SP#1). She needed to choose the clinic and make appointment for herself. We could not make the appointment for her because she has to get into the Hospital #2 system. There is no appointment; it ' s on a first come first serve basis.

In an interview with the Nurse Director of 3 Main on 07/17/14 at 12:05 pm, she stated, the high risk clinic at hospital #2 provides OB (obstetrician) and oncology. Hospital #2 won ' t take appointments from us. She (SP#1) needed to call. We can ' t get appointments.

In an interview with the Quality Management Officer on 07/17/14 at 12:13pm, she stated, only with acute transfer will Hospital #2 take information from us. With outpatient appointments, Hospital #2 doesn ' t take information.

Review of SP#2 closed medical records on 06/30/14 and 07/01/14 show that the patient was admitted to the facility on 02/05/14 for lung mass. Social Services/ Case Management Adult Transition Evaluation dated 02/06/14 show that the patient lives at home and the anticipated transition plan was home with home health. Review of the discharge summary also showed that a chest tube was inserted on 02/10/14 during a lobectomy (lung surgery). On 02/13/14, the chest tube was removed and Physician Ordered daily dressing change to right chest tube insertion site, and to apply Vaseline gauze, 4x4 dry gauze, and tape. The signed Discharge Instructions dated 02/14/14 has that SP #2 was discharged home on 02/14/14. Review of SP #2 record revealed that the reassessment of the discharge plan was inappropriate. There was no documentation of any discharge education regarding the care of the chest tube wound or care of the port-a-catheter surgical site provided to SP#2.

Review of SP#3 closed medical record on 06/30/14 and 07/01/14 show that the patient was admitted to the facility on 03/20/14 for respiratory failure. Review of the Operative report shows that on 03/22/14, the patient underwent surgical placement of an infuse-a-port. Review of the SP #3 record also revealed that the reassessment of the discharge plan was inappropriate. Review of the signed Discharge Instructions dated 03/22/2014 has that SP #3 was discharged home on 03/22/2014. There was no documentation of any discharge education regarding the care of the infuse-a-port surgical site provided to SP#3.

Review of SP#4 closed medical record on 06/30/14 and 07/01/14 shows that the patient was admitted to the facility on 01/18/14 for lymphadenopathy (abnormal lymph nodes).Operative Report shows that the patient underwent a PICC (peripherally inserted central catheter) port insertion on 01/28/14. Discharge Order on 01/30/14 then state that it is ok to d/c home, and to f/u (follow-up) with heme-onc (hematology/oncology) outpt (outpatient). The Discharge Summary showed that the patient was discharged home on 01/30/14. Review of the SP # 4 record further revealed that the reassessment of the discharge plan was inappropriate. There was no documentation of any discharge education regarding the care of the port surgical site provided to SP#4.

Review of SP#5 medical record on 06/30/14 and 07/01/14 show that the patient was admitted to the facility on 05/31/14 for neck swelling. The Operative Note dated 06/04/14 show that the patient underwent insertion of a venous port. Discharge Order on 06/04/14 states, to discharge patient home. Review of the SP #5 record then revealed that the reassessment of the discharge plan was inappropriate. The Discharge Summary on 06/04/14 show that the patient was discharged home with family care. There were no documentation of any discharge education regarding the care of the venous port surgical site provided to SP#5.


In an interview with the Discharge Planner on 06/30/14 at 11:58 am, she states, " the doctor lets us know if patients need rehabilitation, or it is based on assessment of needs. Transition Assessments are completed in 24 to 48 hours of admission and identify discharge needs which are discussed with the doctor. Discharge needs are updated and reassessments are based on patient ' s needs. If a patient needs care at home for ports, this is discussed with the doctor who determines if it is needed. If I see patients who needs or request assistance at home, I tell the doctor that the patient needs assistance and they place the order. With chemo patients, we don ' t make arrangements for the patients for outside care. Sometimes, the patients leave with the appointment with the oncologist.
In an interview with the Quality Management Officer on 06/30/14 at 12:05pm, she stated, that Infusion ports are for possible chemo up to one year. Most of the time the patients leave with HHA (home health agency) services who receives instructions from the doctor. If they follow up with an oncologist, they will receive instructions there. The Nurse (at this facility) would provide education on signs and symptoms.
In an interview with Registered Nurse (RN) #D on 06/30/14 at 12:11pm, the RN stated the discharge plans are explained to the patients along with signs and symptoms of medications and infections. We work with the Social Workers to do arrangements for transfer and explain the progress to the patient. Patient who have lines are explained the symptoms to address, usually with catheters, what to report to the nurse. Usually the patient usually goes home with home health.

In an interview with RN#F on 06/30/14 at 3:23pm, she states, " RNs provide discharge instructions to patient and the teachings are documented in the patients ' medical records. HHA (Home Health Agency) services are arranged for PICC (Peripheral inserted central catheter).

Review of the facility ' s policy : Discharge Instructions/ Food and Drug Interaction, Form states that patient/ significant other (Patient Representative) will receive individualized discharge instructions before leaving the unit. The Special Instructions and Comments are to be documented on Cerner any additional information that will be beneficial to the patient after discharge.

Review of the facility ' s Care and Maintenance of the Groshong Catheter Policy show that sterile dressing changes shall be performed routinely once per week or as needed if the dressing becomes soiled, wet, or loose using a clear dressing. Also, the catheter should be flushed with 5cc (cubic centimeters) of normal saline every seven days when not in use.

Based on interview and record review the facility failed to provide an appropriate referral/ transfer to an outpatient hematology/oncology physician and obstetrician physician in 1 out of 12 sampled patients (SP)#1.

The findings include:
Review of SP#1 closed medical record on 06/30/14 and 07/01/14 show that the patient presented to the facility on 12/29/13 with complaints of pain with urination, pregnancy, chills, and abdominal pain. According to the physician consultation dated 01/02/2014 , the patient underwent 2 bone marrow biopsies which showed acute leukemia. Review of the discharge summary revealed that the patient is advised to follow up at Hospital #2 for her high risk pregnancy as well as hematology outpatient for further (chemo) chemotherapy. The patient ' s medical record then show that the patient was transferred home with a Groshong catheter port for chemotherapy. There were no further specific written instructions of a transfer/referrals regarding which outpatient hematology/oncology physician to contact, or which obstetrician physician to follow up with along with any necessary medical information provided to SP#1.

In an interview with the Social Worker #A on 07/01/14 at 10:30 am she stated, I did the initial assessment (for SP#1) and identified that she was from home. There was an order to transfer to hospital #2 . As per Hospital #2 review, she was deferred for admission. I don't know why she was deferred.

In an interview with Social Worker #B on 07/01/14 on 11:21am, she stated, the list of Hospital #2 clinics was provided (to SP#1). She needed to choose the clinic and make appointment for herself. We could not make the appointment for her because she has to get into hospital #2. There is no appointment it ' s on a first come first serve basis. There is no appointment. This was explained to the patient.


Review of the facility ' s Hospital Case Management Transition Planning policy states, " HCM (Hospital Case Management) will provide post-acute options and available resources. Documentation of the transition planning evaluation(s) and plan (s), patient choice and referrals, if needed, will be made, in the case management documentation system.