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Based on medical record review and interview, the facility does not always obtain informed consent prior to a medical procedure. (Patient#60)

Findings Include:

Medical Record review on 11/08/13, failed to find documented evidence of a signed informed consent prior to a cardiac catheterization that was performed on 10/26/13.

Interview with Staff #1 on 11/08/13 indicated written patient consent should be obtained prior to cardiac catheterization.

Based on policy and medical record review, during an inpatient-to-inpatient transfer, the facility does not always provide the receiving facility with all required information. Specifically, there is no evidence of a transfer order, the patient's status and pertinent medical information. (Patient #70)
Findings Include:
Review on 11/08/13 of policy #PM.6 "Discharge Planning", revised 07/2013, revealed no patient who requires continuing health care services in accordance with the patient ' s discharge plan may be discharged until such services are secured or determined by the hospital to be reasonably available to the patient. Patients are transferred with necessary medical information to appropriate facilities, agencies, or outpatient services, as needed for follow-up or ancillary care.

Review on 11/08/13 of policy "Guidelines for Completing the Adult Patient-Resident Discharge Form (KH00505)", revised 4/2011, revealed that the form should be completed for all patients being sent to another facility outside of Kaleida Health. The original copy is kept with the medical record and a copy is sent with the patient to the receiving facility. Information documented on this form includes (but is not limited to): name of receiving facility, allergies, family notification of discharge, advanced directives, mental status and assistive device(s).

Review of Patient #70's medical record on 11/08/13 revealed the following:

- On 10/11/13 the patient was admitted to the hospital with a diagnosis of congestive heart failure exacerbation
- An Interim Discharge Summary, dictated by the physician on 10/16/13, revealed a past medical history of congestive heart failure, coronary arterial by-pass graft with atrial septal repair, systolic biventricular heart failure, type II diabetes, schizoaffective disorder bipolar type, anemia, hyponatremia, chronic obstructive pulmonary disease and paroxysmal atrial fibrillation. While hospitalized the patient has had erratic behavior: cursing and physically abusive to staff. He has an allergy to Haldol. He is currently on 1:1 observation waiting for an inpatient psychiatric bed at another hospital.
- The Medicine Attending note, dated 10/22/13 and timed 11:38am, indicates "psych is arranging transport to another hospital. "
- A Psychiatry Resident ' s note, dated 10/22/13 and timed 12:00pm, indicates " awaiting inpatient transfer to inpatient psych once bed is available.
- An Attending Physician note, dated 10/22/13 and timed 12:20pm, indicates the patient needs inpatient stabilization.
- A Medicine note, dated 10/22/13 and timed 2:10pm, indicates Staff #2 approved a sitter until the patient is transferred to inpatient psych.
- A Nursing note, dated 10/22/13 and timed 6:09pm, revealed the patient was discharged to a psychiatric unit at another hospital via ambulance with security assistance.
- No documentation was found that medical information such as laboratory studies, allergy status or patient assessments were sent with the patient on transfer.
- Review of Discharge Instructions, dated 10/22/13, revealed medical and psychological diagnoses and with instructions to follow-up with the hospital physician and primary physician in 5 to 7 days. Discharge medications are listed but allergies are not. The document is signed at 5:07pm by the patient and nurse. This document is for a discharge to home. It does not correctly indicate that the patient was transferred to another facility for inpatient psychiatric care
- Review of the Discharge Summary Addendum, dated 10/24/13 (2 days post discharge), instructs the patient to follow up with his psychiatrist, take all his medications, follow up with the cardiologist and come to the emergency department with increased shortness of breath, cough, fever, chills, leg swelling and visual/auditory hallucinations. This document is for a discharge to home. It does not correctly indicate that the patient was transferred to another facility for inpatient psychiatric care