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LEHIGH REGIONAL MEDICAL CENTER
REASSESSMENT OF A DISCHARGE PLAN
Tag No.: A0821
Based on interview and record review the facility failed to provide appropriate discharge planning / instructions in 2 (Patients #1 and #3) of 5 patient discharged records reviewed.
The findings included:
Record review on 5/9/11 at 2:00 p.m. of Patient #1's medical record revealed physician orders dated 4/15/11 at 1410 (2:10 p.m.) ordering BMP in a.m. Further review revealed this order was not transcribed on the 3008 (transfer H&P to a Skilled Nursing Facility) used for discharge planning purposes. The 3008 allows the receiving facility to obtain information and/or orders regarding the patient. The receiving facility was unable to meet the needs of the patient due to this lack of information.
On 5/9/11 at 2:00 p.m., the Chief Nursing Officer (CNO) was interviewed and stated, "yes, I see where the BMP was ordered and no it is not on the 3008."
Record review on 5/9/11 at 2:00 p.m., of Patient #3's medical record revealed a physician order on 3/2/11 at 1630 (4:30 p.m.) ordering: ok to dc (discharge) to L H&R (Lehigh Health & Rehab). If patient does not void overnight bladder scan and place Foley. Patient #3's 3008 form used for discharge instructions was reviewed and revealed this order was not included and the portion of the form addressing bladder / urinary issues was left blank.
On 5/9/11 at 2:00 p.m., the CNO was interviewed and stated, "I see where the physician ordered "ok to dc to L H&R if pt. does not void overnight bladder scan and place Foley and no it is not on the 3008."
On the 3008 there is a section for 'new orders.' This section for Patients #1 and #3 were left blank. Again, the receiving facility was unable to meet the needs of the patient due to the lack of this information.
REASSESSMENT OF DISCHARGE PLANNING PROCESS
Tag No.: A0843
Based on interview and record review the facility failed to provide appropriate discharge planning / instructions in 2 (Patients #1 and #3) of 5 patient discharged records reviewed.
The findings included:
Record review on 5/9/11 at 2:00 p.m., of Patient #1's medical record revealed physician orders dated 4/15/11 at 1410 (2:10 p.m.) ordering BMP in a.m. Further review revealed this order was not transcribed on the 3008 (transfer H&P to a Skilled Nursing Facility) used for discharge planning purposes. The 3008 allows the receiving facility to obtain information and/or orders regarding the patient. The receiving facility was unable to meet the needs of the patient due to this lack of information.
On 5/9/11 at 2:00 p.m., the Chief Nursing Officer (CNO) was interviewed and stated, "yes, I see where the BMP was ordered and no it is not on the 3008."
Record review on 5/9/11 at 2:00 p.m., of Patient #3's medical record revealed a physician order on 3/2/11 at 1630 (4:30 p.m.) ordering: ok to dc (discharge) to L H&R (Lehigh Health & Rehab). If patient does not void overnight bladder scan and place Foley. Patient #3's 3008 form used for discharge instructions was reviewed and revealed this order was not included and the portion of the form addressing bladder/urinary issues was left blank.
On 5/9/11 at 2:00 p.m., the CNO was interviewed and stated, "I see where the physician ordered "ok to dc to L H&R if pt. does not void overnight bladder scan and place Foley and no it is not on the 3008."
On the 3008 there is a section for 'new orders.' This section for Patients #1 and #3 were left blank.
The clinical records failed to contain evidence of communications to the Skilled Nursing Facilities for these new physician orders prior to transfer.