Bringing transparency to federal inspections
Tag No.: A0084
Based on review of the medical record, policies and procedures, staff interviews and other pertinent documentation, it was determined the hospital failed to ensure that the transportation contractor provided a safe discharge when patient #1 was transported to the wrong address at discharge on October 8, 2010 as evidenced by:
Patient #1 is a 38 year old female with past medical history of Cerebral Palsy, Spastic Quadriplegia, Chronic Obstructive Pulmonary Disease (COPD) and profound mental retardation, presented to the Emergency Department (ED) at Northwest Hospital Center on 9/3/10 with acute respiratory distress. The patient was recently discharged from Northwest Hospital Center after receiving inpatient treatment for GI bleed and aspiration pneumonia. The patient developed an increasing cough after meals with vomiting several times. On exam in the ED she had a rapid pulse and respirations with bilateral wheezing and respiratory distress. The medical work-up revealed suspicion of aspiration pneumonia and chest x-ray revealed a large amount of stomach inside the chest (hernia) but no evidence of obstruction. The patient did have an upper GI test which showed reflux. Because of the recurrent episodes of aspiration, surgical consultation was obtained for possible repair of the hernia. The physician obtained a second opinion than discussed the risk versus benefits with the mother , which included open versus laparoscopic, post complications of pneumonia, pulmonary emboli and death. The mother decided to have the surgery performed.
The patient had an open gastrostomy with placement of a PEG tube on 9/30/10. As the patient stabilized there was much discussion regarding discharge including placement back at her prior group home or a long term care placement (LTC) with hospice. Based on the patient care needs, the decision was made by the patient's mother in collaboration with Chimes staff for the patient to be discharged to LTC with hospice care. On 10/8/10 the patient was incorrectly transported by Transcare to her prior Chimes operated home instead of the LTC facility.
The patient's medical record revealed a discharge instruction sheet, transfer summary, discharge order and case management note that stated the patient was being discharged to a Long-Term Care (LTC) facility. The investigation revealed that the hospital uses a contracted vendor, Pulse Medical Transportation, which is an ambulance and wheelchair provider. This company coordinates and executes the medical transportation needs of the hospital. Pulse Medical Transportation employs an on-site Transportation Coordinator (TC) who works with the Case Management Department. Once the treatment team, patient, physician, family, and receiving facility have all agreed upon the discharge plan, a call is placed to the Pulse Medical Transportation Coordinator Office, which is located in Admissions. The transportation coordinator will go to the unit and access the patient's information to prepare for discharge, which includes the insurance information, demographic information and destination. At the same time, the unit secretary will complete the Discharge Checklist Envelope. This envelope has space to document the patient's name, hospital room number, pick-up time and destination. Below this information are four blocks with discharge destinations and the necessary documentation that must be placed in the envelope. The discharge destinations include to Nursing Home, Hospital to Hospital, Home and Psychiatric transfers. The fifth and last block is the block that list all documentation that must go with any transfer and a checklist for nursing. The transportation coordinator or the case manager would complete the information at the top of the Discharge Checklist Envelope, which includes the destination.
In this case, the transportation coordinator, documented the wrong destination address, which is evident from the print out of the trip history from Pulse Medical Transportation. The trip history revealed the patient discharge destination to be her Chimes' home address rather than the address of the LTC facility. Although the Discharge Checklist Envelope cannot be found, it's believed the incorrect address was also placed on the envelope as the destination at discharge. The Pulse Medical Transportation Coordinator faxed this information to the Medicare/Medicaid licensed service for transportation, which is Transcare. Therefore, it was determined that the hospital's contracted service faxed incorrect information to Transcare, which led to the patient being transported back to her Chimes' home address rather than the LTC facility.
Irregardless of the outcome from investigation of the actions by the group home staff and Transcare, the patient was discharged with an incorrect destination address and the hospital relied on the contracted service to assure the safe transport of its patients and therefore are accountable for the outcome.
Tag No.: A0837
Based on the medical record review, policies and procedures, staff interviews, and other pertinent information, it was determined that the hospital failed to discharge patient #1 with the appropriate information for her to receive the appropriate care at the LTC facility, when it discharged the patient to the wrong address.
Patient #1 is a 38 year old female with past medical history of Cerebral Palsy, Spastic Quadriplegia, Chronic Obstructive Pulmonary Disease (COPD) and profound mental retardation, presented to the Emergency Department (ED) at Northwest Hospital Center on 9/3/10 with acute respiratory distress. The patient was recently discharged from Northwest Hospital Center after receiving inpatient treatment for GI bleed and aspiration pneumonia. The patient developed an increasing cough after meals with vomiting several times. On exam in the ED she had a rapid pulse and respirations with bilateral wheezing and respiratory distress. The medical work-up revealed suspicion of aspiration pneumonia and chest x-ray revealed a large amount of stomach inside the chest (hernia) but no evidence of obstruction. The patient did have an upper GI test which showed reflux. Because of the recurrent episodes of aspiration, surgical consultation was obtained for possible repair of the hernia. The physician obtained a second opinion then discussed the risk versus benefits with the mother , which included open versus laparoscopic, post complications of pneumonia, pulmonary emboli and death. The mother decided to have the surgery performed. The patient had an open gastrostomy with placement of a PEG tube on 9/30/10. As the patient stabilized, there was much discussion regarding discharge including placement back at her prior home and LTC care placement with hospice. Based on the patient care needs the decision was made by the patient's mother in collaboration with Chimes' staff for the patient to be transferred/discharged to LTC with hospice care. On 10/8/10 the patient was transported by Transcare to her prior Chimes' home instead of the LTC facility.
Patient #1 was discharged back to her Chimes' home instead of the LTC facility for hospice services. This constitutes an inappropriate discharge since the discharge information (destination address) from the hospital to the post-discharge facility was incorrect which led to disruption in the continuity of care and the patient's re-admission to Northwest Hospital Center. The Manor Care post-discharge facility was equipped to handle the level of care needs for patient #1, but the patient never reached the correct destination due to incorrect information given to Transcare. The hospital failed to assure a safe discharge and continuity of care.