HospitalInspections.org

Based on medical record review, staff and family interview, and review of policies and procedures and care management protocol, the facility failed to evaluate and address post-hospital care needs identified for 1 of 5 sample patients (#4) reviewed for adequate discharge planning. The findings were:

Review of the medical record showed patient #4 was admitted to the hospital on 12/17/17 due to an unintentional overdose of heroin (a highly additive illegal opioid). This review revealed the patient took the drug to relieve a toothache, became overly-sedated, lost consciousness, fell, and fractured his/her leg. This review showed the patient required cardiopulmonary resuscitation, emergency medical service transport, and subsequent admission to the intensive care unit. Further review showed the patient received care and treatment for his/her condition, including an orthopedic consult and therapy for the non-displaced oblique left leg fracture. Review of the physician visit note, dated 12/18/17, showed the "current overdose was likely due to not using heroin since 4/2017 and resumed with same dose." This review also showed the plan to address this specific problem was "substance abuse counseling as outpatient." Review of the discharge summary showed the patient was discharged home with family to another state on 12/20/17.

The following concerns were identified:
1. Review of the 12/17/17, 12/18/17, 12/19/17, and 12/20/17 plans of care showed the nurses identified "drug abuse/detox" as a problem for patient #4. However, further review showed discharge planning interventions did not include post-hospital plans to address "drug abuse/detox."
2. Review of the medical record showed no documented discussions between professional staff and the patient regarding interventions for possible substance abuse after discharge.
3. Review of the 12/20/17 discharge orders and instructions included a prescription for hydrocodone-acetaminophen (an opioid pain medication), scheduled appointment to see an orthopedic physician for the fracture, information regarding smoking cessation, instructions to see a dentist, and follow-up appointment with the primary care physician. Further review showed resources, instructions, follow-up services, and information regarding substance abuse had not been included in the discharge orders and instructions.
4. Interview on 6/20/18 at 12:35 PM with the director of care management revealed the following information: The early phase of the hospital's discharge planning process required an evaluation utilizing a high risk screening tool. The high risk screening criteria was applied to each patient following admission. Patients identified as needing discharge planning through the screening process received services provided by a member of the Case Management Team. The Case Management Team was then responsible for addressing post hospital needs like substance abuse counseling. This was not done for patient #4 because the high risk screening tool "did not trigger the need for discharge planning by the Case Management Team." During the interview the director of care management stated failing to address all identified post-hospital needs was not the hospital's usual practice. She further stated a quality review of this patient's discharge planning process to identify measures that would prevent future similar incidence of unmet discharge planning needs had not been done.
5. Interview on 6/20/18 at 2:50 PM with physician #1 revealed discharging the patient with a limited amount of opioid medications was medically appropriate due to the patient's painful injuries. The physician stated s/he was aware of the patient's past history of substance abuse problems, and during a discussion with patient, understood the patient would be discharged with family to another state and receive follow-up treatment there. The physician stated s/he could not remember when the discussion occurred; and the discussion was not documented. S/he also verified the discharge orders and instructions did not address post-hospital care and/or treatment for substance abuse.
6. Interview on 6/26/18 at 8:45 AM with the patient's family member revealed the family member was present at the time of discharge and remembered being concerned about staff not providing the patient with resources, information, or "something" to help the patient with substance abuse problems. The family member stated this was important because the patient was being discharged with a prescription for an opioid after the patient had resolved problems with heroin use 10 months earlier. The family member further stated s/he was not aware of any discussion about trying to find substance abuse treatment in his/her home state.

Review of the Care Management Protocol Discharge Planning High Risk Tool, reviewed April 2017, showed "The high risk screening criteria is applied to each patient via medical record and documentation review following a patient's admission. Patients identified as needing discharge planning through the screening process are then addressed by a member of the Care Management Team."

Review of the policy and procedure titled, "Discharge Planning," revised 8/1/17, showed all inpatient admissions, other than Women and Children's services, and Behavioral Health Inpatient Unit, will be screened utilizing a high risk screening tool. This review showed the assessment would be completed on every patient by the Case Management Team within an early stage of hospitalization to evaluate the need for social work/discharge planning needs along the continuum. Further review showed the assessment should have a target completion time of 24 working hours from admission (during normal business hours).