HospitalInspections.org

Based on record review, staff interview and policy review it was determined the facility failed to ensure the nurse documented accurately the disposition of the patient at the time of discharge for 1 (#1) of 10 sampled patients.

Findings include:

Review of the facility's policy "Patient Discharge", # 2.00.006.5, last reviewed 2/8/12, requires that following discharge of the patient, the Nurse is to document the time and date of the discharge, the destination, with whom the patient was discharged and the mode of transportation.

Patient #1's Social Work Discharge Disposition reveled patient #1 was discharged at 2:30 p.m. via a transport company. Review of the Inpatient Depart Patient Summary, documented by a Registered Nurse at 12:26 p.m. (two hours before the discharge) indicated the patient had been accompanied by the ex-spouse and was transported via private vehicle.

The patient was interviewed on 7/5/13 at approximately 11:40 a.m. He stated he was taken home in a van, not a private car. His ex-wife did not accompany him.

The Assistant Vice President for Nursing was interviewed on 7/5/13 at approximately 12:30 p.m. and confirmed the nurse failed to accurately document the patient's disposition.