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Based on review of the hospital's policy and procedures, document review, medical record review, and staff interviews, the hospital nursing staff failed to provide discharge instructions for post operative care and pain management at the time of discharge for 6 of 7 surgical patients (#3, 4, 5, 8, 11, & 12).

The findings include:

Review of the hospital's policy and procedure "Protocol: Discharge of Patient, 102" approved date 05/18/2011 revealed "... C. Refer to Perry & Potter's, Clinical Nursing Skills and Techniques, for routine discharge information..."Review of the clinical resource "Perry & Potter Clinical Nursing Skills and Techniques, Chapter 2: Admitting, Transfer, and Discharge: Discharge Planning; pages 21 - 25" revealed "discharging patients ...1c. Conduct teaching sessions with patient and family as soon as possible during hospitalization (e.g. signs and symptoms of complications, information regarding medications...follow-up care, diet, exercise, restrictions imposed by illness or surgery). Review and give the patient discharge materials ...2a. Let patient and family ask questions or discuss issues related to home care ...b. Check physician's discharge orders for prescriptions, change in treatments ...e. Complete medication reconciliation per institution policy. Check discharge medication orders against the medication administration record and home medication list. Provide patient with prescriptions or pharmacy-dispensed medications ordered by physician. Offer a final review of information needed to facilitate safe medication self-administration..."

Review of the hospital's policy "Patient and Family Education" approved date of 09/15/2010 revealed "SPECIFIC EDUCATIONAL NEEDS OF PATIENT/FAMILY: A. The patient/family receives education about how to safely and effectively use medications, according to patient needs, laws and regulations ...Patient/family receives education regarding any new medication/treatments prescribed upon discharge ...D. the patient/family is educated about potential drug-food interactions, and provided counseling on nutrition, interventions, modified diets, or oral health, as appropriate ...J. Patients are educated about pain and managing pain as a part of treatment, as appropriate ...L. The patient/family receives education regarding diagnosis/disease/medication management as required to comply with accrediting agencies ..."

Review of the hospital's policy and procedure "Medication History and Medication Reconciliation" approved date 04/15/2011 revealed "OUTPATIENT SURGERY: 2. Discharge: A. Discharge to home, the patient will be provided with a Depart Summary containing a list of medication the patient will continue to take after discharge ..."

Review of the hospital's policy "Medication Administration" approved date 12/19/2012 revealed "DOCUMENTATION: D. Discharge plan of care should include a list of medications to be continued at home ..."

1. Closed medical record review of patient #4 revealed a 13 year old male admitted to the same day surgery unit on 08/13/2013 for T&A (Tonsillectomy and Adenoidectomy) surgical procedure with discharge to home the same day. Continued review revealed the patient was provided a prescription for post operative pain management. Review of the discharge instructions revealed no documentation of medication education. Continued review of the chart revealed no Depart Summary (medication reconciliation). Continued review revealed no documentation of the patient/family receiving education regarding the pain medication prescribed at the time of discharge.

Interview on 08/14/2013 at 1000 with the discharge nurse (RN #1) revealed "...as for pain medication I tell them to follow whatever instructions their doctor has given them ... I do not write any medications on the discharge medication list unless it is a prescription the doctor has left on the chart for me to give to the patient ... I do not document discharge instructions the doctor has discussed with the patient unless I hear it myself, that includes discussion with over the counter medication ...I did not give any instructions regarding the prescription for pain medication ..." The interview confirmed no discharge instructions were given regarding new medications prescribed upon discharge.

Interview on 08/14/2013 at 1300 with administrative staff revealed the patient had "received a prescription for post op pain medication while in the doctor's office ...there is no Depart Summary on the chart that specifies what the new medication is or dosage and administration. The Depart Summary should list all new medications the patient is to take after discharge ..." Interview confirmed staff failed to document new medications on the Depart Summary as required by policy.

2. Closed medical record review of patient #5 revealed a 7 year old male admitted to the same day surgery unit on 08/13/2013 for T&A surgical procedure with discharge the same day. Continued review revealed the patient was provided a prescription for post operative pain medication. Review of the discharge instructions dated 08/13/2013 revealed no documentation of medication education. Continued review of the chart revealed no Depart Summary. Continued review revealed no documentation of the patient/family receiving education regarding the new pain medication prescribed at the time of discharge.

Interview on 08/14/2013 at 1015 with the discharge nurse (RN #2) revealed "...we should give general discharge instructions related to post op care to every patient and education about the medication the physician has prescribed, even over the counter medications ...we have some doctors that give prescriptions and some that tell the Pediatric patient's to take over the counter Tylenol or Ibuprofen ...most of our Peds patients are instructed to use something over the counter ...I don't document any pain medication unless I hear the doctor tell the patient what he wants them to take or unless he writes it in the chart." The interview confirmed no discharge instructions were given regarding new medications prescribed upon discharge.

Interview on 08/14/2013 at 1300 with administrative staff revealed the patient had "received a prescription for post op (operative) pain medication while in the doctor's office ...there is no depart summary (medication reconciliation) on the chart that specifies what the new medication is or dosage and administration. The Depart Summary should list all new medications the patient is to take after discharge." The interview confirmed no discharge instructions were given regarding new medications prescribed upon discharge.

3. Closed medical record review on 08/14/2013 of patient #12 revealed a 4 year old female admitted to the same day surgery unit on 08/09/2013 for an Adenoidectomy and Bilateral Myringotomy and Tubes (tubes in the ears) surgical procedure with discharge the same day. Review of the "Discharge Instructions: Ear, Nose, or Throat" dated 08/09//2013 revealed a standardized discharge instruction sheet with 13 type written instructions that could be checked as appropriate depending on the procedure performed. Review of the document revealed none of the instructions had been marked. Continued review revealed no instructions for post operative care, diet, medication management, pain management, or follow up care. Continued review of the chart revealed a Depart Summary with no medications listed.

Interview on 08/14/2013 at 1015 with RN #2 revealed "these are the routine instructions we review with every ENT (ear, nose, and throat) patient. The nurse should mark those items that are applicable and review them with the patient or guardian prior to discharge. You don't leave the items blank if they are applicable to the procedure ...we should give general discharge instructions related to post op care to every patient and education about the medication the physician has prescribed, even over the counter medications ...we have some doctors that give prescriptions and some that tell the Pediatric patient's to take over the counter Tylenol or Ibuprofen ...most of our Peds (pediatric) patients are instructed to use something over the counter ..." Interview confirmed post operative care, diet, pain managment, medication, and followup care instructions was not provided at time of discharge.

Interview on 08/14/2013 at 1300 with administrative staff revealed the patient had "...The Depart Summary should list all medications the patient is to take after discharge including OTC (over the counter) medications ..."

4. Closed medical record review on 08/14/2013 of patient #11 revealed a 5 year old male admitted to the same day surgery unit on 07/16/2013 for an Adenoidectomy and Bilateral Myringotomy and Tubes surgical procedure with discharge the same day. Review of the "Discharge Instructions: Ear, Nose, or Throat dated 07/16/2013 revealed a standardized discharge instruction sheet with 13 type written instructions that could be checked as appropriate depending on the procedure performed. Review of the document revealed none of the instructions had been marked. Review of the document revealed no instructions for post operative care, diet, medication management, pain management, or follow up care. Continued review of the chart revealed a Depart Summary (medication reconciliation) with no medications listed.

Interview on 08/14/2013 at 1015 with RN #2 revealed "these are the routine instructions we review with every ENT patient. The nurse should mark those items that are applicable and review them with the patient or guardian prior to discharge. You don't leave the items blank that are applicable to the procedure ...we should give general discharge instructions related to post op care to every patient and education about the medication the physician has prescribed, even over the counter medications ...we have some doctors that give prescriptions and some that tell the Pediatric patient's to take over the counter Tylenol or Ibuprofen ...most of our Peds (pediatric) patients are instructed to use something over the counter ..." Interview confirmed post operative care, diet, pain management, medication, and follow-up care instructions were not provided at time of discharge.

Interview with administrative staff on 08/14/2013 revealed the "the discharge instruction sheet has not been completed ...the boxes are blank and the ones applicable to this patient should have been marked so the family would know what to do for post op care ...there is no evidence of what the patient or family should do for their diet or pain management ..." Interview confirmed post operative care, diet, pain management, medication, and follow-up care instructions were not provided at time of discharge.

5. Closed medical record review on 08/13/2013 of patient #3 revealed a 3 year old male admitted to the same day surgery unit on 05/23/2013 for a Tonsillectomy & Adenoidectomy (T&A) surgical procedure with discharge on the same day. Review of the "Discharge Instructions: Ear, Nose, or Throat" dated 05/23/2013 revealed no instructions for post op T&A care, diet, medication management, pain management, or follow up care. Continued review of the chart revealed a Depart Summary (medication reconciliation) with no medications documented.

Continued review of the medical record revealed no evidence of the "Depart Summary" document (medication reconciliation form). Continued review revealed no documentation of discharge instructions for medication instructions or pain management post discharge.

Further medical record review revealed patient #3 presented to the Emergency Department of Hospital A (the named facility) on 05/26/2013 at 0520 (3 days after first surgery) with complaint of vomiting blood. Continued review of the medical record revealed the patient was evaluated by Physician #2 with a diagnosis of tonsillar bleeding and taken to surgery on 05/26/2013 at 0707. Review of the Surgical History & Physical (no date) revealed "Patient Name (Patient #3) Allergies: NKA (no known allergies) (the box is check marked). Current Medications: PRN (as needed) Tylenol and Motrin."

Review of the Physician's Surgical/Procedure Documentation dictated 05/26/2013 at 0815 revealed "...postoperative diagnosis: bleeding post-tonsillectomy, Procedure Performed: Exam under anesthesia with control of tonsillar bleeding." Continued review of the Surgical History revealed the patient was transferred to 7-East nursing unit for post operative observation and was discharged to home on 05/26/2013 at 1633.

Review of the discharge instructions dated 05/26/2013 revealed no documentation of pain management or medications to be continued or discontinued at discharge. Review of the Depart Summary revealed no list of home medication or new medications.

The discharge nurse (RN #3) was no longer employed at the facility and not available for interview.

Interview on 08/14/2013 at 1015 with RN #1 revealed "these are the routine instructions we review with every ENT (ear, nose, and throat) patient. The nurse should mark those items that are applicable and review them with the patient or guardian prior to discharge. You don't leave the items blank if they are applicable to the procedure ...we should give general discharge instructions related to post op care to every patient and education about the medication the physician has prescribed, even over the counter medications ...we have some doctors that give prescriptions and some that tell the Pediatric patient's to take over the counter Tylenol or Ibuprofen ...most of our Peds (pediatric) patients are instructed to use something over the counter ..."

Interview with administrative staff on 08/14/2013 revealed the "discharge instructions for the Pediatric patient's are vague and we can do a better job with the instructions they are given for post surgical care ...No one addressed the pain and what to do for the pain post discharge ..." Interview confirmed the discharge instructions were incomplete.

Interview on 08/13/2013 at 1400 and 08/14/2013 at 0830 was attempted with Physician #1. Physician #1 declined to be interviewed.

6. Closed medical record review on 08/13/2013 of patient #8 revealed a 32 year old female admitted to the same day surgery unit on 05/22/2013 for a T&A procedure with discharge on the same day. Continued review revealed the patient was provided a prescription for post operative pain medication. Review of the "Discharge Instructions: Ear, Nose, or Throat" dated 05/22/2013 revealed no instructions for the post op T&A patient regarding diet, medication management, pain management, or follow up care. Continued review of the discharge instructions revealed no documentation of medication education. Continued review of the chart revealed no Depart Summary (medication reconciliation) document. Continued review revealed no documentation of the patient/family receiving education regarding the pain medication prescribed at the time of discharge.

Interview on 08/14/2013 at 1300 with administrative staff revealed "The boxes that are applicable should be checked and these are not ...there is no depart summary (medication reconciliation) on the chart that specifies what the new medication is or dosage and administration. A depart summary should list all new medications prescribed along with dosage and administration." The interview confirmed no discharge instructions were given regarding new medications prescribed upon discharge.

NC00090740