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Based on review of facility policy and procedures, medical records, and staff interview, facility failed to ensure a registered nurse supervised and evaluated nursing care for each patient on an ongoing basis to include patient's newly verbalized signs and symptoms prior to discharge, failed to notify the attending physician of the newly verbalized symptoms, and failed to accurately document the patient's discharge paperwork, for 1 of 6 sampled patients (#1).


Findings:

Record review revealed Patient #1 was admitted to the facility on 10/3/23 at 5:57 PM to the 3 East unit as an observation patient where the patient received diagnostic tests and treatment. Following review and assessment of diagnostic test results and a corresponding cardiology consult, the attending physician wrote discharge instructions and follow-up orders on 10/3/23 at 3:13 PM and the consulting cardiologist wrote orders on 10/3/23 at 3:54 PM, clearing patient for discharge.

An interview with the Nurse supervisor and Nurse Manager of 3 East on 10/16/23 at 2:15 PM revealed the Nurse Manager stated that the patient's nurse and charge nurse came to her and said the patient refused to leave. Security was called by her to let them know and she spoke to the patient at length. Patient #1 said she had numbness and tingling in hands and had a new diagnosis of a herniated disc. She said she wished she would have told the doctor. Nurse Manager related the patient was yelling and said, she could not keep doing this to her son and said she would not leave. She related she told the patient the physician had looked at her status and test results and deemed her medically cleared to go and that she could follow-up as an outpatient. The Nurse Manager and supervisor, when questioned, did not have an answer as to why they did not contact the physician at that time regarding her newly verbalized symptoms of numbness and tingling in hands.

Review of the nurse notes for patient #1, revealed no documentation of patient verbalizing any new physical symptoms, or that the patient refused to leave as she did not feel well enough to go home. There was also no documentation that hospital Security was called to respond to the patient's room, or that there was a problematic discharge when patient left the 3 East nursing unit and was taken downstairs by staff via wheel chair to sign in again at the hospital Emergency department and be reevaluated.

Continued record review for Patient #1 noted she left the 3rd floor, transported down to the Emergency Department by security, and again registered in the Emergency department. with her newly verbalized symptoms. Review of a Triage form dated 10/3/23 at 6:02 PM documented "Chief complaint- tingling left eye, left hand/fingers, tongue, left foot onset 2 days ago. Discharged from hospital few minutes ago. -- CT scan and labs."

Interview with Patient # 1's attending physician on 10/16/23 at 13:50 PM, noted she did not know the patient went downstairs to the Emergency Department after she discharged her, and did not know she was readmitted (to observation). She stated the nurse did not call her and let her know anything about the patient complaining of new symptoms and she did not know the patient refused to leave or that anything was wrong. She stated if she had been contacted with the information, she would have come back up to see that patient and do a reassessment of her and reassure her.

The patient was readmitted to a different floor under observation and completed additional diagnostic testing and lab work. The patient was successfully discharged from the hospital on 10/4/23.

Review of the facility Security activity log confirmed a Security Officer responded to patient #1's room at 5:30 PM on 10/03/2023 after a call from the nurse.

Review of the facility policy entitled "Chain of Command,, PolicyStat ID 7634056, approved 2/8/21 , read on Page 1 under PURPOSE:

The Chain of Command policy has been designed to provide hospital staff and physicians direction for prompt handling of patient care issues. This policy makes available a formal line of communication for staff members who have concerns that a prescribed treatment plan (or lack there of), a medical decision or other medical act might adversely affect the welfare of a patient or that of the hospital. ...

Policy: Staff will adhere to the following procedure for problem resolution involving concerns/issues related to care including patient rights.
A. Care issues/concerns include but are not limited to the following:
Life threatening concerns to patients
Potential for complications which may jeopardize the safety or comfort of patients. . .

On page 2 of the policy it read under the section of PROCEDURE:
A. After the staff member evaluates the patient with the prescribed treatment regimen and makes a determination there is a patient management concern, (S)he shall contact the attending physician to obtain clarification of the orders of prescribed treatment."...

Review of the facility policy entitled "Patient Assessment/Reassessment, PolicyStat ID 13430801 read on page 2, 5. under the section GUIDELINES read:

5. Patients in each clinical setting are reassessed at regular intervals to assure that the treatment plan remains appropriate. Patient reassessments are based on the anticipated length of stay, complexity, dynamics, response to specific treatment, or when a significant change occurs in the patient's condition or diagnosis.

Page 5, under the section REASSESSMENT, (Patient Services Nursing) 1. read:
Each patient is reassessed and the Plan of Care is reviewed by an RN at least once every 24 hours. Care plan updates and consultation with the RN. Reassessments are completed every shift but should occur more frequently if ordered or as the patient's condition indicates. Reassessment is based upon, but limited to systems status related to the diagnosis, patient care needs, pain identification, nursing diagnosis, response to treatment, change in condition or reaction to and effectiveness of medications, prior to discharge. . .

Patient #1 had discharge orders written by her physician on 10/03/2023. While remaining in her hospital room, she verbalized she did not feel well enough to leave the hospital and verbalized new symptoms of physical tingling to specific parts of her body. The RN contacted the floor RN Manager, who spoke with the patient regarding her discharge status. Neither nurse performed a nursing reassessment nor did they contact the patient's physician to report the newly verbalized symptoms by the patient. Instead, the nursing manager contacted the hospital security to proceed with the patient's discharge from the floor. The patient upon discharge, was given options to leave, or report to the hospital emergency room upon discharge. The patient chose to be wheeled to the hospital emergency department downstairs, where she was reevaluated and readmitted to an observation status of the same hospital.

Based on interview and record review, the facility failed to ensure complete and accurate data was entered into the patient medical record for 1 (1) of 6 sampled medical records.

Findings are:

Review of Patient #1's electronic health record (EHR) noted documentation on 10/3/23 at 6:00 PM, the patient had a Venous Right Antecubital 20 gage intravenous line inserted. However, continued record review did not reflect the line was ever removed on the day of discharge (10/03/23). In an interview with patient #1's nurse on 10/16/23 at 2:47 PM, she stated she removed the patient's IV line prior to patient leaving to go to the Emergency Department to be seen again but did not remember completing the documentation.

Continued review of Patient # 1's EHR noted a discharge form entitled Patient Signature Page, found in the discharge instructions. Documentation at the bottom of the page read:

"I have read and understand the instructions given to me by my caregivers."

Underneath this line was the printed name of the patient and underneath her name was a space for the patient's signature, date, and time. The line revealed a cursive handwritten statement which read: "Patient refused to sign but did not reflect the date or time documented on the form.

Beneath this statement was a line that documented "Caregiver/RN/Doctor Signature, Date and Time" This line was left blank and omitted any staff signature which is required and the Patient signature Page was completed by the discharging staff member.

Further review of Patient #1's record revealed a progress note by the second attending physician/hospitalist dated 10/4/23 at 12:29 PM documenting under the history of present illness, patient was recently hospitalized and discharged in stable condition and was being seen due to experiencing chest pain thought to be secondary to stress and that she returned to the hospital apparently with episodes of palpitations.

Interview with that second attending physician/hospitalist on 10/17/23 at 11:34 AM, noted he did not recall all of the events leading up to patient's 2nd evaluation and that he dictated what he knew at the time. Review of the history of present illness as dictated by the Dr. did not reflect documentation of patient being discharged from the 3rd floor of the hospital just minutes prior and never leaving the hospital property, thus not accurately noting she was not a return to hospital as she was brought down from the 3rd floor where she was inpatient and discharged even though she was complaining with new symptoms of tingling in left eye, left hand/fingers, tongue, and left foot.