HospitalInspections.org

Based on interview and record review the facility failed to uphold the rights of 1 of 4 patients to participate in the implementation of her plan of care to include disharge planning (Patient ID # 1).

Findingns include:

Patient ID#1/family had not participated in the discharge plan to hospice as evidenced by the facility not responding to the physicians order to set up hospice at discharge.

Observation of the Unit on 3/21/18 at 09:30 AM where Patient ID#1 was admitted was orderly, clean, and hall ways uncluttered. Charge Nurse ID#58 reported the Unit had 30 beds, and staffing ratio consisted of 1-5 ratio based on acuity.

In an interview on 3/21/18 with Director of Quality ID #54 stated, "it is not acceptable that Hospice Care had not been shared with family or set up by case management". Is that the order for hospice to case management from doctor ID #59, "yes it is".

Record review of Patient ID#1 Medical Record read: Order : discharge to Hospice Dr. ID #59 on 12/08/2017.

Record review of facility policy titled, " Patient Discharge Policy", dated 01/2015, Revision, 01/2018 read:

PURPOSE: Pearland Medicacl Center will discharge patients with courtesy, consideration and safety while providing patient/family memmber with thorough and accurate instructions on disease process signs and symptoms, home care needs, equipment, home medications and follow up care.

RESPONSIBILITY; Staff nurse or Discharge Nurse will complete the discharge instructions, review discharge orders and instructions with patient/family member, confirm patienty/family member understanding of instructions and assist as needed

Based on interview and record review the facility failed in 1 of 4 patients discharge plan tohave an effective, ongoing discharge plan that facilitated the follow up hospice care ordered by a physician as evidenced by not transferrring or having hospice referral set up at discharge. (Patient ID #1)

Findings include:

Physician ID #59 wrote order on 12/08/2017 for Patient ID #1 to have Hospice Care per family wishes and Case Management did not follow up nor communicate that information to the receiving facility at time of Patient ID#1 discharge.

Interview on 3/21/2018 with Director of Cae Management ID #56 revealed that it is the responsibility of Caes Management to arrange for hospice care if a doctor orders the service. She further reported that , Yes, there was an order for Patient ID #1 too have hospice care at time of discharge and that no hospice arrangements had been made at discharge. She went onto say it is not acceptable practice to not complete physicians orders.

Record Review on 3/21/2018 of facility policy on patient discharge, titled " Patient Discharge", dated 01/2025, review on 01/2018 reads:
POLICY:
1. A Physician's order for discharge will be obtained..
2. Discharge instructions will be completed in detaill in Meditech. One copy of the instructions will be provided and reviewed wiht the patient/family member abd a second copy will be placed in the chart...

PROCEDURE:
1. Purose: To provide general guidelines for assisting a patient upon discharge and to properlu complete the patient's medical record.
2. Equipment/Requisites: Patient's chart, physician's dischare orders and medicatin reconciliation orders...