HospitalInspections.org

Based on interview and document review the hospital failed to coordinate the written discharge plan for 1 of 5 patient records reviewed (Patient #1) with the agency providing follow-up for the patient in the community.

Failure to coordinate the written discharge plan with the agency following patients in the community puts patients at risk for harm when the discharge plan is not known.

Findings included:

1. Record review of the hospital's policy titled "Discharge Planning and Transitions of Care", effective 08/05/16, showed that patient's post discharge needs were to be communicated with receiving agencies and/or care facilities that may be working with a patient post discharge from the hospital.

2. Review of Patient #1's medical record showed that:

a. The patient had some paralysis of their lower limbs and some wounds to their lower limbs.The wounds were to be kept clean and dry. The wounds were considered stable.

b. The patient had a follow-up appointment to see the vascular surgeon and it would be discussed at that time.

c. The patient was to return to the hospital for signs of infection to the leg wounds or if the patient developed a fever.

d. The Community Agency was called about the patient's discharge back to the community setting.

3. On 06/05/19 at 10:00 AM, the investigator interviewed the licensed nurse (Staff #2). Staff #2 stated that Patient #1 was their own person and could make their own decisions. The patient was given their discharge instructions but the discharge instructions were not sent over to the community agency that would be working with the patient post discharge from the hospital.

4. On 06/06/19 at 9:16 AM, the investigator interviewed the patient. Patient #1 stated that they knew they were to follow-up with the vascular surgeon but they had lost their written discharge instructions. The patient had the name of the vascular surgeon and would be calling them to inquire when their follow-up appointment was scheduled.

5. On 06/07/19 at 8:40 AM, the investigator interviewed the community agency's nurse (Contact #1) that was following the patient in the home. The nurse stated that not having a copy of the patient's written discharge instructions caused some confusion and concerns that the patient was not receiving follow-up care for their leg wounds.

6. On 06/07/19 at 11:00 AM, the investigator interviewed the social worker (Staff #1). Staff #1 verified that the hospital did not routinely send a copy of the patient's discharge instructions to the community agency that would be working with patients upon discharge from the hospital. The discharge instructions would be sent if the community agency requested information at the time of discharge.