The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LEE MEMORIAL HOSPITAL 2776 CLEVELAND AVE FORT MYERS, FL 33901 Sept. 26, 2012
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and interviews, the facility failed to arrange for all the post-hospital services and the education of patient/family about post-hospital care for 1 (Patient #1) of 10 sampled patients.

The findings include:

1. During the review of sampled Patient #1's medical record, on 9/26/12 at 10:00 a.m., the following information was found: The patient was admitted to the facility through the Emergency Department (ED) on 6/9/12 with a diagnosis of [DIAGNOSES REDACTED].

On 6/15/12 at 0730, the physician ordered "Arrange visiting nurse and suction supplies for possible weekend discharge."

The medical record contained no documentation that the patient had been suctioned during his hospitalization and no documentation that he, or his family, had received any instruction on how to perform the procedure.

The patient was discharged home on 6/16/12 at 16:19 (4:19 p.m.). The patient returned to the ED on 6/16/12 at 23:34 (11:34 p.m.) with respiratory failure and cardiac arrest. Suctioning found a firm fibrous plug of mucous and blood. The patient was admitted on [DATE] in severe hypoxic [DIAGNOSES REDACTED]. Life support was discontinued at the family's request and the patient expired.

Review of the facility's policy and procedure Discharge to Post- Acute Services on 9/26/12 found that the Care Management RN (Registered Nurse) is responsible to send referrals to appropriate providers and facilitate transfer and arrange for Durable Medical Equipment (DME) services and equipment, i.e. suction equipment.
Review of the facility policy and procedure Assessment-Discharge Planning on this date found that the role of nursing is to coordinate this function with direction and guidance from the physician and the medical social worker/ case manager. The nurse and physician are also responsible to provide the patient/family with discharge planning instructions and teaching.

During an interview with the hospital Risk Manager on 9/26/12 at 1:30 p.m., she confirmed that Care Management RN missed the suctioning supply order of the physician.
The unit nurse failed to coordinate the patient's discharge with the Care Management RN by checking if the suction supplies were in the home.