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.


Based on review of records and interview, the hospital did not have an effective discharge planning program to facilitate the provision of follow-up care in that the hospital did not furnish a nursing medical report for 1 of 3 patients (Patient #1) discharged to a nursing home in February 2011 with instructions for follow-up care. The hospital nurse called the receiving nursing home to give a medical report after the patient was enroute to the nursing home. This practice presented the risk of potential harm to a patient discharged from the hospital to another health care facility as they may not be prepared to properly care for the patient.

Findings included:

Patient #1, [AGE], was admitted on [DATE]. The "Discharge Summary" (electronically signed 03/03/11) noted that Patient #1 was admitted with "weakness, failure to thrive...underlying dementia...was evaluated and was found to have colon cancer on colonoscopy...underwent a partial colon resection...discharged to a nursing home in stable condition." He was given instructions for discharge medications and discharged on [DATE].

Patient #1's "Discharge/Home Care Instructions" signed by the nurse at 11:00 AM on 02/04/11 noted that Patient #1 was treated for "colon cancer" and was on a mechanical soft diet with activity restrictions. He was to return to a physician for follow-up.

Patient #1's "Ambulance Transport Certification" dated 02/04/11 noted that Patient #1's "... condition requires special handling or treatment...unable to maintain erect sitting position in a chair or wheelchair for the time of transport..."

Patient #1's "Ambulance Trip Details" (Run Number 760, trip number 0013-A, service date 02/04/11 - faxed to hospital on [DATE] for the complaint investigation) noted that the ambulance service was transporting Patient #1 at approximately 12:36 PM and at the nursing home at approximately 12:42 PM.

Patient #1's "Multidisciplinary Re-Assessment Final Chart Copy" noted that on 02/04/11 at 12:30 PM Patient #1's RN (Registered Nurse) documented, "...Report called to...(name of nursing home) transferred by ambulance with all his belongings."

Note: Per the Ambulance Trip Details the patient arrived to the nursing home approximately 10 minutes after the hospital nurse gave report.

During an interview with the Social Worker (Personnel #2) on 03/24/11 at 11:00 AM she stated she assisted with Patient #1's discharge planning. Personnel #2 stated she called the nursing home's nurse's station and was told that they were ready for Patient #2 to come back to the nursing home. Personnel #2 was asked if she called the nursing home before the patient left the hospital and she said that she did and that the patient's hospital nurse was to call the medical report to the nursing home before the patient left the building.

During an interview with Patient #2's RN Charge Nurse (Personnel #3) on 03/24/11 at 11:15 AM she was asked to review the discharge paperwork with the surveyor. Personnel #3 stated she was told Patient #1 was accepted to the nursing home. She stated she wrote up the discharge paperwork on 02/04/11 and made a copy of the medical records to go with the patient. She said that she usually went to the patient's nurse and let the nurse know the time the ambulance will come. Personnel #3 stated she did not remember the time the ambulance came for Patient #1 and that she did not call the medical report to the nursing home. She said usually the nursing home facility was called before discharge by the patient's nurse and the paperwork including discharge instructions and copy of the chart went with the patient to the nursing home. She said she "assumed" when the ambulance came to pick up Patient #1 the nurse's report was already called to the nursing home. Personnel #3 stated paperwork was sent to the nursing home with Patient #1 by ambulance.

During an interview on 03/24/11 at approximately 11:30 AM, the RN (Personnel #5) who cared for Patient #1 was asked if she remembered a discharge and transfer to a nursing home for Patient #1 on 02/04/11. Personnel #5 said that she remembered Patient #1 because she "apologized" that she was a little late with the call regarding Patient #1's medical condition when she called the report to the nursing home. Personnel #5 said that she was told by the nursing home that she was calling the report after the patient arrived at the nursing home. Personnel #5 said that she was the only nurse who would have called Patient #1's report of medical information to the nursing home.

The Administrative "Discharge Planning" (policy #15A-100 revised June 2008) noted: "... It is the responsibility of the nurse manager or his/her designee to coordinate the daily discharge planning for each patient on the unit..."

The Social Work Department's "Referrals for Post-Acute Care Services" (policy PC.04.01 revised 01/07/09) noted that if the patient had special care needs, the Social Worker was to "...ask the nurse on the floor to describe the needs to the facility by phone..."