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COLUMBIA MEMORIAL HOSPITAL 71 PROSPECT AVENUE HUDSON, NY 12534 March 29, 2018
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and clinical record review, the facility failed to ensure that 3 of 11 medical records, contained accurately written nursing notes describing patient discharge including date, time, condition of the patient, mode of transport and destination. The 3 records represented 2 patients and 3 different hospital stays.

FINDINGS:

Review of medical record #1, described the hospitalization of a [AGE] year old female exhibiting behavioral issues. It was noted that the nursing staff failed to document the circumstances of the patient's discharge on 2/12/18. The patient had been transferred from a rehabilitation facility where she was receiving physical therapy for strengthening. The patient had a past history of right below the knee amputation. It was documented that the patient was "legally blind". The patient was transferred to the hospital after she stated that she was suicidal. At the hospital, she was found to be in heart failure, for which she received diuretics. The patient admitted to hospital staff that she was not suicidal but that she had used this excuse to manipulate rehabiliation staff to transfer her to the hospital.

During her hospital stay, the patient demonstrated to staff that she was able to navigate in her hospital room. Her vision was sufficient to perform all acitivites of daily living. The patient was able to sit, stand, pivot and walk utilizing a prosthetic leg and a wheeled walker. The patient refused any contact guard or assistance while walking. The patient refused physical therapy services. On 2/12/18, the day of discharge, social work staff documented that the patient had a wheeled walker available and that the patient was being discharged to the local social services agency. A taxi was to be arranged. There is no time documented on the note. The final nursing note is timed 8:00 AM on 2/12/18 and it describes the patient as having expiratory wheezing and excruciating pain. There are no further entries regarding date and time of discharge, cardiopulmonary status, pain status, emotional status, ability to ambulate, durable medical equipment provided, mode of dress, mode of transport or destination on discharge.

During a 3/27/18 interview, conducted at 3:30 PM, RN #1 stated that on 2/12/18, she had an involved discussion with the index patient encouraging her to dress appropriately for discharge. The patient had several bags of clothing and the patient refused to don any clothing. The patient was discharged in a hospital gown, an adult brief and she had a blanket draped over her shoulders. RN #1 continued, stating that she had seen the patient walking in the hall with a wheeled walker. The patient was walking without difficulty. The patient was discharged on [DATE] and she entered a taxi for transport. RN #1 stated that she did not recall documenting her conversation with the patient, nor did she recall documenting how the patient was dressed on discharge. There was no documentation regarding the patient's ability to ambulate with her wheeled walker and her ability to enter the taxi.

Review of medical record #2, described the patient's return to the hospital on [DATE]. The staff at the social services agency had called for an ambulance and sent the patient back to the hospital a few hours after she was discharged from the hospital. Social services staff reported that the patient was agitated and suicidal on arrival to their office. Social services staff stated that the patient had a severe visual impairment. Social services stated that the patient had an unsteady gait, that she was weak and in need of physical therapy. Social services stated that they could not provide lodging for the patient in the community, as she was too ill.

The patient was readmitted to the hospital as a social admission. Again, she told hospital staff that she had used the excuse of suicidal ideation to manipulate others in her environment. The patient was discharged from the hospital a second time, on or about 11:30 AM on 2/21/18. The medical and social work practitioners make entries around 11:30 AM indicating that the patient will be discharged . The patient was to be discharged to a taxi bound for Sharon, Connecticut to stay with her brother. The 2/21/18, 6:40 AM nursing note documents that the patient was screaming at staff. She was attempting to bite, scratch and kick staff as they changed her bed linens. At 8:21 AM, the patient refused all of her medications. At 9:39 AM, the patient used the bed pan. There is no further nursing documentation describing the date, time, condition of the patient or circumstances of the discharge, such as the use of durable medical equipment, ease of movement, mode of transport or destination.

Patient #2 was a [AGE] year old male admitted to Emergency Department (ED) of the hospital from a skilled nursing facility (SNF) on 3/25/18. Patient #2 had threatened harm to a fell ow SNF resident.

During a medical record review, conducted on 3/29/18, it was noted that administrators at the SNF called the New York State Police to investigate the threat. The patient was then transferred via ambulance to the hospital ED. He was transferred to undergo a psychiatric evaluation. SNF administrators alerted ED staff that they did not want the patient discharged back to their facility. The physician's note of 3/25/18, which was written at 9:18 PM, documents that the patient is to remain in the ED overnight and to be re-evaluated in the morning at which point the patient may be admitted to the Mental Health Unit or alternative lodging will be sought. On 3/26/18, at 12:20 PM, an ED physician addendum note indicates that the patient will be transferred back to the SNF. The patient's official diagnosis was bipolar disorder. The addendum was signed by the physician on 3/27/18 at 10:19 AM. The medical record lacked a description of the circumstances of the patient's discharge.

During the 3/29/18 record review, the discharge planner noted that there was no nursing note describing the date or time of discharge nor was there a description of the patient's condition or mode of transport.

During a 3/29/18 interview, conducted at 1:30 PM, the psychiatric social worker stated that on 3/26/18, the patient was examined and deemed to be mentally competent. Following this, on 3/26/18, a lengthy and in-depth telephone conversation occurred between SNF administrative staff and hospital psychiatric staff. The patient was discharged from the hospital and transported to the SNF via medical ambulette. When the ambulette arrived at the SNF, SNF staff asked the ambulette driver to return the patient back to the hospital. The patient was then transported to the hospital lobby. Later that day, the patient took a taxi back to the SNF. The social worker stated that he realized that he should have written a progress note regarding the telephone conversation.