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THEDACARE REGIONAL MED CTR - NEENAH 130 2ND ST NEENAH, WI 54956 Sept. 18, 2018
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record review and interview, this hospital failed to provide discharge instructions to 2 of 3 patients discharged from the Emergency Department when directed to Sexual Assault Nurse Examiner (SANE) services at another facility (Patient #6 and #8) in a total sample of 20 Emergency Department medical records reviewed.

Findings include:

Record review of work flow titled "SANE patient care at sites other than [F] campus" last updated 10/06/16, #9 revealed "Notify pt (patient) of plan of care. Inform pt of where they can go for definitive SANE care...10. Discharge pt from facility. Pt will be discharged , not transferred to facility with available SANE. Complete charting as discharge."

Record review of policy "Documentation/Charting" #647 dated 7/26/2018 revealed Policy "The services that provide care to patients must document in the patient's health record, both Electronic Medical Record (EMR) and/or paper record... DISCHARGE "The interdisciplinary team must document completion of discharge instructions which must include the elements of self-care instruction, medication review, and plan for follow up.

Record review of policy "ThedaCare Adult and Adolescent SANE Policy" # 1079 dated 2/12/2018 revealed "The purpose of this policy is to provide guidance to care providers on sexual assault nurse examination (SANE) for adult and adolescent patients... Triage... 3. Patient should be assigned primary RN [Registered Nurse] until SANE arrives. Primary RN to encourage patient not to urinate, defecate, wash, change clothes, eat or drink fluids while waiting for SANE RN." Page 13 under Discharge and Follow-up Contact #6 revealed "Give phone number for sexual assault victim advocate and other support services... 8. Give written discharge instruction for all treatment and follow-up."

Patient #6's medical record was reviewed on 9/18/18 at 12:10 PM with Emergency Department (ED) Manager B, revealed ED Note by Registered Nurse H dated 9/06/2018 at 5:41 AM "Patient is planning to go to the location of a SANE for a medical-forensic exam." Under "Patient Education Record" revealed, "No education to display." No written discharge information noted in medical record.

Patient #9's medical record reviewed on 9/18/18 at 1:20 PM with Emergency Department (ED) Manager B, revealed ED Triage Notes by Registered Nurse I dated 4/12/18 at 10:10 AM "Patient is planning to go to the location of a SANE for a medical-forensic exam." Under "Patient Education Record" revealed "No education to display." No written discharge information noted in medical record.

On 9/18/18 at 2:20 PM during an interview with Emergency Department Manager B and Vice President (VP) Quality A, ED Manager B stated that no written discharge instructions were given to SANE patients and patients were verbally instructed where an available SANE was located and "given verbal instructions." When asked if they "encourage patients not to urinate, defecate, wash, change clothes, eat or drink fluids" before the patient contacted the SANE Registered Nurse, as recommended in the SANE policy #1079, VP Quality A stated, "I'm not sure".