HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to assess its discharge planning process on a regular basis; to include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs.

Findings include:

1. On 7/5/2022, the Hospital's policy titled, "Performance Improvement Plan" dated 2020 - 2021, was reviewed. The policy required, "...Clinical departments and ancillary services will identify indicators related to the important patient care and organizational functions that it performs...It is also the expectation that Departments/Divisions implement required measurements for compliance with external regulatory agencies and standards as part of their performance improvement activities..."

2. On 7/5/2022, the Discharge Planning meeting minutes and Quality meeting minutes were requested. The documents requested were not provided.

3. On 7/5/22022 at 10:54 AM, an interview was conducted with the Senior Vice President of Quality and Compliance (E #1). E #1 stated that there is not any formal documentation of discharge planning meetings or review of discharged patients. E #1 stated that the Hospital does not track readmissions.

Based on document review and interview, it was determined that for 1 of 11 (Pt #7) clinical records reviewed for discharge planning, the Hospital failed to ensure that the patient was transferred with the necessary medical information pertaining to the patient's current course of treatment, at the time of transfer.

Findings include:

1. The Hospital's policy titled, "Patient Transfer (to another Facility)", (revised 8/2016), was reviewed on 7/7/2022, and required, "...H. ...For Inpatients, a consent for Transfer and Release of Medical Records form should be signed by the patient or Health Care Surrogate .... I. a patient Transfer Data form for inpatients or Emergency Department Transforms (if appropriate) must be completed by the nurse caring for all patients transferred to another institution. These forms include the signature of the RN."

2. The clinical record for Pt #7 was reviewed on 7/6/2022 at approximately 10:50 AM and indicated:
- Pt #7 was admitted to the 2E respiratory unit on 6/3/2022 with the diagnosis of Sepsis (infection), Unspecified Organism.
- A Physician note and medical screening, dated 6/11/2022, that stated, "...Seen Patient at bedside. Patient continues to request transfer to [another acute care] Hospital where Primary Physician is located. Patient continues to refuse Hemodialysis and remains unstable for discharge at this time."
- An un-signed MD Resident note, dated 6/14/2022 that stated, "Patient transferred to [another acute care] Hospital."
- Pt# 7's clinical record lacked an appropriate Medical screening examination from the Attending Physician clearing for transfer; documentation of a Physician-to-Physician telephone consultation; a Transfer Order; Consent to Transfer and Release of Medical Records form; and a Patient Data Transfer Form signed by the RN.

3. On 7/6/2021 at 11:15 AM, an interview was conducted with the Nursing Informatics RN (E#11). E #11 agreed that there was no record of discharge or transfer in the patient's clinical record and stated, "I spoke with Medical records and that no records exist for transfer or discharge of the patient".