HospitalInspections.org

Based on a review of facility policy, medical records, interview with patients (PT) and interview with staff (EMP), it was determined the facility failed to provide adequate discharge planning to a patient who was likely to suffer adverse health consequences upon discharge for one of four medical records reviewed (MR1)

Findings include:

A review on June 11, 2012, of facility policy 302.22 Discharge Planning revealed "Nursing; To assess discharge needs of the patient/family beginning at admission. To contact necessary resources when preparing the patient for discharge ... To make appropriate social services consultations when it is determined that the patient will need resources at discharge".
A review on June 11, 2012, of MR1 revealed psychiatrist orders written on June 8, 2012, for a "Transfer to detox, start Seroquel, inpatient rehab after detox and follow up by Behavioral Health and Methadone clinic on an outpatient basis". There was no documentation in the record that these orders were followed.

An interview conducted on June 11, 2012, with PT1 revealed the patient was scheduled for discharge later that same day. PT1 expressed a fear of going home to an abusive situation. PT1 stated, "I don't know what I will do, the man I live with is abusive and I have nowhere else to go. I told them in the ER he is abusive, and the staff saw how he was screaming at me. I am afraid to leave the hospital".

An interview conducted on June 11, 2012, with EMP9 confirmed that the orders from the staff psychiatrist had not been followed, that social services was not notified of the discharge and that the patient did not receive discharge planning.

An interview conducted on June 11, 2012, with EMP10 confirmed that the patient did not receive detox intervention, psychiatric medications or discharge planning during the five day stay at the facility.

Based on a review of facility policy, medical record, interview with patients (PT) and interview with staff (EMP), it was determined the facility failed to ensure that a registered nurse or social worker developed a discharge evaluation for one of four medical records reviewed (MR1)

Findings include:

A review of facility policy Discharge Planning/Multidisciplinary Rounds, last revised 9/01 revealed: " ... Within twenty-four (24) to forty-eight (48) hours a preliminary written report should be filed on the medical record, followed by a complete social service evaluation with regular entries indicating the activities and progress in working with the patient ... Plans for the eventual discharge shall be clearly specified in the notes. These plans include very clearly the participation of the patient and/or his family in these plans and their consent to receive the services offered to them ...

A review on June 11, 2012, of MR1 revealed no documentation by social service that an evaluation was conducted.

An interview conducted on June 11, 2012, at approximately 1:00 PM with PT1 revealed that the patient communicated with the physician and several nurses about not receiving psychiatric medications since admission to the hospital. PT1 also indicated not being aware of any discharge plan.

An interview conducted on June 11, 2012, at 10:30 AM with EMP9 confirmed there was no documentation in the medical record that the patient was provided with a discharge plan and that the patient was not provided with a discharge plan.

Based on a review of facility policy, medical record, interview with patients (PT) and interview with staff (EMP), it was determined the facility failed to ensure that a registered nurse or social worker developed a discharge evaluation for one of four medical records reviewed (MR1)

Findings include:

A review of facility policy Discharge Planning/Multidisciplinary Rounds, last revised 9/01 revealed: " ... Within twenty-four (24) to forty-eight (48) hours a preliminary written report should be filed on the medical record, followed by a complete social service evaluation with regular entries indicating the activities and progress in working with the patient ... Plans for the eventual discharge shall be clearly specified in the notes. These plans include very clearly the participation of the patient and/or his family in these plans and their consent to receive the services offered to them ...

A review on June 11, 2012, of MR1 revealed no documentation by social service that an evaluation was conducted.

An interview conducted on June 11, 2012, at approximately 1:00 PM with PT1 revealed that the patient communicated with the physician and several nurses about not receiving psychiatric medications since admission to the hospital. PT1 also indicated not being aware of any discharge plan.

An interview conducted on June 11, 2012, at 10:30 AM with EMP9 confirmed there was no documentation in the medical record that the patient was provided with a discharge plan.

Based on a review of facility policy, medical records, interview with patients (PT) and interview with staff (EMP), it was determined the facility failed to provide an appropriate discharge plan and discuss the evaluation with the patient or an individual acting on behalf of the patient for one of four medical records reviewed. (MR1)

Findings include:

A review of facility policy Discharge Planning/Multidisciplinary Rounds, last revised 9/01 and a review of facility policy Discharge Planning/Multidisciplinary Rounds, last revised 9/01 revealed no procedures in place to include patients rights regarding their post discharge needs.

An interview conducted on June 11, 2012, with PT1 revealed she was not aware of the right to request a plan of discharge needs.

An interview conducted on June 11, 2012, at approximately 1:30 PM with EMP9 confirmed that the patient was not informed of her right to request a plan of discharge needs.

Based on a review of facility policy, medical record, interview with patients (PT) and interview with staff (EMP), it was determined the facility failed to ensure that a registered nurse or social worker developed a discharge evaluation for one of four medical records reviewed (MR1)

Findings include:

A review on June 11, 2012, of a consultation with EMP11 performed on June 8, 2012, revealed new orders for a transfer to detox or to initiate protocol for Benzodiazapine withdrawal, restart Seroquel, inpatient rehab after detox and follow up outpatient basis for behavioral health and Methadone clinic.

A review on June 11, 2012. of MR1 revealed no documentation that these orders were initiated.

An interview conducted on June 11, 2012, with PT1 revealed the patient had requested multiple times throughout the inpatient admission to receive psychiatric meds.

An interview conducted on June 11, 2012, at approximately 11:00 AM with EMP9 confirmed that the orderes had not been followed and that social services was not notified of discharge needs