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Based on interview and record review, the hospital failed to ensure 1 of 2 patient's [Patient #1's] discharge plan and/or instructions was reassessed, which included PICC Line [Peripherally Inserted Central Catheter] instructions and PEG [Percutaneous Endoscopic Gastrostomy] tube instructions upon discharge to home on 03/04/11.

Findings Included:

The physician consultation dated 02/09/11 reflected, "[Patient #1] with history of a stroke...status epilepticus with a prolonged hospitalization at acute and long-term care facilities...never recovered from that event...unable to communicate...he did develop decubitus at the acute care hospital...has been diagnosed with systemic inflammatory response syndrome, pneumonia, urinary tract infection...medical diagnosis include...diabetes mellitus, dyslipidemia, hypertension, seizure disorder, stroke, urinary tract infection, pneumonia and decubitus wounds, severe encephalopathy, PEG tube, dysphagia, discoloration of the left heel and tracheostomy..."

The physician's orders dated 03/04/11 reflected, "Discharge home. HC [Home Healthcare] for nursing, PT [Physical Therapy] and Tracheostomy care, water 150 ml [milliliters] via peg tube after each bolus feeding, follow-up with PCP [Primary Care Physician] in 3 to 5 days..."

The nursing note dated 03/04/11 timed at 08:00 AM, reflected, "Central venous line: IV [Intravenous] from....hospital, right PICC line, triple lumen...site clear, dressing dry and intact..." No documentation was found indicating the PICC line was removed prior to discharge.

The nursing additional note dated 03/04/11 timed at 16:30 PM reflected, "Patient discharged to home with all personal belongings, nurse gave discharge papers to ems [Emergency Medical System] worker to give to patient's wife at home..."

The Discharge Instructions dated 03/04/11 reflected, "Trach supplies and ambu bag, follow-up with physician in 3 to 5 days...home health care, RN tracheostomy care and monitor for transition home, tracheostomy supplies, tube feeding supplies, breathing treatment with albuterol every four hours with mask, tracheostomy care daily and uncap tracheostomy to suction as needed." No documentation was found regarding PICC line instructions. The PEG tube orders written by the physician were not documented on the discharge instructions and/or in the nursing notes.

On 08/02/11 at 11: 25 AM. [Staff #1] was interviewed. [Staff #1] stated Patient #1 was sent home with home health care on 03/04/11. [Staff #1] said contact was made with the home care agency and verified Patient #1 was sent home with the PICC Line. [Staff #1] stated the PICC Line should have been removed before discharging the patient. [Staff #1] stated the home health agency called and obtained orders to discontinue the PICC Line.

On 08/02/11 at 12:25 PM, [Staff #5] was interviewed. [Staff #5] was asked to review Patient #1's discharge instructions. [Staff #5] stated she initiates the discharge instructions before the patient was to be discharged. [Staff #5] said nursing was to fill out the nursing section. [Staff #5] reviewed the medical record and validated the PICC Line was not removed prior to discharge and did not address the PICC Line or PEG tube instructions listed on the physician's orders.

On 08/03/11 at 1:00 PM, [Staff #3] was interviewed. [Staff #3] was asked to review Patient #1's medical record. [Staff #3] stated she did not remove the PICC Line before Patient #1 was discharged. She stated she call the physician and he did not called back with orders. [Staff #3] stated she did not put PEG tube instructions on the discharge summary nor did she address the PICC Line.

The hospital policy entitled, "Discharge Planning" with a revision date of 11/10 reflected, "Case Managers will provide individual discharge planning to each patient...evaluation of the appropriateness of the plan with on-going monitoring, and the coordination of final preparations for discharge...at the time of discharge discuss and document in the patient medical record the post-discharge plan of care, provide patient and family with discharge instruction sheet on treatment, medications, nutrition plan, activity level, follow-up appointments...ask patient/family to verbalize their understanding of discharge instructions and give a demonstration of any care procedures...if modifications for discharge are identified, document findings and changes in the progress notes..."