HospitalInspections.org

Based on a review of patient medical records, facility policies and staff interviews it was determined that the facility failed to provide discharge instructions for one patient (P) (P#1) of five patient records reviewed.


Findings include:


A review of the medical record for P#1 revealed that P#1 was admitted to the facility on 7/29/24 at 8:14 p.m., with a diagnosis of post operative left hip hemiarthroplasty. Continued review of the record revealed that a nursing assessment was completed on admission and every shift for the duration of the hospitalization. The assessment revealed there were no pressure wounds or tears on admission. Orders included pressure ulcer precautions and for the patient to be turned every two hours. P#1 Braden Score was 18 on admission. A review of the physical therapy progress notes revealed P#1 needed 50% assistance with turning. On 8/1/24 at 8:24 a.m. a nursing assessment revealed a wound to the right buttocks area. Wound protocol therapy was initiated. A review of the 'flowsheets' revealed that P#1 was not turned every two hours.


A physician history and physical note on 7/30/24 at 11:25 a.m. revealed that P#1's skin color, texture, turgor normal, no rashes or lesions. Further review of the history and physical revealed nursing care will provide close monitoring of vital signs, mental status, pain control, etc. while keeping open communication between the patient, family and care team.


A review of the discharge summary written by on 8/2/24 at 5:50 p.m., revealed that P#1 was discharged to home with physical therapy, occupational therapy and DME (Durable Medical Equipment) bedside commode and wheelchair.


Wound care treatment was not ordered for home for P#1.


A further review of the nursing progress notes failed to revealed discharge documentation to the patient and/or family members.


A review of the facility's policy titled "Patient Rights," revised 2/5/21, revealed the purpose was to acknowledge patients' rights and the hospital's responsibilities associated with those rights. The following areas where patient's rights were addressed include Access to Treatment, Care Decisions, and Complaints. The organization would assure that patient Investigational Studies, Safety, and Communication and Access to Information. rights are being observed as written in the provision of CMS and National Integrated Accreditation for Healthcare Organizations.


A review of the facility's patient rights brochure that is given to all patient's on admission revealed a patient has the right to participate in the development and implementation of their plan of care, including their inpatient and/or outpatient treatment/care plan, discharge care plan and pain management plan. A patient, or when appropriate, the patient's representative, has the right to make informed decisions regarding their care. The patient's rights include being informed of their health status, being involved in care planning and treatment and being able to request or refuse treatment. Their right must not be considered as a mechanism to demand the provision of treatment, or services deemed medically unnecessary or inappropriate. Making informed decisions include the development of their plan of care, medical and surgical interventions (e.g. deciding whether to sign a surgical consent), pain management, patient care issues and discharge planning.


A review of the facility's policy titled "Discharge Planning Evaluation Procedure (Rehab Hospital)," revision date 08/21/2024, revealed the purpose was to establish a process to complete a discharge planning evaluation in the event it is requested by patients, patient's representative or a member of the rehabilitation team. Discharge planning evaluation would be done on a timely basis, within two business days of request, to ensure that appropriate arrangements for post-acute care services are made and to prevent unnecessary delays in discharge. Final results and update plan of care would be shared with patient for approval. All information would be documented in the patient record.


A review of the facility's policy titled "Plan of Care/Interdisciplinary Treatment Plan Procedure (Rehab Hospital)," last revised 01/21/2022, revealed the purpose was to implement and maintain an on-going interdisciplinary approach to the assessing of patient's needs and developing a plan of care that meets the individual needs of each patient within the resources available. The development of an interdisciplinary plan would include initiation of interdisciplinary plan of care by the admitting nurse and at discharge, patient needs which have not been met, and which would require continuing care, would be addressed. These would be documented in the discharge summary. Nurse assigned to the patient would complete discharge portion of care plan.


A review of the facility's policy titled "Discharge Protocol," revised 1/24/2022, revealed for routine discharges the following would be completed: Complete "Patient Discharge" in electronic medical record, Review Patient Discharge document with patient, For all Patient Education needs, use Mosby to print out education instructions and write in Nursing Notes all pertinent information regarding the discharge including who patient discharge with and how patient transferred into vehicle.


During an interview with Nurse Manager (NM) AA on 10/1/2024 at 9:30 a.m. in the education room she revealed she is the nurse manager over Units One and Two. NM AA does not remember P#1 and that it is her understanding that patients should be turned every two hours around the clock. NM AA said the unit has adequate staff to turn the patients every two hours. NM AA makes rounds during the week and talks to patients to try to solve any complaints before they get out of hand. NM AA states discharge instructions should include wound care.


An interview was conducted with Case Manager (CM) CC on 10/1/24 at 10:15 a.m. in the education room. CC remembers P#1 and her family member. CM CC revealed P#1 wanted to go home. CM CC further revealed there was not any wound care ordered on the discharge orders. She remembers the family member of P#1 was hard to reach on the phone and does not recall talking to family member regarding wound or wound care.