HospitalInspections.org

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital to another facility for a surgical procedure (Patient 2), review of policies and procedures and other documentation, it was determined the hospital failed to implement its discharge planning policies and procedures in the following areas:
* The patient's discharge plan was not clear and complete, and was not evaluated on an ongoing basis, including appropriateness and availability of post-discharge services and settings identified by the hospital.
* The patient's discharge planning evaluation did not include an evaluation of the patient's capacity for self-care with respect to the patient's numerous health conditions.

Findings include:

1. The policy and procedure titled "Discharge Planning" dated last revised "January 2016" reflected the following: "Case Managers will collaborate with patients, families, physicians, healthcare team members, and community resources to ensure that patients have a plan for continuing care after discharged...Case Managers will provide individual discharge planning to all patients...development of a discharge plan, implementation of the plan, evaluation of the appropriateness of the plan with on-going monitoring, and the coordination of final preparations for discharge...Case Managers are responsible for monitoring and facilitating the discharge planning process by coordinating the activities of an Interdisciplinary Team Care Conference. During this weekly conference, staff members discuss the patient's discharge needs and disposition options with...the patient...to determine the appropriate community resources required by the patient at discharge...Actual and potential discharge planning needs of the patient/family will be assessed on the basis of the following criteria...The patient's stated expectations and goals which are given priority when possible...Tasks the patient can/cannot accomplish as a result of his/her current health problems...Physical and/or cognitive limitations...Availability of community or other healthcare resources to assist with care (i.e., SNF, ICF, ALF...Need for special equipment, supplies..."

The policy further reflected that "...the Case [Manager] will develop a discharge plan in collaboration with the patient...focused on...External parties such as...facilities, and community resources...The Case Manager will implement the discharge plan after interdisciplinary team assessment and authorization from all interested participants and document the discharge plan...in the progress notes...The Case Manager will complete weekly routine reassessment and ongoing monitoring and evaluation of the appropriateness of the discharge plan...If the current discharge plan is no longer appropriate, the Case Manager will modify the plan as needed and document modification in the progress notes...At least two (2) days prior to discharge, the Case Manager will confirm the discharge plans with the patient...to complete final preparation by monitoring the following...Focusing on patient readiness for discharge...Current medical condition...Patient concurrence to the plan...The Case Manager will document final preparation information..."

The policy also reflected that nursing staff were required to "...Provide patient and family/caregiver with the discharge instructions sheet on prescribed treatment, medications, (including food/drug interactions), the nutrition plan, activity level, and scheduled follow-up appointments...Have the patient or responsible family/caregiver sign the discharge instruction sheet attesting to the receipt of the information...Sign and dated the form, and give the original to the patient or responsible family/caregiver...Document discharge summary in the medical record...Discharge instructions given..."

2. The record of Patient 2 was reviewed. The patient was admitted to the hospital on 08/11/2015 at 1752 with a complex medical history and numerous diagnoses including but not limited to poorly controlled diabetes mellitus, hepatitis C, necrotizing pneumonia, esophageal necrosis with a recent pouched esophagostomy procedure, and malnutrition with tube feeding dependence.

The record reflected the patient needed a surgical procedure at another facility to address a pre-existing esophagus condition.

The "Patient Care Notes" and "Interdisciplinary Team Meeting/Care Conference" documentation was reviewed between 03/02/2016 and 06/13/2016 and included the following examples:

The "Interdisciplinary Team Meeting/Care Conference" form dated 03/30/3016 reflected the patient was oriented X3, and had "Enteral feeding...J-tube...Sliding Scale Insulin...Wound Care...Surgical Site/s [one]..." The "Discharge Plan/Barrier" section reflected "Ready for discharge...Discharge to safe environment...Financial issues...Patient/Family/Caregiver discharge needs/expectations Seen by UW esophageal surgeon...anticipate surgery in June - Attempt to identify AFH...Other Surgery [at] UW [versus] community [discharge]." The space after "Discharge Plan" was blank. There was no further information or follow up related to the AFH or "community discharge."

The "Interdisciplinary Team Meeting/Care Conference" form dated 04/06/2016 reflected the patient was oriented X3, and had "[Diabetes Mellitus] uncontrolled BS...Wound care which requires extensive time for treatment...Enteral feeding...J-tube...Sliding Scale Insulin...Surgical Site/s [one]..." The "Discharge Plan/Barrier" section reflected: "...Other Surgery [at] UW [versus] community [discharge]." The space after "Discharge Plan" was blank. There was no further information or follow up related to the "community discharge."

The "Interdisciplinary Team Meeting/Care Conference" form dated 05/11/2106 reflected the patient was oriented X3 and had "Enteral feeding...G-tube...Inadequate PO nutrition...Sliding Scale Insulin...Wound Care...Surgical Site/s [one]...changed GJ tube to G tube on 5/6..." The "Discharge Plan/Barrier" section reflected "...Other Surgery [at] UW [versus] community [discharge]." The "Discharge Plan" space was blank. There was no further information or follow up related to the "community discharge."

The "Patient Care Notes" recorded by the RN on 05/21/2016 at 0663 reflected "...CBG 86 [at] this time, due to turning tube feeding off most of the shift, restarted at this time. unable to get an accurate intake [related to] tube feeding due to pt turning on and off."

The "Patient Care Notes" recorded by "Case Management" on 05/24/2016 at 1143 reflected "...Patient letter emailed from UW-contains information about the plan. One copy provided to patient and one to the medical record." However, the record contained no copy of the emailed letter or any other information reflecting what "the plan" referred to.

The "Interdisciplinary Team Meeting/Care Conference" form dated 05/25/2016 reflected the patient was oriented X3, at risk for falls and had "Enteral feeding...G-tube...Sliding Scale Insulin...Wound Care...Surgical Site/s [one]...changed GJ tube to G tube on 5/6..." The "Discharge Plan/Barrier" section reflected "Other Surgery [at] UW [versus] community [discharge]." The "Discharge Plan" space was blank. There was no further information or follow up related to the "community discharge" or the patient's risk for falls.

The "Patient Care Notes" recorded by the RN on 06/06/2016 at 1613 reflected "...Again pt unhooked [himself/herself] from TF...:

The "Patient Care Notes" recorded by "Case Management" on 06/06/2016 at 1658 reflected "Spoke with [an individual] at University of Washington...who said that the patient will need to be at UW on 6/13 for another mesenteric angiogram...Plan to discharge patient to UW on 6/13 with plan for surgery on 6/14..."

The "Patient Care Notes" recorded by the RN on 06/07/2016 at 1501 reflected "...CBG 69 at noon...pt frequently disconnect [himself/herself] from TF..."

The "Interdisciplinary Team Meeting/Care Conference" form was dated 06/08/2016, and reflected the patient was oriented X3 and had "Enteral feeding...G-tube...Sliding Scale Insulin...Wound Care...Surgical Site/s [one]..." The "Discharge Plan/Barrier" section reflected "...Ready for discharge...Discharge to safe environment...Financial issues...Patient/Family/Caregiver discharge needs/expectations...Surgery scheduled for June 14...Projected Discharge Date 6/13/16...Other Surgery [at] UW after second mesonteric angiogram" The space after "Discharge Plan" was blank.

The last "Case Management" note recorded on 06/08/2016 at 1600 reflected "Attended interdisciplinary care conference. Discussed patient's progress, plan of care and discharge plan. Plan for patient to discharge to University of Washington on June 13th for re-do mesenteric angiogram on 6/13 and surgery on 6/14."

The last RN "Patient Care Notes" recorded on 06/13/2016 at 0514 reflected "Pt discharged with private pay transport. VSS. CBG WNL. Pt appeared stable. Pt left at 0513."

The physician discharge summary dated 07/02/2016 at 2016 reflected the following: "...The patient had a prolonged hospitalization at Vibra Hospital...the patient is status post partial gastrectomy...the patient does take [by mouth] liquids and mechanical soft diet for comfort which come out through [his/her] spit fistula. The patient continues to be on PEG tube feedings...Type 1 diabetes with fluctuating glucose levels...Wound team has continued to follow the patient for [his/her] PEG tube leakage and dysfunction...The patient has chronic hepatitis infection. [He/she] will need to follow up with Hepatology...The patient is being discharged to the University of Washington Hospital for surgical repair of [his/her] spit fistula with reanastomosis of small bowel with fistula takedown."

The record contained no further evaluation, information or follow up related to the identified plan for "community discharge" and AFH; no evaluation and determination of the patient's ability to provide self care with respect to the patient's numerous health conditions and functional limitations including wound care, tube feeding with tube leakage, insulin dependent diabetes with fluctuating glucose levels, and identified fall risk; no documentation reflecting the discharge plan was discussed or confirmed with the patient, including patient readiness for discharge and concurrence with the plan; no documentation that the discharge plan was appropriately discussed and coordinated with the receiving facility including that the patient may or may not be able to return to the hospital; no documentation reflecting the patient was provided discharge instructions; and no nurse discharge summary.

3. An interview was conducted with the RN Case Manager on 08/26/2016 at 1210. The RN Case Manager reviewed Patient 2's medical record during the interview. The RN Case Manager stated the discharge plan for the patient was for the patient to go to UWMC to have a surgical procedure. The RN Case Manager stated he/she did not know of any other discharge plans for the patient except that the patient could return to the hospital after the procedure if the patient met the hospital's "medical criteria." The RN Case Manager stated he/she spoke to the patient a couple days before the patient was discharged, and the patient believed he/she was going to UWMC for a surgical procedure and would return to the hospital after the procedure. The RN Case Manager stated he/she then contacted a Case Manager at UWMC who indicated he/she also believed that the patient's discharge plan was that the patient would return to the hospital after the procedure. The RN Case Manager stated he/she couldn't remember telling the Case Manager at UWMC, or anyone else at UWMC that the patient could not return to the hospital unless he/she met the hospital's "medical criteria." The RN Case Manager confirmed there was no documentation in the medical record reflecting that the patient was informed of the discharge plan, including that the patient may or may not be able to return to the hospital. He/she also confirmed the medical record contained no evaluation of the patient's ability to provide self care with respect to the patient's medical conditions, no evidence that discharge instructions were provided to the patient, and no nurse discharge summary.

4. An interview was conducted with the CEO on 08/25/2016 at 1500. The CEO stated that Patient 2 had been at the hospital for approximately a year. The CEO stated the patient needed a surgical procedure and was discharged to a facility "in Washington" in order to have the procedure. The CEO stated that the discharge plan for the patient was that if the patient had a medical necessity after the procedure then he/she could return to the hospital, and if the patient did not have a medical necessity after the procedure the patient could not return to the hospital. The CEO stated that after the patient's surgical procedure, the facility contacted the hospital to make arrangements for the patient to return to the hospital. The CEO confirmed the hospital declined the patient for readmission. The CEO stated he/she did not know if the patient was informed of the discharge plan. He/she stated "It would be reflected in the medical record."

5. Mapquest driving directions reflects that VSH is 177 miles and approximately 2 hours and 54 minutes drive time from UWMC.

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital to have a surgical procedure (Patient 2), review of policies and procedures and other documentation, it was determined the hospital failed to implement its discharge planning policies and procedures.
* The patient or an individual acting on the patient's behalf was not fully informed of the patient's discharge plan.

Findings include:

Refer to the findings cited at Tag A806, 482.43(b)(1), (3), (4) Discharge Planning Needs Assessment. That deficiency reflects that Patient 2 was discharged to another facility in another state for a surgical procedure, and the patient or an individual acting on the patient's behalf, was not informed of the discharge plan, including that the patient may or may not be permitted to return to the hospital after the procedure.

Based on interview, review of documentation in 1 of 1 medical record of a patient who was discharged from the hospital to have a surgical procedure (Patient 2), review of policies and procedures and other documentation, it was determined the hospital failed to implement its discharge planning policies and procedures.
* The patient's discharge plan was not reassessed on an on-going basis to ensure it was appropriately coordinated with the receiving facility.

Findings include:

Refer to the deficiency cited at Tag A806, CFR 482.43(b)(1), (3), (4) Discharge Planning Needs Assessment. That deficiency reflects that Patient 2 was discharged to another facility for a surgical procedure. The hospital did not reassess the patient's discharge plan and coordinate with the receiving facility after it identified that the receiving facility planned to readmit the patient after the procedure.