HospitalInspections.org

Based on review of records and interviews, the hospital failed to send necessary medical information to a skilled nursing facility for 1 of 1 patient (Patient #1) discharged to the skilled nursing facility on 03/18/11. Patient #1 required extended medical care that included intravenous treatment with fluids and monitoring of creatinine levels. This practice could present a risk of potential harm to all discharged patients who may need additional care.

Findings included:

The "History and Physical" of Patient #1, age 77, included that he was admitted to the hospital on 02/21/11 for "intravenous antibiotics...complex medical care...pain control...and physical therapy and rehabilitation." Patient #1's medical history included "hypertension...chronic renal disease...congestive heart failure...diabetes...obesity..." Treatment included intravenous therapy with fluids, antibiotics, and creatinine levels.

The 02/22/11 04:35 AM laboratory results indicated Patient #1's creatinine level was 1.15 (reference range 0.30 - 1.20), BUN3 9 (reference range 6 - 25), and BUN3/Creatinine Ratio L (low) 8 (reference range 9 - 30).

The 3/17/11 04:20 AM laboratory results indicated Patient #1's creatinine level was H (high) at 4.22, BUN3 H at 31, and BUN3/Creatinine Ratio L at 7.

The 03/18/11 05:15 AM laboratory results indicated Patient #1's creatinine level was H at 4.10, BUN3 H at 33, and BUN3/Creatinine Ratio L at 8.

The Case Manager's (Personnel #6) 03/18/11 "Progress Notes" included that she talked with "...Nurse, Interim D.O.N. (Director of Nursing) who stated they will ensure to monitor creatinine levels and give I.V. (intravenous) fluids...notified physician (attending)...who agreed to d/c (discharge) as long as facility can provide these services..."

The nurse's (Personnel #15) 03/18/11 (untimed) "Patient Transfer Form (Discharges to SNF (Skilled Nursing Facility) or Rehab (Rehabilitation) Facilities)" included that Patient #1 was on a 2000 "ADA" mechanical soft diet. The "Medication Reconciliation" was to be referred to and follow-up was to be on 03/23/11. Patient #1's activities of daily living and mental status were addressed on the form. The physician did not sign the form and there was no indication of the need for continued medical care that included intravenous treatment with fluids and creatinine level monitoring.

The 03/18/11 05:00 PM "Nurses Progress/Narrative Notes" indicated Patient #1 was discharged via an ambulance to a skilled nursing facility with "report given."

Physician #11's 03/18/11 "Progress Notes" were timed "06:20 PM late note" and included that Patient #1's discharge planning was in progress. His problems were stable and included "progressive azotemia (presence of nitrogenous bodies in the blood)-assured by CM (Case Manager)...IV (intravenous)...close monitoring can be done..." at the skilled nursing facility.

Patient #1's "Discharge Summary (dictated 04/17/11)" noted that Patient #1's final diagnoses included "progressive azotemia." Discharge medications included "intravenous fluids..." and antibiotics. Patient #1 had "come to the end of his stay...and following reassurances that his azotemia could be monitored and his intravenous fluids continued on an outpatient basis at...he was released with specific recommendations to monitor creatinine levels."

During an interview at approximately 03:15 PM on 06/14/11, the Director of Case Management (Personnel #4) reviewed the medical record information that had been sent with Patient #1 to the skilled nursing facility on 03/18/11 with the surveyor. (Personnel #4 had requested the skilled nursing facility to fax the medical information the skilled nursing facility received with Patient #1 on 03/18/11.) Personnel #4 confirmed that the received information did not include a copy of the late entry physician's progress note of 03/18/11 06:20 PM.

During a telephone interview at 02:25 PM on 06/14/11, the nurse (Personnel #15) was asked what she remembered about Patient #1's discharge. Personnel #15 said that she called Physician #11 to get the okay for the nursing facility placement since Case Management had checked and said that the nursing facility could accommodate intravenous treatments and the monitoring of Patient #1's creatinine levels. Personnel #15 was asked if Physician #11's late entry progress note (03/18/11 06:20 PM) was faxed to the facility since the documentation indicated Patient #1 was discharged at 05:00 PM. She said that she did not know if this was done. The packet with medical information would have been prepared before Patient #1 was discharged. Personnel #15 said that she had called the report.

During a telephone interview at approximately 12:00 Noon on 06/14/11, the physician (Personnel #11) was asked why the information discussed by the Case Manager (Personnel #6) with the skilled nursing facility, that was given to him, was not documented in the discharge paperwork sent with Patient #1. Personnel #11 said that the information "should have been there" to make sure that it was relayed to the new facility.

The "Discharge, Discharge Planning and Instruction Form" policy D03-G revised by the hospital 05/01/01 reflected, "Discharge plans will include...referral for continued treatment through an outside source as appropriate, to ensure continuity of care...necessary parties are notified...inform unit secretary of records that need to accompany the patient if patient is being transferred to another facility...appropriate records will be photocopied...case manager may fax some initial information to the receiving institution...nurse will complete the Discharge Instruction Form...patients discharged to an extended care facility...patient's nurse will document patient instruction for medication...write additional discharge instructions as appropriate...may include treatment routines..."