HospitalInspections.org

Based on medical record review, document and policy review and staff interview, it was determined that for 1 of 2 discharged patients (Patient #1) in the sample, staff failed to provide the necessary medical information for referral/transfer to a long term care (LTC) facility. Findings included:

Review of Patient #1's medical record revealed:

1. Discharged 2/20/18 to LTC facility A with medical issues that included:
a. PEG (percutaneous endoscopic gastrostomy) feeding tube
b. Perative® (tube feeding) at 70 milliliters per hour for 12 hours, to start at 6:00 PM
c. colostomy (an opening is formed by drawing the colon through an incision in abdominal wall)
d. sacral wound requiring Support Surface-dolphin bed (fluid immersion bed used for wound care)

2. "Continuity of Care Document" faxed and sent with Patient #1 to LTC Facility A failed to address the following medical issues:
- PEG with current tube feeding
- colostomy
- Support Surface-dolphin bed

3. No evidence that LTC facility A was provided with information regarding PEG tube and feedings, colostomy and a support surface bed.

During an interview on 4/24/18 between 11:10 AM and 11:30 AM, Director of Case Management A confirmed there was no evidence that LTC facility A received information regarding the need for a specialty bed.

During an interview on 4/24/18 between 11:20 AM and 11:50 AM, Chief Nursing Officer A:
- reported that the "Continuity of Care Document" was the facility's documentation of necessary medical information to provide the receiving facility
- confirmed that Patient #1's "Continuity of Care Document" lacked medical information regarding the PEG, the tube feeding and the colostomy

On 4/24/18 at 12:50 PM, Chief Nursing Officer A confirmed there were no policies related to patients being transferred to a facility or what medical information was required to be provided to the receiving facility.