553.25 Discharge Criteria
A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.
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Observations:
Based on review of facility documents, medical records (MR), and employee (EMP) interview it was determined the facility failed to ensure patients met required discharge criteria prior to discharge in two of ten medical records reviewed (MR4 and MR9).
Findings Include:
On January 11, 2024, review of facility policy "Vital Signs" effective August 2023, revealed "Policy: Patient vital signs are monitored at designated times/intervals while being treated in the Center. Purpose: To document progress and/or change in the condition of the patient. Procedure: Post-Operative/Recovery...A Post-Operative temperature is taken at time of discharge".
On January 11, 2024, review of MR4 revealed there was no evidence of documentation that MR4 had a temperature vital sign assessed prior to discharge.
On January 11, 2024, review of MR9 revealed there was no evidence of documentation that MR9 had a temperature vital sign assessed prior to discharge.
Interview with EMP1 on January 11, 2024, EMP1 confirmed MR4 and MR9 did not have documentation that a temperature vital sign had been assessed prior to discharge.
| | Plan of Correction - To be completed: 03/08/2024
We are working on establishing a Pre-Admission Testing Dept. that would be in contact with patients closer to their appointment date (some patients schedule 3 months in advance) to review an medical changes since they made their appointment.
553.25 (1-6) Discharge Criteria
S 3250
Systemic Changes:
TEMPERATURE VITAL SIGN .PRIOR TO DISCHARGE
On 1/11/2024 CA met with .available nursing staff .to .review the .Center's Vital Signs .policy, staff educated regarding .the documentation of .patient .temperature prior to discharge.
Systemic Changes:
All Nursing staff will review the .Vital Signs policy. Proof of policy review is confirmed by a signed roster and is to be completed by 1/26/2024. Any PRN staff who are not scheduled to work on or before 1/26/2024 will be sent the policy via email and will acknowledge review by replying via email.
Monitoring and Sustaining the .Plan:
The CA or DON will audit 10 .random .charts per day for 30 days, to .verify the documentation of patient .temperature before discharge. Audits will begin 1/29/2024. If .100% compliance is achieved after .the initial 30-day monitoring .period, .the facility will resume monitoring vital sign documentation on a monthly basis during the random Medical Record Review.
Responsible Party and Reporting:
The CA is responsible to implement .the changes identified in the PoC.
The CA will provide results of this .survey, the corrective actions, and .results from monitoring to the QAPI .Committee quarterly for review and .recommendations. Recommendations .will be submitted to the Governing Body for review and approval.
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