Legal RN Reporter (A Publication of Haibeck and Associates Legal Nurse Consulting)

LEGAL RN REPORTER

One area this is evident is the hand-off process, when a patient moves from one area of care to the next. An example would be failure to communicate information from the treating hospital to the receiving nursing home or extended care where continued medical care and rehabilitation are provided. Although ideally discharge planning begins at admission, the actual day of discharge always is chaotic coordinating the transportation time, family presence and signatures on multiple forms. Often, transfer is sooner than expected. Practical questions being asked by staff and family at the time of discharge include: ▪ Is the bed at the facility ready? Are the transfer orders written by MD? ▪ Does he need a wheelchair or cart? Will lunch be ready for him? ▪ Is staff ready to receive the patient? What’s being paid for? What medicines will he stay on? Does he need a pain medication before transfer? Does he understand what is happening? ▪ What doctor is following his care? Who’s filling out the transfer form? This sounds straightforward, but many of these questions are not answered until the day before or morning of discharge and the patient’s nurse is probably caring for several other patients at the same time. The family is hovering and anxious. There are many opportunities for a medication change or an active diagnosis to be documented. The most important question is - Has the patient’s condition changed overnight requiring reassessment of transfer? All these questions take time: to answer, act upon and communicate to the proper health care professional. What we’ve got here is… a FAILURE TO COMMUNICATE. Failure to communicate is a frequent theme in many medically related cases.

Time is usually in short supply on a busy morning on a hospital unit According to Healthcare Quality and Consulting, the handoff process has become very complex because: ▪ It takes many forms. ▪ It is rarely face-to face. ▪ Cut and paste becomes imbedded in the process. Communication gaps lead to mistakes. Many lawsuits involve some sort of communication gaps in the written process. Oftentimes we are looking for something that was never documented or not transcribed properly to the correct document. Upon reviewing medical records involving any transfer of care consider if everything is in order so you would completely understand the care of the patient once received. Is the skin condition documented? What is patient’s level of awareness? Was there a failure to communicate between any two departments or participants in this patient’s care? You may be surprised at who is not communicating (or documenting) with who. Susan was featured in the Legal Nurse Consulting Success Story section in the CLNC Vickie Milazzo Institute for Legal Nurse Consulting Blog in January 2017. Read about how she built a flexible schedule and steady income as a Certified Legal Nurse Consultant: https://tinyurl.com/SusanSuccessStory

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