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Enhancing Patient Safety: The Critical Role of Advocates in Hospital to Skilled Nursing Facility Transitions
Case Study: Critical Incident During Transfer to Skilled Nursing Facility
Client CM, a patient of SunNav Healthcare Advocates, experienced multiple hospitalizations for necrotizing pancreatitis, which necessitated tube feeding and an abdominal drain to manage vomiting. Following stabilization, the client was transferred from the hospital to a Skilled Nursing Facility (SNF) at 2200 hours for rehabilitation and ongoing chronic acute care. Unfortunately, within less than 20 hours of transfer, the client passed away due to complications arising from medication errors, tube feeding mismanagement, and inadequate staff proficiency in handling the abdominal drainage system at the SNF. This case highlights critical gaps in care continuity and staff training, underscoring the need for rigorous protocols and education to prevent similar adverse outcomes in future patient transfers.
Client CM was transferred at 2200 hours to a local Skilled Nursing Facility (SNF) with a PICC line, G-tube, and an abdominal drain for managing nutritional needs and infection control. Upon arrival, the SNF staff were not informed of the IV medications or tube feed requirements, resulting in a 12-hour delay in administering tube feed. Additionally, the staff were unfamiliar with the drainage bag system and failed to connect the abdominal drain to the collection bag. When tube feed administration was finally initiated, it was set at an incorrect rate of 160 ml/hr instead of the prescribed 60 ml/hr. This led to fluid overload, respiratory distress, and vomiting. Client daughter felt she could manage the discharge transfer to a SNF and did not call Advocate to assist in the transfer and communication of transfer. Advocate was called at 1000 the next day and arrived to SNF around 1200. The daughter had already hired a private caregiver to be with CM due to lack of aides at SNF and client unable to get anyone to answer call bell in timely manner. Upon Advocate arrival patient was having mild respiratory distress we called MD to order oxygen, raised HOB, hooked up drainage bag. Advocate noted rate of tube feed immediately requested it to be stopped. Called the hospital to receive copy of discharge orders to include meds and tube feed rate and type of feed (SNF did not have). The nursing staff, lacking an on-site physician and inability to know how to manage the now acute turn of health challenges, was advised by advocate to contact 911. The patient was subsequently transported back to the hospital but passed away within one hour of arrival. This incident underscores the critical need for thorough handoff procedures, proper staff training, and effective communication to ensure patient safety during transitions of care.
There’s a concern in healthcare regarding the transition of patients from hospitals to rehabilitation facilities or skilled nursing facilities (SNFs), especially concerning the timing of these transfers. While there isn’t a wealth of comprehensive statistical data that specifically addresses the danger of transfers after 5 pm or on weekends due to communication issues, some related points can be considered:
By addressing these key areas, healthcare providers can help reduce the risk of complications, medication errors, and rehospitalizations for patients transitioning from hospital to a skilled nursing facility.
When receiving a patient from a hospital to a skilled nursing facility (SNF), it's crucial for the SNF to review and ensure they have all necessary supplies, knowledge, and procedures in place to provide safe and effective care. Here is a list of key things the receiving SNF should review and assure with the hospital:
To prevent rehospitalization, medication errors, and other unplanned adverse events when a patient is discharged from a hospital to a skilled nursing facility (SNF), nurses and discharge planners should review and ensure the following:
1. Medication Reconciliation:
a. Complete Medication List: Verify that the list of medications is accurate, including dosage, frequency, and route.
b. Reconcile Discrepancies: Identify and address any discrepancies between the medications ordered in the hospital and those provided at the SNF.
c. Patient and Family Education: Educate the patient and/or family members about the medications, including potential side effects and proper administration.
2. Detailed Discharge Summary:
a. Comprehensive Summary: Ensure that the discharge summary includes all relevant clinical information, including diagnoses, treatment details, and recommendations.
b. Clear Instructions: Provide clear, understandable instructions for follow-up care, including any required tests or consultations.
3. Care Plan Coordination:
a. Follow-Up Care: Confirm that follow-up appointments and necessary services (e.g., physical therapy, wound care) are scheduled and communicated.
b. Care Plan Review: Share the patient’s care plan with the SNF staff, highlighting any special needs or precautions.
4. Communication of Critical Information:
a. Hand-Off Communication: Use standardized hand-off protocols to communicate critical patient information between hospital and SNF staff.
b. Electronic Health Records: Ensure that all relevant health records and documentation are transferred to the SNF, if applicable.
5. Patient and Family Education:
a. Discharge Instructions: Provide written and verbal instructions regarding discharge care, medication administration, and signs of potential complications.
b. Contact Information: Give clear instructions on how to contact healthcare providers if problems arise.
6. Safety and Environment:
a. Safety Assessment: Ensure that the SNF environment is safe for the patient, including assessing the need for special equipment or modifications.
b. Patient’s Needs: Review the patient’s mobility, dietary needs, and any other special requirements.
7. Emergency Planning:
a. Emergency Plan: Make sure the SNF staff is aware of any potential emergencies or red flags, such as signs of deterioration or specific conditions to monitor closely.
b. Advance Directives: Review and communicate any advance directives or specific patient preferences for end-of-life care.
8. Coordination with SNF Staff:
a. Staff Briefing: Brief SNF staff on the patient's recent hospital course, current condition, and any particular care needs or concerns.
b. Continuous Communication: Establish a plan for ongoing communication between the hospital and SNF to address any emerging issues or concerns.
9. Documentation and Follow-Up:
a. Complete Documentation: Ensure that all relevant information is documented accurately and completely.
b. Follow-Up: Confirm that follow-up care and any needed adjustments to the care plan are in place.
When receiving a patient from a hospital to a skilled nursing facility (SNF), it's crucial for the SNF to review and ensure they have all necessary supplies, knowledge, and procedures in place to provide safe and effective care. Here is a list of key things the receiving SNF should review and assure with the hospital:
1. Patient-Specific Supplies and Equipment
2. Tube Feeding Details
3. Medication Review
4. Knowledge and Training of SNF Staff
5. Documentation and Communication
6. Emergency Procedures
7. Patient Comfort and Safety
8. Coordination of Care
The average rate of medication errors during the transition from a hospital to a skilled nursing facility (SNF) can vary based on several factors including the quality of communication between facilities, the complexity of the patient's medication regimen, and the procedures in place at both the hospital and SNF. Here are some general insights based on research and available data:
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