Worried: Discharge SNAFU

[RiverNurse]

Hey all,

Well, I'm finishing up my final week at my current job. At 3 pm - shift change - there's a transfer to a rehab facility. The social worker arranged for transportation to the rehab facility and it was my job to gather paperwork and prepare the pt for transfer.

What I encountered:

1. The pt hadn't been informed by anyone except me (including her doctor) that she was being discharged/transferred - so - an hour before she was to leave, I had the unpleasant task of telling her she was leaving - not to home - but to another facility. She didn't like it - but like a real trooper - she accepted it.

2. The ambulance arrived as arranged by the social worker and the patient was discharged. The pt was unable to sign the form, so I called the family for that and for other information (50% of the d/c paperwork wasn't ready, either). I couldn't reach the family. I signed the d/c paperwork per our policy, indicating that the pt was unable to sign.

An hour later, the family arrived, wanting to pick up the patient and transport the pt to the rehab facility. I had to explain where the pt went and that I'd been the one to "sign her out"/discharge her. The family was understandably concerned, but not angry. Rather, they said they felt that the social worker was the one they should talk to about the issue.

I didn't chart on this situation, because I had no idea up until that point that anything was out of the ordinary for this d/c. Now I feel like I am up to my patooty in alligators and am in deep caca. Since this all came down after the fact, what should I have charted? Also, how many nurses out there routinely call family members upon discharge? Since I am new at this, I can only relate to the experiences I've encountered on my floor - that is - that the social worker typically notifies the family members (if needed) upon discharge.

Thoughts?

Many thanks,

Shawna

[jessi1106, BSN, RN]

Hi,

I have only been a nurse a bit over 1 year.

Sounds like you did everything per policy.

I am wondering who makes legal decisions for pt? Is it the pt or family?

[RiverNurse]

This pt's family makes decisions for the pt.

[pattylpn54, LPN]

"If it wasn't documented it wasn't done"

[RiverNurse]

Thanks, y'all.

I've also talked to some other nurses as well and the consensus at this point is that I did all that I could do with the information that I had at the time of the patient's discharge.

In regard to charting about my contact with the family members, one nurse told me that she only charts on the patient, not the family unless there is a significant change in the patient's health/condition.

However - there is always room for improvement on my part.

Shawna