Transition, Discharge and System Navigation
Mrs. Rossi is a very pleasant 70-year-old female of Italian descent who speaks very limited English, just enough to get by and lives with her son and her daughter-in-law. She is independent of using the bathroom with her walker and does not say much and just smiles and thanks Sam whenever he comes in to check in on her. Her diet is advanced to regular, and she tolerates it well as she eats all of the content on the tray (cup of soup, pasta, a salad and one butter tart). Jamie follows up with Sam after lunch asking if Mrs. Rossi tolerated her food; Sam reports yes because she didn’t say anything except thank you when they checked on her an hour after lunch. Jamie calls the physician with the update who faxes the discharge paper and tells Jamie to send the patient home.
Sam and Jamie, take the discharge summary and new prescriptions for daily pantoprazole PO for the next week to the patient’s bedside. Jamie instructs Sam how to remove her IV, and they assist Mrs. Rossi to change into her personal clothes and pack all her personal belongings. Jamie had called Mrs. Rossi’s son who reported that he would come to pick her up at 1730 hr on his way home from work. Jamie quickly goes over the discharge summary with Mrs. Rossi, explains the follow-up appointment with the internal medicine clinic in 1-week time that she needs to book, and reviews her new prescriptions. Mrs. Rossi smiles and nods. Jamie and Sam give a report to their POD nursing partner and let them know that Mrs. Rossi’s son will pick her up at 1730 hr, the wheelchair is at the bedside, and they go for a break. When they return Mrs. Rossi is gone.
One week later when Sam returns for his day shift, he is surprised to see that Mrs. Rossi is back for another GI bleed and abdominal pain. When he reads the emergency report, he sees that the patient reports blood in her stool, abdominal pain with eating, has not been taking her pantoprazole at home and never attended a follow-up appointment at the internal medicine clinic. Sam wonders if they may have sent Mrs. Rossi home too early and if she understood the discharge instructions due to her limited English.