HospitalInspections.org

Based on interview and record reviews, the hospital failed to ensure all patient records included complete documentation of outcomes of hospitalization, complete disposition of care, and complete provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure the treating licensed practitioner completed an accurate and complete discharge summary for 1 (#2) of 5 patient records reviewed for discharge summaries from a total sample of 20 patients.

Findings:

A review of Patient #2's medical record revealed he was admitted on 06/30/2020 at 4:43 p.m. after getting overheated at work resulting in a syncopal episode and hitting his forehead and mouth on gravel. Further review revealed he was treated for lacerations to his upper and lower lips and Rhabdomyolysis. A CT of the face and sinuses revealed an acute, traumatic avulsion fracture from the anterior left parasagittal maxillary alveolus along with tooth #9. Further review revealed Patient #2 was discharged with a Diagnosis of Heat syncope and non-traumatic rhabdomyolysis. The record also revealed Patient #2 was discharged with instructions related to Rhabdomyolysis and heat exhaustion and to follow up with his primary care physician. The record failed to reveal instructions related to wound care for the sutured lacerations or the avulsion fracture noted on the CT.

On 01/13/2021 at 2:53 p.m. in an interview S3RN verified the medical record failed to have any information related to discharge instructions for Patient #2's sutured lacerations or avulsion fracture.

On 01/14/2021 at 12:45 p.m. in an interview S1MD stated Patient #2's discharge instructions should have included wound/ laceration care as well as the avulsion fracture.