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Based on interview and record review, the facility failed to include special instructions and precautions for therapy for a patient with a hip fracture, in the discharge instructions for 1 (#1) of 4 sampled patients. Findings include:

Patient #1 was admitted on 2/26/18 and discharged on 3/9/18 with diagnosis of left hip fracture.

Review of the discharge instructions showed allergy information, immunization information, medication list, and follow up appointments. Under discharge information there was no information in the sections labeled teaching packets given, diet, discharge activities or additional discharge instructions. There was no information regarding home program instructions for continued therapy.

During an interview on 5/1/19 at 10:04 a.m., patient #1 stated she had not received exercises to be done at home following discharge. Patient #1 stated she did not have outpatient therapy until three weeks following discharge.

During an interview on 5/1/19 at 10:55 a.m., staff member E stated the patient usually comes with a booklet or preprinted instructions when they are admitted to the facility. Staff member E stated the facility has pre-made out exercises that are started on admission and utilized throughout the patient's stay. Staff member E stated the therapy department provides the patient with printed instructions for exercises upon discharge. Staff member E stated the information given to the patient should be documented in the clinical record. Staff member E stated there was not a discharge form for therapy in the electronic medical record. Staff member E stated the information should be in the progress notes.

Review of patient #1's therapy progress notes, from 2/26/18 through 3/9/18, did not show therapy discharge instructions were discussed with the patient.

During an interview on 5/1/19 at 12:07 p.m., staff member F stated if the patient is going home independently, then a home exercise program had already been given to the patient. Staff member F stated when the patient was given a home exercise program, it was usually documented in the progress notes.