HospitalInspections.org

Based on document review, the facility failed to provide accurate follow-up care in the Discharge Documentation, for 1 of 10 patient's Medical Records reviewed (patient #1).

1. Review of Policy Documentation in the Medical Record by Nursing Personnel Utilizing the Computerized System, 6010-10-15, last updated 8/2012, which indicated: 8. A. The following medical records reports will be printed on the sending unit upon transfer to another facility 1. B. Clinical History 1. C. Assessment for Transfer/Perm.

2. Review of documentation dated 4/18/2017 at 0753 hours, physician indicated in progress note that patient was reported to have started a decubitus in the sacral area. Wound care consulted and treatment begun.

3. Review of patient #1's medical record dated 4/19/2017 at 1336 hours indicated patient had a sacral decubitus, the clinical discharge documentation for patient #1, dictated by QMP #7, NP, (which is sent to receiving LTC, rehabilitation facility #3), lacked documentation of medical information needed for care of the sacral decubitus.

4. The discharge summary for patient #1 lacked documentation in Discharge Diagnosis of patient's medical condition including sacral decubitus, cervical-spine fracture and quadriplegia.