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Based on record review and interview, the behavioral health hospital failed to include a discharge summary with the complete outcome of hospitalization, treatment rendered, disposition of care, and provisions for follow-up care for 1 of 1 Patient (#1) reviewed with a complaint regarding the discharge summary; and in accordance with the facility's By Laws.

Specifically, Patient #1's discharge summary completed by the Psychiatrist did not include the following:
1. All Final diagnosis including Medical diagnosis with the reasons for diagnosis.
2. All medical care, treatment and services provided (summary of hospital course).
3. Provisions for follow-up care for medical issues identified.
4. BEH [Behavioral Health]: Axis I-V

Findings Included:

Record review of the complaint submitted by Patient #1's mother/guardian indicated her son had diagnosis of mental retardation, autism, and intermittent explosive disorder. She stated her son [Patient #1] was discharged from the behavioral health facility on 9/24/19 with multiple unknown injuries observed that he did not have upon admission on 9/13/19. Patient #1 had noted bruising to his forearm, wrist (right), laceration on left foot (2 inches); which appeared to be infected. There was no explanation provided to Patient #1's mother/guardian regarding these injuries upon discharge. Patient #1's mother called the facility to find out what happened to her son and the nurse stated she could not speak to her since it was during shift change. On 9/25/19 Patient #1's mother then contacted the facility Director (B) requesting additional information and a discharge summary. Facility Director -B reported to her that Patient #1 entered the facility with the laceration on his foot with no further information provided to Patient #1's mother.

Review of the facility's By Laws and Rules and Regulations of the Medical staff last revised 8/19/19 revealed on page 103, G-11-6. The Discharge Summary should include:
a. Final diagnosis
b. Reason for Diagnosis
c. Surgeries and Procedures performed
d. The care, treatment and services provided (summary of hospital course)
e. Last physical exam
f. Condition at the Time of Discharge
g. Disposition at Discharge
h. Information provided to the patient and family
i. Provisions for follow-up care
j. BEH [Behavioral Health]: should also include: Axis I-V and a mental status exam on discharge.

Record review of Patient #1's medical record revealed the following:

Upon admission on 09/13/19 at 19:46, BH Registered Nurse (RN-A) completed an initial nursing assessment; skin assessment, documenting the following on the diagram: A scar to the left knee and on the right lower forearm; "IV [Intravenous] D/C [Discharged] removed." There was not any documentation of findings to Patient #1's left foot.

On 9/14/19 at 19:00 RN-A completed a second skin assessment documenting the following on the diagram: bruise below the right knee, scratch on the top of right foot, scratch to the outer left foot and overall redness and swelling to left foot.

RN-A nursing note 9/14/19 at 19:00 indicated Patient #1 had "redness and swelling to left foot. Will follow up with Medical Dr." Left pedal pulse is +2 and capillary refill is less than 3 seconds.

During phone interview on 12/10/19 at 04:30 PM with RN-A stated when he first assessed Patient #1 on 9/13/19 it was "very briefly" because he did not follow directions very well. When asked, RN-A confirmed that he did look/assess Patient #1's feet during his first assessment on 9/13/19; stating again, "very briefly." RN-A confirmed that he did not see any injuries to Patient #'1's feet the first assessment on 9/13/19. RN-A stated he noticed the "2nd day" (9/14/19) the injury to his left foot at the beginning of his shift after the "Tech" [Mental Health Tech] let him know that he had been hitting and slapping his foot.

Review of the Health and Physical (H&P) Consultation Note completed by Physician - A dated 9/16/19 at 09:50 documented Diagnosis: "Left foot trauma/rule out cellulitis." Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and can damage the kidneys. Plan: left foot x-ray will be ordered, start Keflex 500 milligrams po (by mouth) q (every) 8 hours. Rhabdomyolysis: encourage oral hydration, Chem 7 CPK in the morning (9/17/19). Total Creatine Kinase (CK) noted High at 1340 on 9/13/19, High at 922 on 9/14/19, High at 965 on 9/16/19. Normal range is 22 to 198 units per liter.

Review of the left foot radiology report dated 9/17/19 at 12:56 indicated findings: some soft tissue stranding and edema noted on the posterior and plantar aspect of the heel may be related to trauma. Soft tissue swelling also noted in the proximal and mid foot. No acute bone or joint abnormalities. No fractures or dislocations noted.

Record review of Patient #1's Discharge "Inpatient Patient Summary" dated 9/24/19 that is provided to the patient upon discharge according to the Clinical Assistant (A) of BH records, revealed Psychiatrist (A) documented the following discharge diagnosis: Autism, History of Mental retardation, and Intermittent explosive disorder. Reason for visit: Depression. The discharge diagnosis did not include any medical problems diagnosed or treated during Patient #1's inpatient visit from 9/13/19-9/24/19. The discharge diagnosis did not include Depression; the reason for Patient #1's visit and the medications prescribed to Patient #1; paroxetine and trazodone (anti-depressants). Further review of the Discharge Instructions presented to Patient #1 revealed only a "Follow-up appointments" were for the Psychiatrist. There was no information provided to the outcome of hospitalization, treatment rendered, disposition of care, and provisions for follow-up care regarding Patient #1's left foot and Rhabdomyolysis identified during inpatient and had not been resolved on discharge.

Record review of Patient #1's Discharge Summary dated 9/27/19 that is part of Patient #1's Electronic Health Record (EHR), but not provided to the Patient on discharge according to the Clinical Assistant A; documented Left foot redness, Dry swelling, Not intact. Total CK lab remained High at 226 on 9/24/19. Final Diagnosis documented as Intermittent explosive disorder, Autism and Unspecified intellectual disability with behavioral disturbances. "Medical diagnosis as noted in chart." AXIS III: "Deferred." There was no information in the Discharge Summary that documented the outcome of hospitalization, treatment rendered, disposition of care, and provisions for follow-up care regarding Patient #1's left foot and Rhabdomyolysis identified during inpatient and had not been resolved on discharge.

Interview with the facility's Chief Medical Officer (CMO) on 12/10/19 at 05:40 PM confirmed Patient #1's Discharge Summary did not include the Keflex antibiotic treatment, x-ray completed to left foot, and all medical diagnosis for Patient #1 including the Rhabdomyolysis. The CMO confirmed that Patient #1's left foot issue had not been resolved upon discharge according to the discharge assessment. The CMO stated the BH EHR platform would need to be evaluated and corrected to ensure the medical treatment, diagnosis and follow-up care is documented for the BH facility Psychiatrists that complete the Discharge Summary's.