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Based on medical record review, document review and interview, the facility failed to ensure all diagnoses were listed in the discharge summary and discharge instruction sheet for one of five medical records (MR) reviewed (MR100).

Findings:

1. Review of MR100 on 02/09/11 indicated the discharge summary and discharge instruction sheet to F2 lacked the diagnosis of coccygeal pressure wound.

2. Review of policy titled Medical Record Chart Requirements Inpatient and Medical Observation indicated the Discharge/RHC Summary would contain a principal and secondary diagnoses. The policy lacked requirements for completion of the discharge instruction sheet.

3. Interview with S2 and S3 on 02/09/11 at 2:30 PM confirmed the findings.

Based on document review and interview, the facility failed to ensure the necessary medical information regarding a pressure wound was communicated upon referral of MR100 to F2.

Findings:

1. Review of policy NPP#: BCS: D-01, Discharge Planning, on 04/06/11 indicated under "Procedure: 3. If a patient is discharged to an ECF" (extended care facility)....."the Administrative Partner faxes the Behavioral Health Services Discharge Instruction Sheet, .....to the next level of care."

1. Review of MR100 on 02/09/11 indicated the discharge summary and discharge instruction sheet to F2 lacked the diagnosis of coccygeal pressure wound and lacked documentation that required per policy discharge instruction sheet had been faxed to F2.

2. 12:50 PM, 02/09/11: Telephone interview with S4 indicated he/she wasn't sure why there was no reference to the pressure wound in the discharge instruction sheet to F2.

3. No additional documentation to indicate communication between F1 and F2 was presented prior to exit.