HospitalInspections.org

Based on record review, interview, and facility policy review, the facility failed to ensure discharge instructions were provided for 1 (Patient #2) of 3 sampled patients reviewed for discharge instructions.

Findings included:

A facility policy titled, "[Facility Name] - Emergency Department - Process: Patient Discharge," dated 08/25/2022, indicated, "C. Each patient, parent or responsible party is to receive a copy of the discharge instructions, have them explained and acknowledge understanding of instructions by signing the instruction sheet."

Patient #2's "Patient Visit Information" dated 11/01/2023, indicated the patient was treated for left sided epistaxis (nosebleed). The Patient Visit Information included instructions for home care related to nosebleeds in adults, nasal packing, and included that the patient should follow-up with their healthcare provider and the nasal packing should be rechecked or removed within two to three days. The Patient Visit Information revealed the "Patient Signature Page" was unsigned by the patient in the area that indicated "I have read and understand the instructions given to me by my caregivers."

During interview on 06/10/2024 at 3:45 PM the Emergency Department (ED) Nurse Manager stated that the ED staff provided discharge education and would have the patient sign the paperwork prior to leaving the facility.

On 06/11/2024 at 1:15 PM, the ED Nurse Manager stated that once a patient was educated on the discharge instructions and follow-up process, the patient signed the discharge paperwork. The ED Nurse Manager stated she was not sure if the signed patient signature page was than scanned into the electronic medical record (EMR) that was stored by the Medical Record's department.

On 06/11/2024 at 2:00 PM, the ED Nurse Manager confirmed that Patient #2's signature was missing from the patient signature page, which would confirm the patient was educated on discharge instructions.