HospitalInspections.org

Based on Medical Record (MR) review, policy and procedure review, and interviews the facility failed to document patient education and what type of medication to take following discharge. The facility also failed to identify what physician the patient was to call following discharge.

The findings include:

Policy and Procedure:
"Discharge Planning ... 3. Standard: ... 3.3. The patient/ family shall participate in the discharge planning process and verbalize understanding and satisfaction with discharge plans prior to initiation of the plan. ... 3.7 Documentation of Discharge Planning: 3.7.1. All disciplines should contribute to the Discharge Plan in the electronic medical record. ... 3.7.4. All professional staff shall document patient/family participation, understanding of and satisfaction with discharge plans. ... 3.8 At time of discharge, ... 3.8.1. Nursing will review the printed Discharge Plan with patient/family, answer any questions, and document to whom the information provided.

Discharge Process of Patients ... 4. Standards ... 4.7.5. The "Physician Discharge Plan" or "Patient Information Discharge Form" will be reviewed with the patient and or family member/ guardian and signed by the patient or representative as well as the nurse to signify patient/ family notification of discharge information."


1. MR#1 was admitted to the facility on 1/16/10 and discharged 1/18/10. The Discharge Summary listed, "She will have her lisinopril up titrated to 40 mg to help with her hypertension. Also, her Coumadin will be adjusted. She will take 7.5 mg on Friday, Saturday, and Sunday with Coumadin 5 mg every day besides Friday, Saturday, and Sunday. ... Discharge follow up: with Dr. ... In one to two weeks."

A review of the signed Patient Discharge Summary did not contain documentation the changes in medications were reviewed with the patient. There was no documentation the patient was informed she needed to call for a follow up with the physician identified in the discharge summary.

During an interview with the nurse on 2/9/10 at 4:30 PM, she verified there was no documentation the patient was instructed on the medication changes or given the name and number for the physician to contact for follow up appointment.

2. MR# 2 was admitted to the facility on 1/19/10 and discharged on 1/21/10.
The medical record was reviewed 2/11/10. The Physician discharge summary was electronically signed on 1/22/10. The report documented, "Procedures/Imaging: ... 2. EEG (1/20/10): No evidence of epilepsy. ... Hospital Course: ... On the morning following admission, the patient was connected to long-term EEG. While connected, the patient had several of her typical spells which were reviewed by the attending epileptologist and no definitive seizure activity was seen. It was felt that the patient was most likely suffering from non-epileptic events. We will defer to her primary neurologist to taper her off of her current antiepileptic medicines."
A review of the Patient Discharge Summary signed by the patient revealed there was no medications listed, no patient education was listed and no follow up information supplied to the patient on the discharge summary.
There was no documentation the physician or staff discussed the EEG reports or medications with the MR# 2.

During an interview with the Director of Corporate Compliance on 2/11/10 at 1 PM, she verified there was no documentation the patient was instructed on her medications or given the name and number for the physician to contact for follow up appointment.