HospitalInspections.org

Based on document review, medical record review and interview, the discharge instructions for Patient #1 following an Emergency Department encounter did not include instructions for all of the planned patient follow-up.

Findings include:

Review of Medical Staff Rules and Regulations, approved 12/9/19, revealed medical records of patients who have recieved emergency care will include instructions for follow-up care.

Review of facility Policy and Procedure entitled "Medical Record Documentation" last reviewed 08/18/18 revealed that the medical record will include documented instructions to the patient.

Review of Emergency Department Medical Provider Assessment for Patient #1 dated 10/05/19 at 04:04 AM stated that Patient #1 was discussed with the behavioral health counselor who discussed the case with the covering psychiatrist. Recommendations consisted of discharging the patient with follow-up with outpatient counseling and detoxification. The plan was for Patient #1 to follow-up at outpatient crisis counseling when the clinic opened that same day.

Interview on 01/23/20 at 03:00 PM with Staff (Q), ED Physician Assistant (PA), revealed the discharge plan for Patient #1 was for follow-up at the outpatient crisis clinic.

Review of Emergency Department Medical Provider Discharge Clinical Summary, which includes the patient discharge instructions, dated 10/05/19 at 07:11 AM revealed instruction for follow-up with primary care provider within 3-5 days. The same day follow-up at the outpatient crisis counseling clinic and the recommendation for detoxification were not included in the patient discharge instructions.