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Based on interview, record review, and review of facility documents, the facility failed to ensure that 3 of 3 medical records (#1, 4, & 5) for discharged patients were complete and accurate.

Findings:

Review of patient #1, 4, and 5 's medical records revealed a form entitled "After Visit Summary (AVS). The AVS documented the following categories regarding the patient discharge needs:

"Your Next Steps, Care Providers, Discharge Instructions, Follow-up Appointments, Home Care and durable medical equipment information, Your allergies, Unresulted labs, Medication List, Take these mediations, Where to pick up your medications, Immunizations, Select My Chart information, Case Management instructions, Wound care instructions, and Emergency contact information and preparedness.

Below this area was a section that read..."This information in this After Visit Summary (AVS) is up to date as of: (date and time documented).
I, (Patient name documented) on (date of discharge), received patient instructions and the after visit summary was received with me. I have read or had the instruction reviewed with me and understand the instructions given to me by my caregivers, "

Underneath this statement was a line that read "Patient Signature: _______________Date: ________.

The signature lines on Medical records # 1, 4, and 5, were completely blank, without the patient signature , and did not document a date or time . The medical records showed no confirmation the patient or representative had received the discharge instructions or the form.

In an interview with the Chief Nursing officer and the Director of Case Management on 10/11/23 at 2:40 PM, they stated the facility process is for the patient to sign the form and it is given to them to take home. After reviewing the records, they related a copy of the form was not in the record showing the patient's signature, and it was not scanned into the record. They stated the nurse should document in the record in the nurse notes, that the discharge information was discussed and given to the patient.

Patient #1, 4, and 5 records were reviewed for nurse documentation concerning discharge information with the patient and none was found for any of the records.

Review of the facility policy entitled Discharge, Discharge Planing and instruction form, #DO3-G, read on page 1 under Policy:

#4. Each patient going home with home health will receive written and verbal discharge instructions and appropriate educational material, and discharge instructions will be documented according to procedure.

Page 3 of 3 under Procedure for Discharge Instructions: read:
#1. The appropriate discharge instruction form is to be completed on all patients.
#3. The patient's nurse will document patient instruction for medication, diet, activity, wound care, and follow-up visits, and provide appropriate patient teaching. The nurse will document additional discharge instructions as appropriate. This may include treatment routines and equipment/supplies sent with the patient or instructed to purchase.
#4. The nurse will document the patient and/or family's understanding of the instruction."