HospitalInspections.org

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to assure the patient and family members were counseled to prepare for post-hospital care for two of seven medical records reviewed (MR1 and MR2).

Findings include:

Review of facility policy, Routine Discharge of Patient, last revised July 2016, revealed, "... Routine discharges: 1. When the discharge order is entered into the EMR, the attending physician will complete the discharge instructions. 2. The discharge instructions will include the following information: a. Level of activity, b. dietary restrictions, c. Wound care in detail according to MD instructions if applicable. d. A complete listing of the medications the patient is to be taking including dosage, frequency and special instructions. Prescriptions written by the physician are to be given to the patient. Medication information will be given for new medications. ..."

1. Review of MR1 discharge instructions dated July 5, 2018, revealed no level of activity or dietary restrictions were included. Further review revealed, "Your Complete Medication List: aspirin 1 MG/ML Solr oral syringe (no dosage or frequency instructions) ... calcitriol 0.25 Mcg capsule (no dosage or frequency instructions),... cholecalciferol (vitamin D3) 1,000 unit capsule take as directed (no dosage or frequency instructions) ... cyanocobalamin 1,000 mcg/mL injection (no dosage, frequency, or special instructions), losartan 50 MG Tablet (no dosage or frequency instructions), metoprolol tartrate 25 MG tablet (no dosage or frequency instructions) simvastatin 20 MG tablet (no dosage or frequency instructions)."

2. Interview with EMP2 on September 6, 2018, at approximately 12 PM confirmed the above findings would not be clear to a patient.

3. Review of MR2 discharge instructions dated July 6, 2018, revealed, "Your Complete Medication List: allopurinol 100 MG tablet. 150 mg daily (unclear dosage instructions) ... Complete Multivitamin Tab (no dosage or frequency instructions) ... omeprazole 20 mg capsule 20 mg daily. Twice a day (unclear frequency)."

4. Interview with EMP2 on September 7, 2018 at approximately 11 AM confirmed the above findings would not be clear to a patient.