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Based on interview and record review the hospital failed to include complete discharge instructions for 1 of 2 patients (Patient #1) that reflected documentation regarding Patient 1's burn diagnosis and follow-up treatment of the burns. This failure prevented the patient from participating in his developement and inplementation of his discharge plan.

Findings included:

A review of Patient #1's medical record on 11/29/2023 indicated the patient was a 65-year-old male who presented to the Emergency Department on 12/12/2022 with "concerns of not being himself per wife, acting weird and confused with some agitation. Wife says he wasn't cooperating over there [local hospital] and they even couldn't get VS on him. Per wife pt has hx of Crohn's, s/p ileoscopy and colonic resection; patient currently self catheterized to release fecal matter x 2 a day, epilepsy, RA."

12/14/22. Wound Care Note.
"Spoke with RN, reported that patient had spilled hot chicken broth on himself early this morning the area is now blistering and red. Small serous fluid filled blisters to mid chest and right and left chest, some ruptured, some intact and new blisters forming. Moist but no active drainage. First degree partial thickness burns... Recommend medihoney gel and telfa guaze daily. "

12/17/22. Discharge Summary.
Patient #1 "is a 65 y.o. male with Bowel obstruction and possible stenosis to the Kock pouch. Patient presents with a history of Crohn's disease and status post colonic resection with ileostomy with Kock pouch. Patient self catheterizes himself twice a day however he is noted decreased stool output and concern for possible volvulus." There were no discharge instructions for follow-up daily wound care treatment of his burns. There was no diagnosis or mention of Patient #1's burns.

During Patient #1's medical record review on 11/29/2023 at 1:15 PM with Personnel #3 and Personnel #4 they confirmed the patient's discharge summary did not include a burn diagnosis or follow-up wound care instructions for the patient's burns.

The Hospital's Documentation Standards policy, revision date of 10/2021, reflected, "The minimum required content of the inpatient care record includes ... Summarization of the patient's hospital course to include final diagnosis, condition on
discharge and discharge/ follow up instructions."

The Hospital's Patient Rights & Responsibilities policy with a revision date of 11/11/2020 reflected, "...You have the right to the information necessary for you to make informed decisions, in consultation with your physician, about your medical care including
information about your diagnosis, the proposed care and your prognosis in terms and a manner that you can understand before the start of your care. You also have the right to take part in developing and carrying out your plan of care..."

Based on interview and record review the hospital failed to include a complete discharge summary for 1 of 2 patients (Patient #1) that reflected documentation regarding Patient 1's burn diagnosis and follow-up treatment of the burns.

Findings included:

A review of Patient #1's medical record on 11/29/2023 indicated the patient was a 65-year-old male who presented to the Emergency Department on 12/12/2022 with "concerns of not being himself per wife, acting weird and confused with some agitation. Wife says he wasn't cooperating over there [local hospital] and they even couldn't get VS on him. Per wife pt has hx of Crohn's, s/p ileoscopy and colonic resection; patient currently self catheterized to release fecal matter x 2 a day, epilepsy, RA."

12/14/22. Wound Care Note.
"Spoke with RN, reported that patient had spilled hot chicken broth on himself early this morning the area is now blistering and red. Small serous fluid filled blisters to mid chest and right and left chest, some ruptured, some intact and new blisters forming. Moist but no active drainage. First degree partial thickness burns... Recommend medihoney gel and telfa guaze daily. "

12/17/22. Discharge Summary.
Patient #1 "is a 65 y.o. male with Bowel obstruction and possible stenosis to the Kock pouch. Patient presents with a history of Crohn's disease and status post colonic resection with ileostomy with Kock pouch. Patient self catheterizes himself twice a day however he is noted decreased stool output and concern for possible volvulus." There were no discharge instructions for follow-up daily wound care treatment of his burns. There was no diagnosis or mention of Patient #1's burns.

During Patient #1's medical record review on 11/29/2023 at 1:15 PM with Personnel #3 and Personnel #4 they confirmed the patient's discharge summary did not include a burn diagnosis or follow-up wound care instructions for the patient's burns.

The Hospital's Documentation Standards policy, revision date of 10/2021, reflected, "The minimum required content of the inpatient care record includes ... Summarization of the patient's hospital course to include final diagnosis, condition on
discharge and discharge/ follow up instructions."