HospitalInspections.org

Based on review of the medical record (MR) and facility policies, and staff interview (EMP), it was determined the facility failed to ensure the patient was discharged with a complete and accurate list of instructions to ensure the provision of self care post hospitalization for one of 18 medical records reviewed (MR1).

Findings include:

Review of facility policy "Patient Discharge" reviewed August 2014 revealed, "...8. At the time of discharge all patients will be provided with discharge instructions, which include a list of medications, special diet instructions, activity restrictions and follow-up care provisions."

Review of facility policy "Discharge Planning" revised September 2014 revealed, "RESPONSIBILITY...2. ...The physician is responsible for documenting specific discharge instructions including a complete list of patient's medications. ...COMPLETING THE DISCHARGE TRANSITION OF CARE RECORD (DTOC)...Information provided to patients on discharge includes Discharge Transition of Care Record and Medication Reconciliation (Reason for inpatient admission, Major procedures and tests including summary of results and principal diagnosis at discharge); Post-discharge/Patient Self-Management (Current medication list, studies pending at discharge, and patient instructions)."

1. On May 28, 2015, review of MR1 revealed the patient had wounds to both wrists at the time of discharge and there was no instruction related to care of these wounds included on the DTOC.

On May 29, 2015, at approximately 11:00 AM EMP16 confirmed the above findings.

2. Further review of the DTOC for MR1 revealed the medication reconciliation included an order for the patient to administer three (3) units of insulin three (3) times a day before meals. A progress note by the physician, dated February 6, 2015, revealed the patient was for discharge and should administer ten (10) units of insulin three (3) times a day before meals. There was no evidence of written instruction on how often or when the patient should check his blood sugar upon discharge.

On May 29, 2015, at approximately 1:00 PM EMP14 confirmed the patient discharge instructions should have been updated to direct the patient to administer ten (10) units of insulin three (3) times a day and should have stated how often to check the blood sugar levels.