HospitalInspections.org

Based on document review and interview, it was determined for 1 of 4 (Pt#1) closed records reviewed, the Hospital failed to ensure the discharge summary contained all required information.

Findings include,

1. Pt#1 was a 67 year old male post surgical patient (laminectomy) admitted to to the Hospital on 9/24/13 with documentation of a Stage II pressure ulcer. On 9/25/13 the Wound Care Nurse documented, "deep tissue injury". Pt #1 was discharged on 9/27/13 to the Rehabilitation unit of the Hospital. Pt #1's discharge summary from the Hospital to the Rehab Unit failed to include Pt#1 had developed a pressure ulcer, treatment and plan.

On 10/11/13 Pt #1 was discharged to another facility (nursing home rehab facility). Discharge summary dated 10/11/13 failed to include Pt #1's decubitus ulcer, measurements and staging, treatment, progress and plan of the sacral pressure sore.

2. Hospital policy entitled "Discharge Summary" (Revised 10/2011) included, "...5. Discharge summaries include the following.... secondary diagnosis...physical findings,...treatment provided....results of procedures and abnormal results...."

3. On 9/11/13 at approximately 2:30 PM, E #3 (Director of Quality) stated the policies of the Hospital are valid for the acute units as well as the rehabilitation unit. E #3 shook her head and acknowledge the discharge summary failed to include the required items.