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1000 NORTH LEE AVENUE

OKLAHOMA CITY, OK 73101

STABILIZING TREATMENT

Tag No.: A2407

Based on record review and interview, the facility failed to ensure:

1. documentation that patients discharged from the emergency department received and understood discharge instructions for eight (Patient #3, 7, 11, 12, 13, 18, 19, 20) of 20 patients.

2. discharge instructions addressed diagnoses for one (Patient #9) of 20 patients

This failed practice has the likelihood to place patients at the risk of a worsening medical condition by not knowing what signs and symptoms to recognize as a change in medical condition and when to seek additional emergency care.


Findings:

1) A review of a document titled "After Visit Summary (AVS) Discharge Planning" read in part, "The patient or caregiver/guardian documents understanding and receiving the instructions by signing the AVS along with the discharging nurse and it is scanned into the patient's medical record."

A review of records showed no patient signature on the After Visit Summary (AVS) signature form and no documented reason for no patient signature for the following:

Patient #3 - discharged on 06/02/19 at 1:11 pm

Patient #7 - discharged on 05/04/19 at 6:33 am

Patient #11 - discharged on 09/04/19 at 3:42 am

Patient #12 - discharged on 10/10/19 at 12:52 am

Patient #13 - discharged on 06/23/19 at 4:30 pm

Patient #18 - discharged on 06/29/19 at 4:39 pm

Patient #19 - discharged on 06/27/19 at 11:52 pm

Patient #20 - discharged on 06/12/19 at 11:36 am

On 12/18/19 at 2:20 pm, Staff A stated patient signatures should have been found on the After Visit Summary (AVS) signature forms which would document the patients understood their discharge instructions. Staff A stated patients that refused or were unable to sign the form would have the reason documented on the form and in the chart. Staff A stated there were no documented reasons why these patients did not sign the forms.

On 12/18/19 at 2:40 pm, Staff J stated Patient #20 should have signed the After Visit Summary (AVS) signature form and could not find documentation why they had not signed it.


2) Patient #9

A review of an ED Provider note dated 10/23/19 at 4:54 PM showed a clinical impression of "Burn." A review of the After Visit Summary dated 10/23/19 at 4:33 PM showed a diagnosis of "Burn." A review of the discharge instructions dated 10/23/19 at 6:21 PM showed no instructions relating to a burn.

On 12/17/19 at 10:30 AM, Staff H stated he or she did not see burn information provided on the discharge instructions.