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Based upon record review and interviews, the facility failed to ensure that an appropriate discharge plan, including written and verbal discharge instructions, were provided to patients receiving procedures in the radiology department in 5 of 8 records reviewed (Patient IDs # 1,6, 7, 8 and 9).

Findings Include:
Record review of Memorial Herman Health System "Nature & Scope of Service Imaging Department" document (no date) stated "Standards of Care/Assessment: Education of Patients and Family: The patient and/or, when appropriate, his or her family are provided with appropriate education to increase knowledge of hte patient's exam being performed."

Record review of Memorial Hermann Heath System "General - Patient Education Procedure for Radiologic Tests", published 2/24/2015 stated "Responsible Party: All Radiology Technologists" and "Action: 1) The patient, or when appropriate, the family, are provided with appropriate education and training relative to the patients ago to increase understanding the patient's diagnostic procedure." "8) Explain any aftercare instructions to the patient and emphasize the importance of following these instructions. (i.e. proper diet proceeding barium studies, after care following arthrogram, myelogram studies, biopsies, etc.)."

Record review of institutional policy and procedures revealed that the facility failed to have a written policy which included discharge criteria for patient's post-procedure, need for written and verbal discharge information to be provided to patients and families post-procedure and policy describing documentation needed for validation of the process.

Record Review of 5 of 8 patient medical records (#1, #6, #7, #8, #9) revealed no documentation of discharge instructions, verbally or in writing.

a) On 10/20/22 10:55 a.m., record review of Patient ID # 1 ' s clinical record with Staff ID #56 revealed she had a myelogram performed by physician Staff ID #64. She was discharged home from the facility with no documentation of verbal or written discharge instructions.

b) On 10/20/22 12:19 p.m., record review of Patient ID #6's medical record with Staff ID #56 revealed he had a liver biopsy performed by physician Staff ID #58. He was discharged home from the facility with no documentation of verbal or written discharge instructions.

c) On 10/20/22 12:45 p.m., record review of Patient ID #7's medical record with Staff ID #56 revealed she had a lumbar puncture performed with intrathecal chemotherapy administration by physician Staff ID # 58. She was discharged home from the facility with no documentation of verbal or written discharge instructions.

d) On 10/20/22 12:05 p.m., record review of Patient ID #8's medical record with Staff ID #56 revealed she had a lung biopsy performed by physician 59. She was discharged home from the facility with no documentation of verbal or written discharge instructions.

e) On 10/20/22 12:15 p.m., record review of Patient ID #9's medical record with Staff ID #56 revealed she had a myelogram performed with physician Staff ID # 64. She was discharged home from the facility with no documentation of verbal or written discharge instructions.

Interview 10/20/22 12:15 p.m. with Radiology RN, Staff ID #56, during record reviews revealed "I don't see it" when asked to show documentation of verbal and/or written instructions in Patient ID # 1, 6, 7, 8, and 9 medical records. She stated, we print instructions from external "Krames" program, however she stated she could not see proof of instructions in the medical records. She verified that nursing is not involved with all procedures being performed in radiology department.

Interview with Radiology Director, Staff ID #54 on 10/20/22 1:15 p.m., she stated that they previously had a printed duplicate sheet which was a discharge instruction sheet and the patient would be given the original form and a copy placed in the medical record. She stated the facility eliminated this form. She validated that there was not a policy and procedure, process or form which addressed discharge instructions process in the radiology department. She verified there was no tracking or monitoring of the discharge process. She stated that some tests are perfomed with radiology technologist and physicians exclusively. She validated that those patients may not have a nursing assessment or involvement in the discharge plan. She verbalized recent awareness of opportunities for changing processes based on lower than desired patient satisfaction scores related to discharge processes in radiology.