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Based on review of the medical record for patient #1, the hospital failed to accurately document care instructions to the post care setting, when the hospital failed to send a complete discharge summary with patient #1 to the subacute rehabilitation center. The summary did not include the patients routine respiratory medications for his COPD.

Patient #1 is a 54 year old male who presented to John Hopkins Bayview Medical Center on 8/13/10 with a history of End Stage Renal Disease with dialysis on Tuesday, Thursday and Saturday, Type II Diabetes, Right 4th and 5th digit of right foot amputation, Hypertension, and Chronic Obstructive Pulmonary Disease (COPD) on 3 liters of oxygen. On the 8/13/10 the patient presented to the ED because he noted that his 3rd right toes was blackened and painful. The patient had surgery times two with the final procedure resulting in a BKA (below the knee amputation). Once the patient was stable he was assessed by the hospital and found to be an unsafe discharge to home. Instead, the patient was discharged to a subacute rehabilitation center for physical and occupational therapy. The patient was subsequently transferred to the subacute facility on 8/20/10.

Patient #1 's medication reconciliation record revealed that on admission the patient was taking Advair 250/50 one puff twice daily, Spiriva 18mcg one puff inhaled once daily and Albuterol inhaler two puffs as needed every four hours. It is documented on the medication administration record (MAR) that patient #1 received these medications while he was in the hospital. However, the patient's discharge summary listed only the Albuterol. The Advair and Spiriva were not documented on the discharge summary. Per the patient's physician orders and medication administration record from the subacute rehabilitation center the Advair and Spiriva were also not listed among the medications ordered for the patient. The hospital noted that the medication reconciliation form was not complete because the patient was transferred to a subacute rehabilitation center. The hospital noted that when they transfer a patient to another facility, they will send a packet that contains the eMAR (electronic medication administration record) and discharge summary. The purpose of providing the eMAR along with the discharge summary is to provide a complete list of medications to be used with the discharge summary. However, the discharge summary and the eMAR contained inconsistent information.