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Based on document review and interview, it was determined that for 1 of 10 (Pt #4) patient records reviewed for discharge planning, the Hospital failed to ensure that all necessary medical information pertaining to the patient's current course of illness and treatment was provided, at the time of discharge, This has the potential to affect all hospital patients with a current average census of 365.

Findings include:


1. On 4/6/2021 at 9:00 AM, the Grievance and Complaint log for 11/2020-4/1/2021, was reviewed. Pt #4 had lodged complaint's on 3/24/2021, concerning patient care, not understanding discharge instructions, and error in medications.

2. On 4/6/2021 at approximately 3:00 PM, an interview was conducted with the Patient Experience Manager (E #8). E #8 stated that there is an on-going investigation for the complaints lodged by Pt #4, including the medications not given to Pt. #4.


3. On 4/6/2021 at approximately 3:30 PM, the policy titled "Discharge Planning" (dated 7/2020) was reviewed. The policy required that "Arrangements made for discharge of the patient to his/her home or institution, including written instructions to the patient/family or institution. ...Nursing unit colleges gives a copy of the discharge plan to patient/family/caregivers. Include any additional written instructions, prescriptions ..."

4. On 4/6/2021 at 4:00 PM, the record of Pt #4 was reviewed. According to Pt #4's record, Pt #4 was admitted on 3/11/2021, for a large laceration of the left leg due to a work-related accident. He was placed on IV (Intravenous) antibiotics and had the wound " washed out " This was followed by surgical debridement, placement of a drain, and partial closure. After discussion with consulting physicians, the patient, and the family, Pt #4 was taken to surgery on 3/12/2021 for " further wash out and debridement " Following the procedure another drain was placed. Pt #4 was placed on daily dressing changes, IV antibiotics, and IV pain medications. " It was discussed with pharmacy, the appropriate antibiotics for coverage of corn-based bacteria. Plan is to send patient home with doxycycline, penicillin, G (antibiotics) and fluconazole (anti-fungal). Scripts were placed in the chart. " On 3/13/2021. The discharge papers which were given to Pt #4, stated to take two antibiotics until all gone. The antibiotics were omitted from the "Medication Discharge Report" documents given to the patient . Pt #4 was discharged home on 3/13/2021.

5. According to Pt #4's record, on 3/16/2021, Pt #4 was admitted to the facility with cellulitis (infection) and edema (swelling) of the left leg. According to Pt #4's discharge summary dated 3/23/2021 and authored by Physician (MD #1) " Patient was sent home (3/13/2021) with antibiotics. ...unfortunately, patient did not have all the antibiotic prescriptions and came to the clinic/office with cellulitis and edema." Patient was admitted to the facility on 3/16/2021 for IV antibiotics and symptom management. Patient was discharged on 3/23/2021, with a PICC line for infusion of antibiotics.

6. On 4/7/2021 at 1:34 PM, an interview was conducted with 3G Registered Nurse (E#14) and 3G Nurse Manager (E #15). E #15 stated, the process for discharge is that the discharge medications ordered by the Physician should reconcile and transfer over to the discharge medication list, as well as, scripts sent to the patient's pharmacy of choice. "In the case of Pt #4 this did not occur, so the antibiotics did not show up on the patients medication discharge list or sent to the pharmacy. This was an isolated incident"

7. On 4/7/2021 at 2:15 PM, the policy titled "Medication Reconciliation" (dated 7/2020) was reviewed. The policy requires that" Discharge: When the patient is ready for discharge the physician will complete the electronic Discharge Reconciliation. When this has been completed fully there will be a green check mark present next to the Discharge on the Reconciliation Status of the Order Summary page in the EMR...Once the medications have been reconciled by the physician, the nurse or pharmacy when appropriate will then click on the reconciliation tab click on discharge, then click notes to patient section ...Once finished entering this patient information the nurse will sign and print the medication list for the patient. The nurse will review the discharge medication list with the patient, family, or appropriate care giver to ensure understanding."