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Based on medical record review, policy and procedure review and interview, facility staff did not ensure provisions were in place for follow-up medical care for Patient #1. This has the potential to negatively impact the continuity of patient care.

Findings include:

Review of ED Physician Impression and Plan in medical record dated 8/28/15 at 5:14 PM revealed the patient was discharged to home with instructions to follow up with "PHYSICIAN NONE within 1 to 2 days".
Review of the facility policy and procedure titled " Standards of Reasonable Care " , last revised 2/16, stated the following:
- Discharge assessments completed by the Registered Nurse include: Patient ' s knowledge and understanding of his/her plan of care, instructions, medications and follow-up care.
- Related Standards of Care: The patient and/or family will receive verbal and written instructions regarding aftercare, follow-up and/or referrals.

Review of the facility policy and procedure titled " Discharge Instructions " , last revised 1/15, stated the following:
- All patients discharged from the Emergency Department will receive condition-appropriate instructions for home care and appropriate referrals.
- Appropriate follow up referral will be given utilizing the " Physician On-Call List. "

Interview with Staff #3 on 5/12/16 at 10:30 AM revealed that when patients are registered into the facility system, the primary care physician should be entered in the Encounter Information. The primary care physician (PCP) information will download into the discharge follow-up instructions. Staff #3 stated that since Patient #1 ' s PCP in the Encounter Information was listed as NONE, this same information transferred into the discharge instructions. Staff #3 stated that specific information regarding provider follow-up should be included in the discharge instructions.