HospitalInspections.org

Based on record review and interview the facility failed to discuss the results of the discharge plan with the patient or the patient's representative. This failed practice is likely to expose patients to ineffective or dangerous care from inadequate planning.

Findings are:

A. Record review of P#1's medical charts revealed, the chart did not have signed discharge instructions, no discharge summary, or any notes of any discussion with the patient or the patients' family in regards to the discharge plan for P#1.

B. On 12/02/20 at 10am during interview with S#2 (Case Management Director) confirmed, P#1's medical chart did not have signed discharge instructions, a discharge summary, or any notes about conversions with P#1"s family about P#1's discharge plan.

C. On 12/03/20 at 11:10am during interview with S#5 (Director of Health Information Management (HIM) confirmed, the area in which the case manager used to note in P#1 chart does not cross over to the patients' chart and they have found three other charts since January with the same issue.





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