HospitalInspections.org

Based on record review and interview the facility failed to ensure that records were complete and accurately documented as evidenced by 1 of 10 patients (Patient #1) reviewed did not have signed discharge instructions prior discharge as required by facility policy.

Findings include:

Review of the facility policy "Discharging patient", last revised 9/2024, reflected:
"POLICY: IT IS A POLICY OF LYNN COUNTY HEALTHCARE SYSTEM FOR ALL PATIENTS TO RECEIVE WRITTEN AND VERBAL INSTRUCTIONS CONCERNING THEIR CARE UPON DISCHARGE FROM THE HOSPITAL.
1. Print off the appropriate instructions and education from the EMR, explain and give to patient, answering any questions they may have.
2. List date and time of follow-up appointments.
3. List medication to be taken including dosages on the home medication reconciliation form.
4. After signed by the patient and nurse, give the patient a copy of the instructions, registration to scan signed copy into EMR ..."

Review of Physician orders, dated 01/05/24 08:36, reflected "Dismiss with Home Health Evaluate & Treat Skilled Nursing and Physical Therapy."

During a telephone interview, on the afternoon of 1/27/24, Staff #8, RN, reported "the patient's family called (the nurse caring for the patient) and told her that the patient just wanted to go home after her infusion... The patient's sister and brother-in-law came by that afternoon to review the discharge instructions, pick up the patient's belongings, and sign the paperwork. At this time the patient's sister reported that the patient just wanted to go home after her appointment."

During an interview, on the afternoon of 1/27/24, the Staff #3, DON, verified that the facility did not follow the discharge policy.