HospitalInspections.org

Based on record review and interview, the facility failed to ensure that discharge summaries contained psychiatric recommendations related to anticipated problems, and suggested means of intervention after discharge for 4 of 5 discharged patients whose records were reviewed (228, 229, 230 and 231). This failure results in a lack of critical clinical information that indicates the patient's level of psychiatric symptomatology and risk being available to aftercare providers.

Findings include:

A. Record Review

1. Patient 228: The discharge summary, dictated 10/3/12, in the section titled "Discharge/Aftercare Plan and Treatment Recommendations," related information only in regard to medications at discharge and living arrangements.

2. Patient 229: The discharge summary, dictated 9/22/12, in the section titled "Discharge/Aftercare Plan and Treatment Recommendations," related information only in regard to follow up concerning sobriety.

3. Patient 230: The discharge summary, dictated 9/5/12, noted no information about treatment recommendations or anticipated problems.

4. Patient 231: The discharge summary, dictated 10/1/12, in the section titled "Discharge/Aftercare Plan and Treatment Recommendations," related information only in regard to living arrangements and crisis care availability.

B. Interview

In an interview on 11/28/12 at 10:30 am, the Medical Director acknowledged the problems with discharge summaries continuing during the months of September and October.