HospitalInspections.org

Based on record review and interview, the facility failed to maintain a medical record for a patient that shall include the discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care, in that, for one of one patients (Patient #1) whose Discharge Summary for 7/25/2023 did not evidence Patient #1 had developed a stage 3 pressure injury during hospitalization.

Findings

The physical therapy wound care evaluation completed on 7/17/2023 for Patient #1 reflected the patient had developed a stage 3 pressure injury on the sacrum requiring dressing changes. The Discharge Summary dated 7/25/2023 did not contain the information that the patient had developed a stage 3 pressure ulcer.

During an interview with Personnel #1, Personnel #1 verified the Discharge Summary did not contain the information that the patient had developed a stage 3 pressure injury during hospitalization.

The facility's 10/27/2020 Medical Staff Rules and Regulation reflected the following, " ...Discharge Summary/Transfer Summary/Death Summary: a. The discharge summary should recapitulate: i. Reason for Hospitalization; ii. Significant Findings; iii. Procedures performed and treatment rendered; iv. Condition of the patient on discharge; v. Provisions for follow-up care, unless documented in the electronic health record generated discharge instructions; iv. Any specific instructions given to the patient and/or family, if any, unless documented in the discharge instructions ..."