HospitalInspections.org

Based on document review and interview, the nursing staff failed to ensure discharge instructions and medication list were provided to the patient for 1 of 11 MRs (medical record) reviewed. (Patient # 8).


Findings include:

1. Review of established hospital policy titled: "Patient Discharge-AMA" (Against Medical Advice), Policy Stat ID 13916075, indicated under Procedure, page 2, 8. "The prescriber will evaluate medications and provide prescriptions. If the provider declines to provide prescriptions to the patient the provider will document the rationale". Last revised 6/2023.

2. Review of established hospital policy titled: "Patient Education about Discharge Medications", Policy Stat ID 10009376, indicated on page 1, under Policy "The patient shall receive appropriate education about medications provided at discharge." and under Procedure, "Documentation of education regarding discharge medications shall be recorded." Last revised 12/2021.

3. Review of Patient # 8 MR, indicated the following:
A. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 12/29/2023.
B. Patient signed out; left AMA on 1/2/2024 at 10:45 am.
C. MR lacked documentation for the following:
1. Discharge instructions.
2. A discharge medication list and education.
D. MR lacked documentation by Social service staff, Nursing staff, and provider in regards to why above not provided to patient on 1/2/2024.

4. In interview with A # 3 (Quality/Risk) on 2/5/2024 at approximately 10:45 am, and on 2/6/2024 at approximately 12:15 pm, the following was confirmed:
A. Patients receive medication list; prescriptions called in to pharmacy; discharge instructions; even if sign out AMA; unless Doctor documents for none to be received/given.
B. Confirmed/verified MR for patient # 8 MR lacked part of discharge plan document, lacked medication list and education for discharge. Discharge summary lacked documentation of discharge instructions and lacked documentation of medication list.