HospitalInspections.org

Based on record review and interview, the facility failed to ensure that 1 of 10 medical records reviewed for discharge summaries included each patient's disposition of care (Patient #11).

Findings were:

Patient #11's clinical record reflected Patient #11 was admitted 8/17/2022 at 17:05.

Interdisciplinary notes dated 8/17/22 reflected in part, "...72-year-old male presenting to the psych hospital on EDO (emergency detention order) status due to confusion and psychosis."

The discharge summary dated 9/1/2022 reflected, "He is leaving today. He has been medication compliant. He has improved with the medication changes. He will need continuing medication management."

The facility policy and procedure "Patients' Discharge Summary" Revised 4/1/22 reflected in part, "...5. The record of each patient or outpatient discharged needs to include a discharge summary with the following information: Conditions and disposition at Discharge.."

During an interview on the afternoon of 12/20/22, Staff #2 stated "we have been looking through the chart and we see where there was contact with the patient's brother. The discharge summary does not address the patient's disposition post discharge, but the physician's orders do."