HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to arrange for the initial implementation of the patient's Discharge Plan in one (#6) of ten (#1-#10) discharged patients. The failed practice did not ensure Patient #6 had appropriate medical equipment or follow-up care as ordered by the physician. The failed practice had the potential to affect any patient needing medical equipment or follow up care upon discharge. Findings follow:

A. Review of Clinical Record #6 dated 07/20/20 at 3:02 PM showed Order for "Immobilizer to affected shoulder; leave in place for 24 hours."
1) Review of the clinical record showed no evidence that Patient #6 was placed in and sent home with an immobilizer to the affected shoulder post-operatively.
2) Review of the patient complaint showed "Complainant found out later that the patient's arm was supposed to be in a sling and she was not discharged with one."
3) The Quality RN (Registered Nurse) verified in an email on 10/2/20 at 2:12 PM that "the Medical Representative stated the patient did not receive a sling during their encounter."
B. Review of Clinical Record #6 dated 07/20/20 at 3:02 PM showed Order for "Make appointment for patient to meet with Pacemaker Representative for device interrogation the morning after procedure." Review of Clinical Record #6 Discharge Documentation showed no evidence that Patient #6 was scheduled for an appointment with the Pacemaker Representative for device interrogation the morning after the procedure.