HospitalInspections.org

Based on record review and interview the facility failed to provide recommendations for appropriate services concerning follow-up or aftercare for 3 ( P#5, P#7, P#8) of 10 emergency room patient records reviewed. This failed practice could lead to patient harm due to lack of understanding or inappropriate follow-up care instructions.

The findings are:

A. Record review for P#5 discharge date 11/7/2019 at 16:10 (4:10 pm) record discharge instructions revealed, "please educate yourself on Wikipedia (a free online encyclopedia, created and edited by volunteers around the world) for endometriosis (development of uterine's inner lining tissue outside the uterus).

B. Record review for P#7 discharge date 10/7/2019 at 11:45 am record discharge instructions revealed, "follow educational materials", (the educational materials given was for children) the patient is 59 years old.

C. Record review for P#8 discharge date 10/7/2019 at 21:37 record discharge instructions revealed, "see pmd (primary medical doctor) two days, gi (gastrointestinal) asap (as soon as possible), general surgery after cgi (unknown what MD was referring to based on acronym) consult coordinate care with your pmd. Po (by mouth) fluids bed rest, ok to do needful". Patient is 91 years old.

D. Record review for P#9 discharge date 10/11/2019 at 20:20 record discharge instructions revealed, "po (sic) fluids and meds increasing pain return to er stat (immediately), eat healthy. follow educational materials". (the educational materials given was for children) patient is 26 years old.

E. On 3/3/2020 at 12:10 during interview S#3 (Director of Nursing) confirmed, "No, it is never appropriate in a discharge plan to instruct a patient to look at Wikipedia".

F. On 3/3/2020 at 8:30 during interview S#10 (Registered Nurse) confirmed, discharge summary instructions should be clear to the patient and Wikipedia should not be used as a source.

G. Record review of Policy for Discharge Instructions with review date of 2019, stated, "The provider, licensed nurse will verbally and in writing on the discharge instructions sheet, instruct patient on specific discharge instructions and appropriate follow up referrals will be given.