HospitalInspections.org

Based on the review of one medical record (MR) MR1, facility document review, and staff interviews, it was determined that the facility failed to ensure that documentation in the medical record is accurate.

Findings include:

Facility policy titled, "Documentation (ER26) IHN [Name of facility]," last reviewed 12/07/22, stated, "... The patient record is initiated upon the patient's arrival ... All documentation should be complete and legible..."

During review of MR1, with Staff (S) 13 (Director of Social Work) and S15 (Director of Care Coordinators), the following was identified:

The "ED [Emergency Department] Nursing Note," dated 12/24/24 at 00:25 (12:25 AM), stated, "pt [patient] discharged home." MR1 lacked documentation of a discharge summary or an order for discharge for P1. S13 and S15 explained that the original plan was to discharge P1 to home, however that plan was changed. S13 and S15 confirmed that the nurse note documented in MR1 was inaccurate.

The "Discharge Planning Initial Assessment" written by S14 (ED social worker), dated 12/24/25 at 9:36 AM, stated, " ... Patient was brought in by EMS [emergency medical services] and dc'd [discharged] home. Subsequently, EMS brought patient back to ER [emergency room] due to poor living conditions at home ..."

The transport log dated 12/24/24 -12/25/24 was reviewed and it lacked documentation that P1 was transported home on 12/24/24. The facility provided a copy of the communication with the transport company. The "Trip Details" report for the transport called for P1 dated 12/24/24 at 1:28 AM, stated, " ... per [staff name] cancel trip. Pt [patient] is being admitted ..."

On 03/06/25 at 2:00 PM, during an interview conducted in the presence of S13 and S15, S14 stated that the information documented in the "Discharge Planning Initial Assessment" found in MR 1 dated 12/24/24 at 9:36 AM, was based on information verbally provided to S14 by another staff member. S14 stated that based on what he/she knows now, the note is inaccurate, and the patient did not leave the facility on 12/24/24. S13 confirmed that the original plan was to discharge P1 to home, however that plan was changed and P1 was held in the Emergency Department overnight until the social work evaluation was conducted.

This finding was confirmed by S13, S14, and S15 on 3/6/25 at 2:10 PM.