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Based on interview and record review the facility failed to include necessary medical information for 1 (Patient #1) of 1 patient when she was discharged from the facility. There was no continuity of care for the patient following her discharge. As a result, Patient #1 returned to the hospital's ED (emergency department) eight days after her discharge with symptoms of blood clots.

Findings included:

Patient #1 was an 89-year-old female who was admitted to the hospital on 3/06/23 for a right comminuted intertrochanteric femur fracture with displacement. She underwent a right hip open reduction internal fixation on 3/7/2023.

During a review of Patient #1's medical record there was no documentation of a discharge order for Lovenox (anticoagulant), or any other blood thinning medication provided to Patient #1's skilled nursing facility at discharge on 3/10/23.

A review of Patient #1's emergency department medical record dated 3/18/23 reflected she presented to the ED for right upper extremity weakness, worsening shortness of breath, and pleuritic chest pain. Patient #1's tests revealed she had several blood clots. She had a small non-occluding thrombus in the superior sagittal sinus (in the brain). She had extensive pulmonary emboli in the bilateral lungs.

During an interview on the morning of 6/06/2023 with Physician #4, he said he found out about Patient #1's blood clots when the patient returned to the hospital's ED. He said FNP #5 (Family Nurse Practioner), had not ordered a DVT protocol (deep vein thrombosis) when she discharged Patient #1. He spoke with her about Patient #1. FNP #5 didn't know why she didn't order the Lovenox. She felt bad and embarrassed. Physician #4 said patients should be on a DVT protocol for 14-30 days.

This hospital's Multidisciplinary Discharge Planning policy with a review date of 02/2023 reflected,
"2.4 Discharge Function:
2.4.1 The discharge planning function focuses on meeting the patient ' s continuing healthcare needs after discharge... 3.2 Each discipline assesses needs for after care as part of their ongoing assessment and reassessment processes. 3.2.1 It is the responsibility of each discipline assessing discharge planning needs to document associated assessment findings within the medical record..."