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Based on interview and record review, the facility failed to ensure Patient 8 and Patient 13 received necessary information for continued care during discharge.

This failure had a potential for the patients to limit their right to participate in implementing their plan of care with insufficient discharge information.

Findings:
Review of Patient 8's "ED provider Notes", dated 11/18/24, indicated Patient 8 presented to the Emergency Department (ED) with gastrointestinal (GI) bleeding (bleeding from the stomach). During the course of the ED visit Patient 8 had an unwitnessed syncopal event (fainted)/ collapse hitting his head causing a laceration that was repaired/sutured in the ED.

Review of Patient 8's "Gastroenterology Consult Note" dated 10/18/24, indicated Patient 8's complaint was rectal bleeding, the patient was admitted for an emergent inpatient colonoscopy.

Review of Patient 8's After Visit Summary (AVS) (a paper or electronic document given to patients after a hospital visit, which is intended to summarize patients' health and guide future care, including self-management tasks), dated 10/20/24, indicated Patient 8's reason for hospitalization was "cellulitis", there was no indication in Patient 8's medical record of treatment for cellulitis. There was no indication Patient 8 received information regarding the care of the sutures placed in the ED or follow up care.

During a concurrent interview and record review on 11/15/24 at 10:15 a.m. with the Manager of Regulatory Affairs (MRA), the MRA stated, the after visit summery had some incorrect information for Patient 8.

Review of Patient 13's "Discharge Summary" dated 9/6/24, indicated Patient 13 was admitted due to a rattlesnake bite to his right finger complicated by right upper extremity swelling requiring antivenom and observation of airway.

Review of Patient 13's After Visit Summary, dated 9/6/24, indicated there was no evidence of discharge instructions regarding snakebites, warning signs to watch for and symptoms of worsening condition, or side effects to monitor following the antivenom (treatment for snake bites) administered.

During an interview on 11/15/24 at 11:13 a.m. with the Registered Nurse/Nursing Director (RN) A and Registered Nurse (RN) B, RN B stated "the after visit summary has specific discharge information for the patient including information about patients' diagnosis, care, and when to follow up. RN A stated in follow up, "absolutely, specific instruction on snake bites should have been provided to the patient"

Review of the facility's policy & procedure (P&P), "Admission Assessment and Reassessment, Adult & Pediatric", dated 1/18/23, indicated The patient will be assessed, and condition documented on the fields in the electronic record Nursing Discharge Navigator 4. Special instructions .... 10g. Follow up care instructions."