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TAMARACK HEALTH ASHLAND MEDICAL CENTER
No Description Available
Tag No.: C0304
Based on record review and interview the facility failed to ensure the discharge summary includes after care plans for the patient, in 5 of 10 medical records reviewed (1, 5, 6, 7 and 8).
Findings include:
Review of the facility's Rules and Regulations of the Medical Staff dated January 2012, revealed #15 "A discharge summary (clinical resume) to include discharge instructions to the patient shall be written or dictated on all medical records of all inpatients...All summaries shall be authenticated by the responsible Practitioner and should include..any special instructions given to the patient or family or both."
Patient #1's medical record review on 1/24/18 at 9:08 AM revealed the discharge summary completed 7/25/17 did not have discharge instructions included for the patient.
Patient #5's medical record review on 1/24/18 at 11:10 AM revealed the discharge summary completed 10/7/17 revealed the following under Discharge Plan "Refer to BH (Behavioral Health) Social Service Discharge Note for list of appointments made." There was no other documentation of discharge instructions.
Patient #6's medical record review on 1/24/18 at 11:20 AM revealed the discharge summary completed 11/23/17 revealed the following under Discharge Plan "Refer to BH Social Service Discharge Note for list of appointments made." There was no other documentation of discharge instructions.
Patient #7's medical record review on 1/24/18 at 11:30 AM revealed the discharge summary completed 11/30/17 revealed the following under Discharge Plan "Refer to BH Social Service Discharge Note for list of appointments made." There was no other documentation of discharge instructions.
Patient #8's medical record review on 1/24/18 at 11:40 AM revealed the discharge summary completed 1/15/18 revealed the following under Discharge Plan "Refer to BH Social Service Discharge Note for list of appointments made." There was no other documentation of discharge instructions.
The above deficiencies were confirmed in interview with BH Manager B on 1/24/18 between 9:08 AM and 11:40 AM, who acknowledged the plan should be in the summary.