The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LAKELAND REGIONAL MEDICAL CENTER 1324 LAKELAND HILLS BLVD LAKELAND, FL 33805 March 29, 2016
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of the facility's policy and procedure it was determined the facility failed to ensure staff provided the patient and family members or interested persons of discharge instructions to prepare them for post-hospital care for one (#4) of ten patients sampled.

Findings included:

Review of the medical record for patient #4 revealed the patient was admitted on [DATE]. Review of the record revealed the patient had a history of ESRD (End Stage Renal Disease) and received dialysis treatments three times weekly. .

Review of the record revealed the patient was discharged home with family on 3/01/2016. Review of the record revealed documentation of discharge instructions. Nursing documentation on 3/01/2016 stated the patient was discharged home with family and all parties were agreeable to the discharge plan. Review of the record revealed no evidence the patient signed or received a copy of the discharge instructions.

Review of the facility policy "Patient Discharge" with an effective date of 8/05/2013 indicated the RN (Registered Nurse) was responsible to ensure the accuracy of the discharge instructions, prints the "Patient Instruction for Aftercare" and reviews it with the patient/family/healthcare representative. The RN was responsible to obtain the patient/family/healthcare signature and to provide a copy of the instructions.

The medical record was reviewed with the Director of Strategic Performance & Quality Assurance on 3/29/2015 at approximately 11:00 a.m. An interview was conducted at the time of the record review at which time it was confirmed there was no evidence the patient signed or received a copy of the patient instructions for aftercare.