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.
|RIVERSIDE MEDICAL CENTER||350 N WALL ST KANKAKEE, IL 60901||Sept. 10, 2014|
|VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY||Tag No: A0468|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined for 1 of 4 (Pt#1) closed records reviewed, the Hospital failed to ensure the discharge summary contained all required information.
1. Pt#1 was a [AGE] year old male post surgical patient (laminectomy) admitted to to the hospital on [DATE] with documentation of a Stage II pressure ulcer. On 9/25/13 the Wound Care Nurse documented, "deep tissue injury". Pt #1 was discharged on [DATE] to the Rehabilitation unit of the Hospital. Pt #1's discharge summary from the Hospital to the Rehab Unit failed to include Pt#1 had developed a pressure ulcer, treatment and plan.
On 10/11/13 Pt #1 was discharged to another facility (nursing home rehab facility). Discharge summary dated 10/11/13 failed to include Pt #1's decubitus ulcer, measurements and staging, treatment, progress and plan of the sacral pressure sore.
2. Hospital policy entitled "Discharge Summary" (Revised 10/2011) included, "...5. Discharge summaries include the following.... secondary diagnosis...physical findings,...treatment provided....results of procedures and abnormal results...."
3. On 9/11/13 at approximately 2:30 PM, E #3 (Director of Quality) stated the policies of the Hospital are valid for the acute units as well as the rehabilitation unit. E #3 shook her head and acknowledge the discharge summary failed to include the required items.