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.
|THE VINES HOSPITAL||3130 SW 27TH AVE OCALA, FL 34474||Feb. 21, 2018|
|VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS||Tag No: A0469|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, interview, and review of the facility's Policy and Procedures, 2 of 10 discharge patients failed to have a complete discharge without the signature of the physician (Patients #3 and #5).
The findings include:
Record review of Patient #3 did not reveal a signed completed discharge by the physician within 30 days. Further review of the medical record revealed that the patient was admitted voluntarily on 01/05/18 at 11:50 AM to the acute psychiatric unit for suicidal ideation. The patient was placed on one to one (1:1) due to aggressive behaviors to another patient and discharged to law enforcement on 01/05/18. at 9:30 PM.
Record review of Patient #5 did not reveal a signed and dated completed Discharge Plan Part I by the physician within 30 days. Further review of the medical record revealed that the patient was admitted involuntarily of a Baker Act on 12/17/17 to the acute psychiatric unit for suicidal ideation. discharged on [DATE].
Review of the facility's Policy and Procedures titled Discharge Summary/Termination Report revealed the following:
Policy: A Discharge Summary shall be completed following the discharge within a reasonable length of time, and not to exceed 30 days for Acute Care and 15 days for Intensive Residential Treatment. A completed discharge summary means that the summary is dictated and signed.