HospitalInspections.org

Based on medical record review, policy review and interview, the facility failed to ensure the medical record for one patient (Patient #2) contained all pertinent information regarding the patient's alleged refusal of home health services upon discharge.

Findings include:

Patient #2 was admitted to the facility on 08/06/24 and discharged home on 08/23/24.

Review of the progress note documented by Staff E on 08/14/24 at 12:36 PM revealed Patient #2's current discharge plan was to return home with home health.

Review of the progress note documented by Staff E on 08/21/24 at 9:32 AM revealed the current discharge plan was for Patient #2 to return home. Patient #2 had a home health agency three days per week for four hours per day. Patient #2 wanted to return home with resumption of home health care.

Interview on 10/03/24 at 1:48 PM with Staff G revealed when Staff G discharged Patient #2 home, he did not have home health, he said he did not need home health and refused home health.

The medical record for Patient #2 did not contain documentation stating the patient refused home health care.

The findings were shared with Staff A on 10/03/24 at 2:27 PM and confirmed.

Review of the facility's Documentation Standards Policy revealed the medical record would provide current, complete, and consise description of the patient's status.