HospitalInspections.org

Based on document review and interview, nursing services failed to ensure that patient's discharge instructions were signed and placed in patient's medical record in 2 out of 3 (patient 1 and 2) medical records reviewed.

1. Review of policy titled, titled, "CORE: Discharge Planning", approved 06/2023, indicated the nurse will have the patient or responsible family/caregiver sign the discharge instruction sheet attesting to receipt of the information and the nurse will sign and date the form.

2. Review of Patient 1's medical record indicated patient was discharged on 01/08/2024. The medical record lacked documentation of discharge instructions signed by the patient or responsible family/caregiver and the nurse's signature and date.

3. Review of Patient 2's medical record indicated patient was discharged on 01/05/2024. The medical record lacked documentation of discharge instructions signed by the patient or responsible family/caregiver and the nurse's signature and date.

4. Interview with A3 (Director of Case Management) on 02/14/2024 at approximately 11:15 am confirmed that Patients 1 and 2's medical record lacked documentation of signed discharge instructions by the patient or responsible family/caregiver or the nursing staff.