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Based on interview and record review the facility failed to ensure 1 of 1 patients (Patient #1) was provided with Discharge planning.

Findings included:

On the morning of 04/12/2023 the surveyor reviewed Patient #1's medical record. There was no documentation or evidence of discharge planing.

During an interview on 04/12/2023 at 2:05 PM with Personnel #1 confirmed the patient did not have discharge planning. He said the facility didn't have a case manager during the time of the patient's admission.

Based on interview and record review the facility failed to include a discharge summary for 3 (Patients #1-#3) patients who had been discharged from the facility in March, 2023 and September, 2022.

On 04/12/2023 the surveyor conducted a record review of Patient #1's medical record. There was no discharge summary included.

During an interview on 04/12/2023 at 1:45 PM with Personnel #1 he said there had been some issues in obtaining discharge summaries from Physician #2. Personnel #1 provided additional patients (Patients #1-#3), that Physician #1 had not provided a discharge summary. There had been 30 days or more since the patient's discharge dates.

Based on interview and record review the facility failed to include necessary medical information for 1 (Patient #1) of 1 patient when he discharged from the facility. There was no continuity of care for the patient following his discharge,

Findings included:

During a review of Patient #1's medical record there was no documentation of medical information being provided to Patient #1 when he discharged from the facility. Physician #2's nurse's notes reflected on 09/04/2022 at 2330, "...Patient's son concern and requesting
father to be sent to ER. Provider notified. Provider stated there is no medical emergent reason for patient to go to ER. Provider stated to son can take patient out AMA [against medical advice]. This nurse present as supervisor explained AMA to patient's son. Patient's son notified that he would be responsible to set up transportation. Patient's son agreed and signed AMA form." On 09/05/2022 at 1320, "EMS with vent equipment here to transport pt to facility of choice... 1345-Pt transferred @ this time."

A review of Patient #1's emergency department medical record (at a local acute care hospital) dated 09/05/2022 reflected, per EMS the facility did not "provide EMS with any documentation prior to transport."

During an interview on 04/12/2022 at 12:22 PM with Personnel #3 she said the receiving hospital that Patient #1 went to called the facility and requested Patient 1's medical information. Always before the facility did not provide any medical information if the patient discharged AMA. She the instructed the facility staff that going forward, it was okay for them to send medical information with a patient if they left AMA. She said that was the right thing to do. The surveyor asked Personnel #3 if there was a policy indicating that medical information could not be sent with patients who discharged AMA and she said no.

The hospital's Transfer/Transport Care and Reporting policy with a review date of 04/2021 reflected, "...To provide a process that facilitates a consent to transfe and the communication of accurate information regarding the patient's health status prior to and following transport to/from an alternate institution or another unit for continuation of care services... Discharge from PH [Promise Hospital] 1. Upon discharge from PH for any reason, patient or patient's legal representative must be informed of the transfer/transportl and must provide consent through verification of signature on a Transfer/Transport Consent form... The patient's medicaltion reconciliation form will be printed from Meditech and accompany the patient upon transfer..."

Based on interview and record review the facility failed to provide discharge planning for 1 of 1 (Patient #1) patients.

Findings included:

On the morning of 04/12/2023 the surveyor reviewed Patient #1's medical record. There was no documentation or evidence of discharge planing for the patient.

During an interview on 04/12/2023 at 2:05 PM with Personnel #1 he confirmed the patient did not have discharge planning. He said the facility didn't have a case manager during the time of the patient's admission.