HospitalInspections.org

Based on record review and interviews the hospital failed to provide or transmit necessary medical information to the post-acute care service provider, an inpatient rehabilitation facility upon discharge 01/30/2025 for 1(P [patient] 2) of 4 (P1-P4). This deficient practice could result in misdiagnosis and inappropriate treatment by the receiving facility.

The findings are:

A. Record review of the facility's Policy ID 17244750 titled "Discharge Planning Process-After Care Plan "dated 01/2025 stated the following:
"The discharge planning process should:
j. Include timely and direct communication with and transfer of information to other programs agencies, or individuals that will be providing continuing care."

B. Record review of P2's admit date 01/24/2025 a social work note dated 01/29/2025, documented patient had been accepted, and transportation had been arranged to an inpatient rehabilitation facility. There wasn't any evidence that necessary medical information pertaining to patient's illness, treatment, and goals of care were sent to the receiving facility. There wasn't any documentation of a telephone call from hospital to receiving facility for the purpose of transmission of necessary medical information.

C. During an interview with S (staff)1, nonclinical, 06/25/2025 at 1:15 PM, S1 stated the hospital does not transfer any medical information unless it is requested. S1 said a nurse will usually call a report to receiving facility, however no documentation was found of a call taking place.