HospitalInspections.org

Based on a review of documentation and interview the facility failed to ensure that patient discharge summaries included the outcome of hospitalization and disposition of care.

Findings included:

Review of medical records revealed 2 of 10 patients had discharge summaries that did not accurately reflect the outcome of hospitalization and/or the disposition of their care.

* Patient #1 was discharged from the facility via ambulance after the patient called 911 on 05/16/20.
However, the discharge summary for this patient stated in part, "She was DCD [discharged] home with HHC [home health care] and meds as ordered." This did not accurately reflect what occurred at discharge or the actual disposition of the patient. There was no update to the discharge summary to reflect this unanticipated change in the discharge process or destination.
* Patient #2 was discharged from the facility Against Medical Advice (AMA) via ambulance on 06/01/20 at 2046.
However, the discharge summary for this patient stated in part, "Discharge disposition: discharge to home into the care of family member." This did not accurately reflect what occurred at discharge or the actual disposition of the patient. There was no update to the discharge summary to reflect this unanticipated change in the discharge process or destination.

In an interview on 12/09/20 staff member #1 verified that the above discharge summaries did not reflect the actual outcome of hospitalization and disposition of care for these two patients.