HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of nine acute and swing bed patients. Based on medical record review, document review and staff interview the CAH failed to complete patient's discharge summary within thirty days in accordance with Medical Staff Rules and Regulations for four of twelve closed medical records reviewed (#'s 22, 27, 28, and 31). Failure to promptly complete a discharge summary denies access to a complete medical record

Findings include:

-The CAH's Medical Staff Rules and Regulations review on 1/29/14 at 9:55am directed, " ...records must be completed and signed by the attending physician as soon as possible following discharge. Any staff member that is 30 days behind in completing his or her charts will receive a written notice of noncompliance with medical staff rules and regulations ... "

-Patient #22's closed medical record review on 1/27/14 revealed an admission date of 11/9/13 and discharged on 11/12/13. The medical record review revealed a discharge summary dictated on 12/6/13, typed on 12/10/13 and signed by the physician on 12/22/13 (40 days after discharge).

-Patient #27's closed medical record review on 1/29/14 revealed an admission date of 10/14/13 and discharged on 10/18/13. The medical record review revealed a discharge summary dictated on 12/6/13, typed on 12/9/13 and signed by the physician on 12/22/13 (64 days after discharge).

-Patient #28 s closed medical record review on 1/29/14 revealed an admission date of 10/24/13 and discharged on 10/28/13. The medical record review revealed a discharge summary dictated on 12/6/13, typed on 12/9/13 and signed by the physician on 12/22/13 (54 days after discharge).

-Patient #3's closed medical record review on 1/28/14 revealed an admission and discharged date of 12/3/13. The medical record review revealed a discharge summary dictated on 12/3/13, typed on 12/6/13 and not signed by the physician (56 days after discharge).

Administrative staff A, Administrative staff B, and Administrative staff C on 1/28/14 at 5:10pm indicated they were aware medical staff failed to complete patient medical records within thirty days in accordance with Medical Staff Rules and Regulations.