HospitalInspections.org

Based on document review, medical record review, and staff interview, the facility failed to ensure a discharge summary was written, dictated and/or authenticated by the physician and in the medical record for 4 of 5 (N1, N2, N3 and N5) closed patient medical records reviewed.

Findings:

1. Medical Staff Rules and Regulations, indicated on pg. 9, point 2., "The physician's portion of the medical record shall be complete, pertinent, timely, legible and shall include...physician discharge summary or note..."

2. Review of closed patient medical records on 8/9/10 at 10:22 AM, indicated patient:
A. N1 was admitted on 6/16/10 and discharged on 6/19/10 and lacked documentation of a physician discharge summary.
B. N2 was admitted on 6/21/10 and discharged on 6/23/10 and lacked documentation of a physician discharge summary.
C. N3 was admitted on 5/17/10 and discharged on 5/18/10 and lacked documentation of a physician discharge summary.
D. N2 was admitted on 7/8/10 and discharged on 7/15/10 and lacked documentation of a physician discharge summary.

3. Personnel P4 was interviewed on 8/9/10 at 11:00 AM and confirmed all patients are to have a Physician Discharge Summary in their medical record no later than 30 days from discharge as required per facility Medical Staff Rules and Regulations.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to implement a Case Management Discharge Planning and Evaluation and a Case Management Discharge Planning Summary and ensure a copy was in the medical record for 2 of 5 (N1 and N3) closed patient medical records reviewed.

Findings:

1. Policy No. CM-01 titled, "Case Management Assessment Plan" was reviewed on 8/9/10 at 1:00 PM and indicated:
A. on pg. 1, point C., 4., "Case Manager shall formulate a discharge plan by...Document plan on discharge planning sheet and place in patient record."
B. on pg. 2:
a. point E., 3., "Assure completion of required forms and documents."
b. point F., 4., "Document final note and evaluate the chart to note completion of charting. See Case Management Discharge Planning Summary."

2. Policy No. CM-22 titled, "Discharge Planning" was reviewed on 8/9/10 at 1:00 PM and indicated on pg. 1, point 1.0, "Document on the Environmental Assessment form or ancillary notes the anticipated discharge needs."

3. Review of closed patient medical records on 8/9/10 at 10:22 AM, indicated patient:
A. N1 was admitted on 6/16/10 and discharged on 6/19/10 and lacked documentation of Case Management Discharge Planning and Evaluation and Case Management Discharge Planning Summary.
B. N3 was admitted on 5/17/10 and discharged on 5/18/10 and lacked documentation of Case Management Discharge Planning and Evaluation and Case Management Discharge Planning Summary.

4. Personnel Personnel P4 was interviewed on 8/9/10 at 11:00 AM and confirmed all patients are to have a Case Management Discharge Planning and Evaluation and Case Management Discharge Planning Summary in their medical record. The Case Management documentation related to discharge planning is started on admission and continues until the patient is discharged. This was lacking for the above-mentioned patients.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to reassess the patient's discharge plan by failing to ensure Case Management Progress Notes were documented daily in the medical record for 2 of 5 (N1 and N3) closed patient medical records reviewed.

Findings:

1. Policy No. CM-01 titled, "Case Management Assessment Plan" was reviewed on 8/9/10 at 1:00 PM and indicated on pg. 1, point A., "Determine the Potential Discharge Planning needs for all patients...on an on-going (daily) basis..."

2. Review of closed patient medical records on 8/9/10 at 10:22 AM, indicated patient:
A. N1 was admitted on 6/16/10 and discharged on 6/19/10 and lacked documentation of daily Case Management Progress Notes.
B. N3 was admitted on 5/17/10 and discharged on 5/18/10 and lacked documentation of daily Case Management Progress Notes.

3. Personnel Personnel P4 was interviewed on 8/9/10 at 11:00 AM and confirmed all patients are to have documentation of daily Case Management Progress Notes in their medical record. The Case Management documentation related to discharge planning is started on admission and continues until the patient is discharged. This was lacking for the above-mentioned patients.