HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a discharge summary was completed for three of nine applicable medical records (MR) reviewed (MR16, MR20 and MR22).

Findings include:

Review on December 14, 2017, of the "Bucktail Medical Center Medical Staff Bylaws Rules and Regulations, last reviewed June 2, 2017, revealed "... Bucktail Medical Center Medical Staff Rules and Regulations The Professional Staff ... 12) ... At the time of discharge, the attending physician shall see that the record is complete, state his final diagnosis, and sign the record. 13) The attending physician shall be held responsible for the preparation of a complete professional record for each patient. This record shall include ... final diagnosis; condition on discharge; discharge summary. ..."

Review of MR16, on December 14, 2017, revealed MR16 was admitted on September 21, 2017, and discharged on October 8, 2017. A discharge summary was not present in MR16.

Review of MR20, on December 14, 2017, revealed MR20 was admitted on March 14, 2017, and discharged on March 17, 2017. A discharge summary was not present in MR20.

Review of MR22, on December 14, 2017, revealed MR22 was admitted on March 20, 2017, and discharged on March 21, 2017. A discharge summary was not present in MR22.

Interview with EMP1 at 2:30 PM on December 12, 2017, confirmed MR16, MR20 and MR22 did not have a discharge summary completed.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a discharge order was written for three of nine applicable medical records (MR) reviewed (MR9, MR18 and MR19).

Findings include:

Review on December 14, 2017, of the "Bucktail Medical Center Medical Staff Bylaws Rules and Regulations," last reviewed June 2, 2017, revealed "... Bucktail Medical Center Medical Staff Rules and Regulations The Professional Staff ... 12) Patients shall be discharged only on written order of the attending Physician or designee. At the time of discharge, the attending physician shall see that the record is complete, state his final diagnosis, and sign the record. ..."

Review of MR9, on December 14, 2017, revealed MR9 was admitted on December 5, 2017, and discharged on December 10, 2017. An order for discharge was not written for MR9.

Review of MR18, on December 14, 2017, revealed MR18 was admitted on February 28, 2017, and discharged on March 3, 2017. An order for discharge was not written for MR18.

Review of MR19, on December 14, 2017, revealed MR19 was admitted on March 1, 2017, and discharged on March 3, 2017. An order for discharge was not written for MR19.

Interview with EMP1 at 2:30 PM on December 12, 2017, confirmed MR9, MR18 and MR19 did not have an order for discharge.

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure medical entries were authenticated with signature and/or title for six of 25 medical records (MR) reviewed (MR7, MR8, MR12, MR13, MR16 and MR18).

Findings include:

A review on December 14, 2017 of the facility policy "Medical Records: Preservation of Medical Records," last reviewed by the facility on March 29, 2017, revealed "Bucktail Medical Center will maintain medical records on all acute... swing bed, emergency room... patients in accordance with state and federal regulations..."

A review of MR7 on December 12, 2017 at 10:00 AM revealed:
Chart note dated November 27, 2017 14:04 with signature. There was no title of the person signing the MR.
Chart note dated November 28, 2017 10:28 with signature. There was no title of the person signing the MR.
Chart note dated December 4, 2017 10:27 with signature. There was no title of the person signing the MR.
Chart note dated December 11, 2017 13:07 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated December 12, 2017 08:00 with signature as "rn2, agency. There was no identification of the name of the person signing the MR.
Abnormal assessment note dated December 13, 2017 08:00 with signature as "rn2, agency." There was no identification of the name of person signing the MR.

A review of MR8 on December 12, 2017 at 11:30 AM revealed:
Chart note dated November 7, 2017 11:12 with signature. There was no title of the person signing the MR.
Chart note dated November 9, 2017 10:13 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated November 9, 2017 19:56 with signature. There was no title of the person signing the MR.
Chart note dated November 10, 2017 06:39 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated November 10, 2017 19:40 with signature. There was no title of the person signing the MR.
Chart note dated November 11, 2017 06:54 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated November 11, 2017 20:08 with signature. There was no title of the person signing the MR.
Chart notes dated November 11, 2017 at 21:05, 21:15, 21:30, and 23:00 with signature. There was no title of the person signing the MR.
Chart notes dated November 12, 2017 at 02:49, and 21:45 with signature. There was no title of the person signing the MR.
Abnormal assessment notes dated November 12, 2017 at 08:00 and 20:30 with signature. There was no title of the person signing the MR.
Chart note dated November 14, 2017 14:00 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated November 16, 2017 20:22 with signature. There was no title of the person signing the MR.
Chart note dated November 17, 2017 15:28 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated November 17, 2017 21:00 with signature. There was no title of the person signing the MR.
Chart note dated November 18, 2017 02:10 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated November 24, 2017 21:13 with signature. There was no title of the person signing the MR.
Abnormal assessment note dated December 12, 2017 08:00 with signature as "rn2, agency." There was no identification of the name of person signing the MR.

A review of MR12 on December 13, 2017 at 9:30 AM revealed:
Chart note dated September 14, 2017 19:00 with signature as "student2, med" that did not identify the title or name of person signing the MR.
Chart note dated September 16, 2017 06:40 with signature as "agency, lpn" that did not identify the name of person signing the MR.
Chart note dated September 17, 2017 06:45 with signature as "agency, lpn" that did not identify the name of person signing the MR.
Chart note dated September 25, 2017 16:15 with signature as "student, med" that did not identify the title or name of person signing the MR.
Chart note dated September 26, 2017 11:44 with signature as "student, med" that did not identify the title or name of person signing the MR.
Abnormal assessment note dated September 28, 2017 20:00 with signature as "agency3, acute" that did not identify the title or name of person signing the MR.
Abnormal assessment note dated September 29, 2017 20:00 with signature as "agency3, acute" that did not identify the title or name of person signing the MR.

A review of MR13 on December 13, 2017 at 10:30 AM revealed:
Chart note dated September 25, 2017 16:19 with signature as "student, med" that did not identify the title or name of person signing the MR.
Chart note dated September 26, 2017 11:57 with signature as "student, med" that did not identify the title or name of person signing the MR.
Chart note dated September 27, 2017 07:57 with signature as "student, med" that did not identify the title or name of person signing the MR.
Chart note dated October 1, 2017 21:24 with signature as "agency3, acute" that did not identify the title or name of person signing the MR.

A review of MR16 on December 12, 2017 at approximately 1:00 PM revealed a discharge summary dated October 8, 2017 with signature as "agency3, acute" that did not identify the title or name of person signing the MR.

A review of MR18 on December 12, 2017 at 2:30 PM revealed a discharge summary dated March 31, 2017 with signature as "student2, med" that did not identify the title or name of person signing the MR.

Interview with EMP3 on December 12, 2017 at 11:45 AM confirmed there were no titles with signatures in the charts reviewed.

Interview with EMP4 on December 13, 2017 at 2:15 PM confirmed there were no identifiers in the electronic medical records correlating to the medical students and agency nursing staff to identify who had signed the medical records.