HospitalInspections.org

Based on clinical record reviews, review of hospital polcies and procedures and interviews with facility personnel for one of three sampled patients (Patient #2),. the facility failed to ensure that discharge summaries were completed in a timely manner. The findings include:

1. Patient #2 was admitted to the hospital on 11/25/11 with Cirrhosis and Hepatitis. Review of the clinical record failed to identify that a discharge summary was completed for the patient. Subsequent to surveyor inquiry on 1/5/12, the discharge summary was completed on 1/9/12. Review of hospital policy identified that all discharge summaries are to be completed within 30 days of discharge. Interview with the Performance Improvement Coordinator on 1/9/12 identified that the discharge summary for Patient #2 was not complete.

Based on review of hospital documentation, review of hospital policies and procedures and interviews with facility personnel, the facility failed to ensure that physicians who were suspended for not completing their medical record was not able to perform surgeries.
The findings include:

1. Review of the physician suspension list dated 12/21/11 identified that a surgeon who was suspended for not completing his/her medical records was able to perform surgery on 12/21/11. Review of hospital policy identified that any physician on the suspension list is not able to book surgical procedures. Interview with the VP of Patient Care Services on 1/10/12 at 1:00pm identified that the surgeon was suspended for not completing his/her medical records and was not suppose to perform surgical procedures until all medical records were complete.