HospitalInspections.org

Based on review of documents, medical records and staff interview, it was determined the Governing Body failed to ensure Physicians were following the Medical Staff Bylaws, Rules and Regulations. This pertained specifically to no or late discharge summaries in five (5) of ten (10) medical records reviewed (#1, 2, 3, 6 and 8). This has the potential to negatively affect all patients by leaving them with incomplete medical records which could compromise future medical care. Findings include:

1. Medical Staff Bylaws, Rules and Regulations (last revised 7/09) state in part: "The patient's medical record shall be complete at the time of discharge, including progress notes and final diagnosis. The written or dictated discharge summary shall be completed within thirty (30) days of discharge."

2. Patient #1 was admitted to the hospital on 2/3/11 and expired on 2/7/11. As of 3/23/11 there is no discharge summary in the medical record.

3. Patient #2 was admitted to the hospital on 9/10/10 and expired on 9/13/10. As of 3/23/11 there is no discharge summary in the medical record.

4. Patient #3 was admitted to the hospital on 9/11/10 and expired on 9/11/10. As of 3/23/11 there is no discharge summary in the medical record.

5. Patient #6 was admitted to the hospital on 1/18/11 and expired on 1/19/11. The discharge summary was dictated and transcribed on 3/22/11.

6. Patient #8 was admitted to the hospital in the morning of 11/16/10. In the evening of 11/16/10, the patient signed out Against Medical Advice. The discharge summary was not dictated until 1/3/11.

7. During an interview in the morning of 3/23/11 with the Quality Director and the Director of Nursing, these medical records were reviewed and they agreed with the findings.