HospitalInspections.org

Based on a review of the medical record, the facility failed to provide An Important Message from Medicare (IM) to this patient on admission and in a timely manner prior to discharge.

This 69 year old Medicare beneficiary was admitted to Northwest Hospital Center on 8/1/10. Within two days she should have received the standardized notice and signed and dated it to acknowledge receipt. Then, not longer that two days prior to discharge, the same notice is to be given to the patient, and again signed an dated upon receipt. The patient was discharged on 9/2/10. There are no IMs present in the patient's medical record.

"An Important Message from Medicare" must be provided to all Medicare beneficiaries. It is a part of the entire patient rights package. The IM is one of the ways to ensure that patients have the information necessary to exercise their rights.

Based on a review of the patient#1's medical record, the following medical record deficiencies were found:

Physician progress note written between two nursing progress notes with dates of 8/14/10 has an illegible date, no time, and the handwriting is totally illegible. The signature is illegible.

Physician progress note between two nursing notes dated 8/15/10 has no time noted and again the handwriting and signature are illegible. The same is true of a physician progress note found between two nursing progress notes written 8/16/10 and 8/18/10.

On 8/17/10 there appears a physician progress note in the same illegible handwriting with no time and no signature. On 8/19 there is a physician progress notes written in the margin without time, the handwriting and signature are illegible.

On 8/20 there is another illegible physician progress notes without the time noted. The signature does not match a previous signature, though the handwriting resembles the earlier cited notes. On 8/21 there is physician progress note that is illegible and lacks a time written. Some of the words and abbreviations are legible but not enough to understand the entire note.

The remainder of the physician progress notes through 9/2/10 are lacking time and all are illegible, though one physician's handwriting is slightly more legible than the other. . Signatures are illegible on all notes.

A handwritten discharge instructions sheet is illegible. It has medications with dosages listed which one would have to guess at or possibly compare to the record to decipher. This could be a serious patient safety issue and relates to medication reconciliation.

All entries in the medical record must be legible. Entires that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events. Timing and dating of entries is necessary for patient safety and quality of care. Timing establishes when an activity happened or when an activity is to take place; timing establishes a baseline for future actions or assessments and establishes a timeline of events.

Based on a review of the medical record, this patient has three (3) discharge summaries for this 8/1/2010 - 9/2/2010 admission. Each summary fails to meet regulatory guidelines as evidenced by:

The patient has a Discharge Summary which was electronically signed on 8/19/10 by a physician. There is no date dictated or transcribed and there is no discharge diagnosis. It actually appears that is may be a transfer summary for intrahospital purposes, but that is not clear.

There is a second Discharge Summary dictated and transcribed on 8/19/10 the same physician who wrote the one above. The patient discharge date is 8/20/10. It is electronically signed by the physician on 8/22/10. There are several blanks in the transcription throughout the summary. Under "ALLERGIES: She is allergic to aspirin and ________."; the number 2 discharge medication is "_________." and Lactulose is listed twice transcribed as "Lactulose 20______p.o. daily." No discharge disposition appears in this summary.

A third Discharge Summary appears as an Addendum, dictated the day of the patient's discharge from the hospital. This addendum does not provide disposition or provisions for followup care.

This particular patient proved to be very difficult to manage as reported in the medical record. This may account for some of the confusion with Discharge Summaries. Regardless, the hospital failed to meet federal regulations by supplying inconsistent and incomplete discharge summaries. The discharge summary is an important part of the continuing care of the patient in reporting how post hospital care needs will be met and providing ongoing medication regimen. An accurate discharge summary helps provide a safe discharge for the patient.