HospitalInspections.org

Based on record review, policy review and staff interview the facility failed to ensure that patient discharge summaries were completed in a timely fashion defined by hospital policy requirements for 2 of 5 discharge patients (D1, D2). This compromises the effective transfer of the patient's care to the next care provider.

Findings include:

A. Record Review

1. D1 was admitted 6/15/10 and was discharged on 8/25/10; record was reviewed on 9/13/10. D1 patient record contained no discharge summary.

2. D2 was admitted on 7/23/10 and was discharged on 8/25/10; record was reviewed on 9/13/10. D2 patient record contained no discharge summary.

B. Policy Review

The Medical Bylaws, received on 9/13/10 at 5:00p.m. and dated December 2009 stated "Members must complete the discharge summary within 15 days of discharges." This comment is found on page 8 section 5.3.2 of the Medical Bylaws

C. Staff Interview

1. On 9/13/10 at 3:30p.m., the Medical Record Supervisor reported that records D1 and D2 "had no discharge summary."

2. On 9/13/10 at 3:30p.m., the Quality Assurance Director reported that records D1 and D2 "had no discharge summary."