HospitalInspections.org

Based on medical record review, review of policy and procedure and staff interview; the CAH (Critical Access Hospital) failed to ensure that swing bed patient records included a recapitulation (a concise summary) of the swing bed stay for 1 of 5 swing bed patients (Patient 21) reviewed. This had the potential to affect all discharged swing bed patients. Total swing bed admits from 4/15/18 to 4/16/19 was 14.

Findings are:

A. A review of Patient 21's entire medical record (4/17/19 at 3:10 PM) revealed no documented evidence of the required recapitulation of the patient's swing bed stay from 12/10/18-12/15/18.

B. Review of policy and procedure (Revised 4/1/19) revealed "The "Recapitulation Statement", a summary of the swing bed patient's stay, will be completed upon discharge in the EHR [Electronic Health Record], chart notes."

C. Interview with the CNO (Chief Nursing Officer) (4/18/19 at 8:55 AM) confirmed the above medical record was missing the required recapitulation that summarized the patient's swing bed stay.