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CEDAR CREST HOSPITAL & RTC
CONTENT OF RECORD: DISCHARGE SUMMARY
Tag No.: A0468
Based on review of medical records and interview, the facility failed to ensure the record of each patient who had been discharged had a discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care.
Findings included:
Patient #1 was discharged on 7/21/17, there was no discharge summary documented.
Patient #2 was discharged on 7/21/17, there was no discharge summary documented.
Patient #5 was discharged on 7/20/17, there was no discharge summary documented.
Patient #6 was discharged on 6/27/17, there was no discharge summary documented.
The above was verified in an interview with staff #1 on the afternoon of 10/25/17.
RECORDS OF DISCHARGED PATIENTS INCLUDE DISCHARGE SUMMARY
Tag No.: B0133
Based on review of medical records and interview, the facility failed to ensure the record of each patient who had been discharged had a discharge summary that included a recapitulation of the patient's hospitalization.
Findings included:
Patient #1 was discharged on 7/21/17, there was no discharge summary documented.
Patient #2 was discharged on 7/21/17, there was no discharge summary documented.
Patient #5 was discharged on 7/20/17, there was no discharge summary documented.
Patient #6 was discharged on 6/27/17, there was no discharge summary documented.
The above was verified in an interview with staff #1 on the afternoon of 10/25/17.