HospitalInspections.org
Bringing transparency to federal inspections
LAREDO MEDICAL CENTER
CONTENT OF RECORD: DISCHARGE SUMMARY
Tag No.: A0468
Based on review of patient #1 medical record and interview with staff it was observed that this requirement was not met as followed:
Findings:
A. In review of medical record it was observed on November 6, 2013 that patient #1, 86y/o was discharged on August 14, 2013. The patients discharge summary was not completed and included in the medical record.
B. In an interview with Staff # 1, Director of Quality at 2:20pm on November 6, 2013 who also reviewed the medical record and observed that a note was made for the attending physician of the patient to complete the discharge summary. As of November 6, 2013 , 83 days after the patient was discharged from the medical unit and discharged and transferred to a skilled nursing unit, a discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up was not completed. Staff #1 could not show evidence that this requirement was met.
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on review of patient #1 medical record and interview with staff it was observed that this requirement was not met as followed:
Findings:
A. In review of medical record it was observed on November 6, 2013 that patient #1, 86y/o was discharged on August 14, 2013. The patients discharge summary was not completed and included in the medical record withing 30 days following discharge. There were several entries through out the record tagged by the medical record staff for the physician to complete which were not completed within 30 days of the patients discharge.
B. In an interview with Staff # 1, Director of Quality at 2:20pm on November 6, 2013 who also reviewed the medical record and observed that a note was made for the attending physician of the patient to complete the discharge summary and other tagged entries in the medical record for his signature, date and time. As of November 6, 2013 , 83 days after the patient was discharged from the medical unit and discharged and transferred to a skilled nursing unit, a discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up was not completed. Staff #1 could not show evidence that this requirement was met.