HospitalInspections.org

Based on interview and record review, the facility failed to ensure the medical record contained a discharge summary with outcome of hospitalization, disposition of care, and provisions for follow-up care; and final diagnosis with completion of medical records within 30 calendar days following discharge for 1 of 10 patient records reviewed (Patient #1).

Findings include:

Review of the clinical record for Patient #1 on 4/5/2022, revealed the patient was discharged 1/8/22 and there was no discharge summary completed or provided by the physician.

During an interview 4/5/2022, with staff member #3, the Director of Quality reported she was unable to find a discharge summary for Patient #1. She stated "a discharge summary is completed within 30 days of discharge and should be a part of the clinical record."

Review of medical staff rules document provided by staff #3 titled "Rules and Regulations of the Medical Staff of Austin Oaks Hospital," effective 3/23/22, reflected in part: "...7.3 Practitioner Responsibility for Medical Record ...7.3.2 The Attending Practioner is ultimately responsile for providing a complete medical record on each patient...(j) the discharge planning evaluaton done for the patient (k) diagnoses at the time of discharge, and (l) completion of the discharge summary within 30 days of discharge, and all other discharge summary and aftercare information..."