HospitalInspections.org

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K-0225, K-0321, K-0324, K-0353, K-0511, K-0541, K-0761 and K-0918.

Based on interview and document review, the facility failed to ensure a discharge summary was completed within 30 days after the day of the surgical procedure for 7 of 7 patients (P21, P22, P23, P24, P25, P26, P27) reviewed for surgical procedures.

Findings include:

P21's operative report dated 3/20/25, identified P21 had a right inguinal hernia repair on 3/20/25. P21's electronic medical record (EMR) lacked a discharge summary for P21.

P22's operative report dated 4/10/25, identified P22 had a colonoscopy on 4/10/25. P22's EMR lacked a discharge summary for P22.

P23's operative report dated 4/10/25, identified P23 had an esophagogastroduodenoscopy (EGD) (a procedure where a thin, flexible tube with a camera (endoscope) is inserted through the mouth to examine the lining of the esophagus, stomach, and part of small intestine.) on 4/10/25. P23's EMR lacked a discharge summary for P23.

P24's operative report dated 4/30/25, identified P24 had a colonoscopy on 4/30/25. P24's EMR lacked a discharge summary for P24.

P25's operative report dated 4/30/25, identified P25 had a colonoscopy on 4/30/25. P25's EMR lacked a discharge summary for P25.

P26's operative report dated 6/2/25, identified P26 had a left carpal tunnel release (a surgery on the left wrist to help relieve pain) on 6/2/25. P26's EMR lacked a discharge summary for P26

P27's operative report dated 6/5/25, identified P27 had a right inguinal hernia repair on 6/5/25. R27's EMR lacked a discharge summary for P27.

During an interview on 3/13/25 at 4:58 p.m., the vice-president of patient care services confirmed the facility had not completed discharge summaries on the above identified surgical patients. They stated it was something the facility should have had in place.

A policy regarding provider documentation following discharge was request however, none was received.