HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to document a discharge summary with the outcome of hospitalization in 2 of 10 electronic medical records reviewed. This was not consistent with facility Medical Staff Rules and Regulations and resulted in incomplete records.

The findings were:

The facility Medical Staff Rules and Regulations reflected in part "43. The following should be documented at the time of discharge: a. all diagnosis and surgical procedures; and b. all complications and infections occurring during hospitalization. 44. The final diagnosis shall be recorded in full, without use of symbols or abbreviations, and dated and signed by the responsible practitioner no later than 30 days following discharge. This will be deemed equally as important as the actual discharge order."

Electronic medical records were requested during the survey on 9/29/20 and were provided password protected on a CD on 9/30/20. The electronic records were subsequently reviewed off-site. The original record of patients #1 and #7 provided at the time of the survey exit on 9/30/20 did not contain a discharge summary. An e-mailed inquiry was made on 10/7/20 asking for confirmation that there were no discharge summaries in the records of patients #1 and #7. Subsequently, a discharge summary for patient #1 dictated on 10/7/20 was provided by secure e-mail on 10/9/20 which noted patient #1 had been admitted the morning of 8/21/20 and expired later that same day. A discharge summary for patient #7 dictated on 10/3/20 was provided by secure e-mail on 10/9/20 which noted patient #7 had expired on 8/28/20.

In response an e-mailed question on 10/9/20, staff #1 acknowledged by e-mail that discharge summaries for patients #1 and #7 were not completed within 30 days as required by the Medical Staff Rules and Regulations.

Based on observation and review of documentation, the facility failed to maintain equipment to ensure an acceptable level of safety as an unsecured oxygen cylinder was found stored unsecured in 1 of 1 nursing units observed. This was not consistent with facility policy and potentially could have been a safety hazard if the cylinder were to tip over.

The findings were:

The facility policy entitled Respiratory Therapy-Handling and Use of Compressed Gas Cylinders, #4773548 dated 6/18 reflected in part "Freestanding cylinders must be properly chained or supported in a proper cylinder stand or cart."

During a tour of the 2 West Telemetry Unit on the afternoon of 9/29/20 an unsecured oxygen cylinder was observed to the right of the door of the medication room standing on the floor not secured in any way outside of the rack containing other oxygen cylinders.

In an interview with the unit director, staff #15 during the tour on the afternoon of 9/29/20, staff #15 acknowledged that the oxygen cylinder was unsecured and stated it should be in the rack.