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Based on record review and staff interview, it was determined that the facility failed to ensure compliance with the Medical Staff bylaws regarding discharge summary for one (#1) of six sampled patients.


Findings include:

The facility's medical staff bylaws require a discharge summary for all patients. The bylaws also stated that a final progress note may substitute for the discharge summary for patients whose hospitalization is less than 48 hours. Patient #1 was admitted the facility on 1/9/11 and left against medical advice on 1/10/11. Review of the medical record of patient #1 revealed no discharge summary and no final progress note. During interview on 3/1/11, the Director of Quality confirmed the physician failed to comply with the requirement for a final progress note.

Based on record review and staff interview, it was determined that the registered nurse failed to ensure appropriate nursing interventions for one (#1) of six patients.


Findings include:

The medical record for patient #1 was reviewed. The attending physician documented, in the History and Physical the plan to continue the patient's home medications for hypertension and hormone replacement therapy. Review of the physician's admission orders revealed an order to continue home medications. Review of the medical record revealed no evidence the nursing staff clarified the order. The initial nursing assessment revealed the patient's blood pressure was 157/100. There was no evidence that the nursing staff questioned the physician regarding the need for an antihypertensive. At 4:00 p.m. the patient's blood pressure was elevated at 168/88. At 4:55 p.m. the patient sign out against medical advice. The nurse spoke with the physician at 4:00 p.m., however, there was no documentation that the elevated blood pressure was reported to the physician.