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Based on medical record review, staff interview, and policy review the Hospital failed to ensure the physician completed the discharge summary within thirty days after discharge for five of ten discharged patients sampled (#'s 1, 2, 5, 7, and 9). This deficient practice had the potential for inadequate follow-up care.

Findings include:

- Patient #1's closed medical record reviewed on 4/18/2016 revealed an admission date of 1/11/2016 and a discharge date of 1/21/2016. Patient #1's medical record contained a discharge summary dated of 4/11/2016 (81 days after discharge).

- Patient #2's closed medical record reviewed on 4/18/2016 revealed an admission date of 1/25/2016 and a discharge date of 2/1/2016. Patient #2's medical record contained a discharge summary dated 3/16/2016 (44 days after discharge).

- Patient #5's closed medical record reviewed on 4/18/2016 revealed an admission date of 2/24/2016 and a discharge date of 3/1/2016. Patient #5's medical record contained a discharge summary dated 4/16/2016 (46 days after discharge).

- Patient #7's closed medical record reviewed on 4/18/2016 revealed an admission date of 12/10/2015 and a discharge date of 12/17/2015. Patient #5's medical record contained a discharge summary dated 2/4/2016 (49 days after discharge).

- Patient #9's closed medical record reviewed on 4/18/2016 revealed an admission date of 11/13/2015 and a discharge date of 11/20/2016. Patient #9's medical record contained a discharge summary dated 12/30/2015 (40 days after discharge).

- The Hospital's policy in the Medical Staff Rules and Regulations "Criteria for discharge" reviewed on 4/18/2016 at 3:00 PM directed, "...If the discharge summary is not completed within thirty (30) days after the discharge, the medical record will be deemed delinquent ..."

Administrative Staff A and Quality Manager Staff B interviewed on 4/18/2016 at 3:25 PM acknowledged some of their physicians were late completing their discharge summary, more than the 30 days per policy.