HospitalInspections.org

Based on review of documents, medical records and staff interviews it was determined the facility failed to ensure the medical staff enforced the Bylaws, Rules and Regulations as they pertained to the completion of the medical records in six (6) of six (6) medical records reviewed (#1, 2, 3, 4, 5 and 6). This has the potential to impact the continuity of patient care by leaving them with an incomplete medical record.

Findings include:

1. The Medical Staff Bylaws, Rules and Regulations, effective 7/31/2013 state in part: "All discharge summaries and other medical record documentation shall be completed within fifteen (15) days following the patient's discharge. Incomplete records exceeding fifteen (15) days following discharge will be considered delinquent."

2. Patient #1 was discharged from the hospital on 2/21/14. The discharge summary wasn't dictated until 4/5/14 and on 4/14/14 remained unsigned.

3. Patient #2 was discharged from the hospital on 2/21/14. The discharge summary was not completed until 3/30/14.

4. Patient #3 was discharged from the hospital on 3/4/14. As of 4/14/14, there was no discharge summary found in the medical record.

5. Patient #4 was discharged from the hospital on 2/19/14. As of 4/14/14, there was no discharge summary found in the medical record.

6. Patient #5 was discharged from the hospital on 2/17/14. As of 4/14/14, there was no discharge summary found in the medical record.

7. Patient #6 was discharged from the hospital on 2/14/14. The discharge summary was not dictated until 3/8/14.

8. These medical records were reviewed with the Director of Quality Improvement on 4/15/14 at 1410 and she agreed with these findings.