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FRYE REGIONAL MEDICAL CENTER
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on Medical Staff Rules and Regulations review and medical record review, the medical staff failed to dictate a discharge summary for 1 of 14 patients (patient #2).
The findings include:
Review of the hospital's, "MEDICAL STAFF RULES AND REGULATIONS", dated September 2012 revealed, "...4.10 Discharge Summary. ...A discharge summary shall be dictated on all patients hospitalized over 24 hours. Any record lacking a discharge summary greater than 5 days post discharge is deemed incomplete until dictation of the discharge summary has been dictated/transcribed."
Closed medical record review conducted on 03/20/2013 revealed patient #2 was admitted to the hospital on 03/17/2012 and discharged on 09/15/2012. Record review revealed as of 03/20/2012 (197 days after discharge date), no discharge summary had been dictated.
Interview with hospital staff #4 (Director of Health Information) conducted on 03/21/2013 at 0925 revealed, "The patient had a discharge summary dictated on 04/11/2012. The patient was not reentered into the system (computer documentation systems notifying the physician to complete a discharge summary); therfore, no discharge summary was dictated for 09/15/2012."
Telephone interview with physician #1 (Attending-primary doctor) conducted on 03/21/2013 at 0935 revealed, "Originally, the patient had an interim discharge summary dictated on 04/11/2012, because the patient was going to rehab (rehabilitation-therapy). But the patient coded (heart stopped beating); therefore, the patient did not go to rehab and was not discharged until 09/15/2012."
FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
Tag No.: A0724
Based upon policy review and observations, the facility failed to ensure empty O2 (Oxygen) tanks were stored separately from full O2 tanks on 1 of 3 units ( nursing unit #3).
The findings include:
Review of the hospital's policy, "Oxygen Cylinder Storage", reviewed on 08/28/11 revealed, "...POLICY: ...6) Empty O2 (oxygen) tanks shall be stored separately from full tanks...".
Observation conducted on 03/21/2013 at 1300 revealed nursing unit #3 (3-Adult Health) had 12 full O2 tanks and 3 empty O2 tanks were stored together in the respiratory storage area.
Interview conducted on 03/21/2013 at 1300 with hospital staff #3 (Unit Manager of 3-Adult Health) confirmed full and empty O2 tanks were stored together.