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LINCOLN SURGICAL HOSPITAL
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on review of Medical Staff Rules and Regulations, medical record review and staff interview, the facility failed to ensure documentation of physician orders for discharge in accordance with facility's Medical Staff Rules and Regulations for 3 of 30 medical records(Patients 8, 13, 19) reviewed. This failed practice had the potential to affect all patients of the hospital. The hospital had 13,052 surgical cases for fiscal year 2022.
Findings include:
A. Review of facility's Medical Staff Rules and Regulations (approved January 2019) revealed that a patient may be discharged only on the order of the admitting physician or designee practitioner.
B. Review of Patient 8's medical record (12/5/23 at 1:43 PM) revealed the patient was admitted on 8/7/23for a Robotic Assisted Sleeve Gastrectomy (surgical removal of a part or whole of the stomach) and lacked documentation of a physician order for discharge.
-Review of Patient 13's medical record (12/6/23 at 12:32 PM) revealed the patient was admitted on 10/20/23for a Robotic Right Colectomy (surgical removal of all or part of the colon) and lacked documentation of a physician order for discharge.
-Review of Patient 19's medical record (12/6/23 at 3:51 PM) revealed the patient was admitted on 6/22/23 for a Laparascopic Sleeve Gastrectomy (surgical removal of a part or whole of the stomach) and lacked documentation of a physician order for discharge.
C. Interview with Nursing Service Leader (12/7/23 at 10:56 AM) confirmed the above medical records lacked evidence of a documented physician order for discharge.